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Fever, rash, swollen joints, and sore throat in a young man
  1. C S Arun,
  2. M A M Abbas,
  3. E B Henderson,
  4. A N Gorsuch
  1. Conquest Hospital, St Leonard's on-Sea, East Sussex, UK
  1. Dr C S Arun, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK csarun{at}lineone.net

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An 18 year old man developed a sore throat followed within two days by pain and swelling of both wrists, knees, and ankles, the metacarpophalangeal joints of both hands, and the metatarsophalangeal joints of both feet. This was associated with erythematous rash over his hands, arms, chest, and thighs down to both knees (see figs 1 and 2). His past medical history was otherwise unremarkable.

Figure 1

Erythematous rash on hands.

Figure 2

Erythematous rash on arm.

On examination he was febrile with a temperature of 38.6°C orally. He had an erythematous rash over the dorsal aspects of both hands, both arms, both thighs down to the knees, and chest. There were small effusions in both knees. Both wrists, both ankles, the metacarpophalangeal joints of both hands, and the metatarsophalangeal joints of both feet were tender and slightly swollen. Examination of the rest of his peripheral joints and of his axial skeleton was normal. Abdominal examination showed moderate splenomegaly, but nothing else. Other systemic examinations were unremarkable.

Investigations on admission included:

  • Haemoglobin = 119 g/l

  • White cell count = 23.0 × 109/l (neutrophils 21.6 × 109/l)

  • Platelets = 338 × 109/l

  • Erythrocyte sedimentation rate = 92 mm in one hour

  • C reactive protein = 234 mg/l (normal 0–10 mg/l)

  • Serum total bilirubin = 16 μmol/l

  • Serum alanine transaminase = 166 IU/l

  • Serum alkaline phosphatase = 465 IU/l

  • Serum albumin = 33 g/l

  • Antistreptolysin-O titres = normal

  • Serum ferritin = 22 515 μg/l (normal 40–350)

  • Blood cultures and viral titres = negative

  • Latex and antinuclear antibodies = negative

  • White cell scan = normal

  • Bone scan = normal

Ultrasound scan of the abdomen confirmed a modest degree of splenomegaly and nothing else.

Question

(1)
What is the most probable diagnosis?

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