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1998 Presentations for the Poster and Vignette Sessions
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TB OR NOT TB: THAT IS THE QUESTION. Ravi Rao, MD. University of Wisconsin Hospital & Clinics. Madison, WI

A 39 yr. old Tibetan male presented to the Rheumatology clinic for evaluation of joint pains of two months duration. He had pain and early morning stiffness involving mainly the small joints of his hands, elbows and knees prior to presentation. Review of systems was negative for any involvement of other systems. His past history was significantly for a positive PPD test six years ago for which he had refused Isoniazid prophylaxis. His wife had taken a course of anti­tubercular drugs for TB a year prior to this. He also was a chronic carrier of Hepatitis B. Exam revealed a healthy appearing male. Joint exam revealed no effusions and a normal range of motion except in his hands, where his grip was weak because of stiffness. Respiratory system exam revealed a right basal dullness, with decreased vocal fremitus, suggestive of an effusion. Chest x­ray confirmed the effusions. He was placed under respiratory isolation, given the strong suspicion of pulmonary tuberculosis.

He had normal joint x­rays. Serum chemistries were significant for ESR of 92, RF positive at 1: 640, ANA positive at 1:140. He was slightly anemic with a hematocrit of 30%, with normal blood indices. A diagnostic thoracocentesis was performed. The glucose was 12 mg/dL, cell count was 302 nucleated cells per mm3 with 80% lymphocytes, protein 5.9mg/dL, RF positive at 1:640, ANA positive at 1:160, pH was 7.1, ADA was non diagnostic. A pleural biopsy was then performed, and was negative for granulomas. The PCR and culture of the pleural fluid was negative for mycobacteria. A three­phase bone scan was done and showed a markedly increased symmetric uptake in his wrists, elbows, knees and ankles. A diagnosis of Rheumatoid Arthritis was made, and he was taken out of respiratory isolation, and begun on steroids. He had a quick and gratifying relief of his symptoms. He was subsequently begun on gold injections as a steroid sparing agent.

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