A 46-Year-Old Man With Diffuse Musculoskeletal Pain, Swollen Joints, and Rash

Herbert S. Diamond, MD, MACP


July 17, 2014

Editorial Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions.


A 46-year-old white male presents to the office complaining of diffuse musculoskeletal pain and morning stiffness lasting about one hour. Six months ago he developed a painful, diffusely swollen right fourth toe. The pain was improved with over-the-counter naproxen, but the swelling never completely resolved. Over the next six months, pain spread to involve his cervical and lumbar spine; he also developed swelling and pain affecting his right wrist and forearm, the left fourth distal interphalangeal (DIP) joint, and the right ankle. In addition, there was tenderness in the area of the greater trochanter. Past medical history was positive only for nasal pollen allergies, acne as a teenager, and dandruff for the past five years. Family history was positive for myocardial infarction, in his father at age 49 years; psoriasis, also in his father; and stage 1 breast cancer, in his mother, who was treated with radiation and a lumpectomy, with good outcome to date.


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