Thread by @MaxKonigMD

1/ A 46-year-old man with a history of #malaria presented to the @JohnsHopkinsDOM on 8/12/1923 with

-- 3 years of generalized arthralgia
-- intermittent joint swelling

-- 40 lbs weight loss

@CPSolvers @DxRxEdu #medtwitter #MedEd

2/ Exam

-- synovitis of the 2nd and 3rd MCPs

-- diffuse joint tenderness

-- lymphadenopathy

-- pyorrhea alveolaris* of the few remaining teeth.


What do you want to do next? What's your #DDX?

Remember: Sir William Osler died in 1919, so it's all you...

So far, we have #tuberculosis on the differential. “Consumption” or “#phthisis”, wasting away, as #Tb was often referred to, certainly could explain this patients weight loss and adenopathy.

But does it explain the rest?

Great DDX so far:

#ID
Tb
Malaria
Whipple's disease
Endocarditis

#Rheum
RA (aka "asthenic gout" @AliDuarteMD)

#Hereditary
Hemochromatosis

#Tox
Lead poisoning

Need some ID help @TxID_Edu

@AliDuarteMD @TxID_Edu Let's add some labs. It's 1923, but we have some labs:

Chem:
Uric acid 3.2 (wnl)
Non-protein nitrogen 28 (wnl)
Glucose 85 (wnl)

Blood:
WBC 2680 (PMN 26%)
RBC 3.75
Platelets 330

UA normal

Wassermann reaction negative
BCx negative

@AliDuarteMD @TxID_Edu Let's recap:

46M with a history of #malaria presents with weight loss, #lymphadenopathy, #polyarthritis (likely erosive), and periodontal disease. It is 1923 on the @OslerResidency service. Labs are limited, but you identify #anemia and #leukopenia. BCx are negative.

@AliDuarteMD @TxID_Edu @OslerResidency An epitrochlear lymph node is excised (@pekor002):
"Chronic lymphadenitis"

Tissue cultures are negative.

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 One last thing before you make diagnosis:

You re-examine the patient and note that the spleen is palpable at the umbilicus, 6 cm below the costal margin.

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 In case you wondered, this is a photo of you. You are an Assistant Resident in Medicine. You got this.

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 Beautiful @AliDuarteMD.

You are Augustus Roi Felty and you just saw your first case of what will become #Felty's disease.

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 You will find 3 more cases of arthritis deformans (#RA), splenomegaly, and leukopenia in the records of @JohnsHopkinsDOM.

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 @JohnsHopkinsDOM Here is your report of 4 cases published in the Bulletin of the Johns Hopkins Hospital in 1924. (fast peer review)

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 @JohnsHopkinsDOM Felty's syndrome is NOT limited to the triad of severe #RA, #splenomegaly, and #leukopenia.

Common features are #anemia, #thrombocytopenia, #lymphadenopathy, and extra-articular manifestations of #RA (rheumatoid vasculitis/ leg ulcers, pericarditis, pleuritis, scleritis).

@AliDuarteMD @TxID_Edu @OslerResidency @pekor002 @JohnsHopkinsDOM Things that would have been useful nowadays:

1. Anti-CCP and RF (Felty's patient are seropositive)
2. Peripheral smear (looking for large granular lymphocytes, #LGL)
3. Flow and clonality assessment to exclude LGL leukemia

We see less and less Felty's syndrome today, likely because of early treatment of RA (and the availability of many drugs that actually work).

It is debated whether Felty's and LGL leukemia are the same diseases. I don't think, but that's beyond today's scope.

Think SANTA (splenomegaly, anemia, neutropenia, thrombocytopenia, and arthritis)

Great job everyone!

Special thanks to @AliDuarteMD @pekor002 @TxID_Edu @DxRxEdu