ABSTRACT
A 64-year-old Caucasian woman with a history of hypertension and systemic lupus erythematosus (SLE) was referred to a nephrology clinic due to persistent microscopic hematuria and trace proteinuria. Initial tests showed elevated antinuclear antibodies (ANA), anti-double-stranded DNA (anti-dsDNA), and anti-Sjögren's syndrome-related antigen A (anti-SSA) levels, while other markers remained within normal limits. Over the course of a year, her urine protein-creatinine ratio increased, prompting a renal biopsy. The biopsy revealed focal crescent formation in some glomeruli and mild segmental mesangial hypercellularity in others. Although the possibility of antineutrophilic cytoplasmic antibody (ANCA)-associated nephritis with superimposed IgA nephropathy was considered, negative myeloperoxidase and proteinase 3 antibody tests led to a final diagnosis of IgA nephropathy. The patient's treatment included adding prednisone to her existing valsartan prescription for hypertension, which resulted in improved proteinuria. SLE is an autoimmune disease that can cause chronic inflammation and damage to vital organs. Approximately 50% of SLE patients may experience lupus nephritis (LN), underscoring the importance of urinalysis and renal function tests. This case presents a female patient with SLE and IgA nephropathy, a rare association that requires distinction as it affects disease management. IgA nephropathy is the most common cause of idiopathic glomerulonephritis and can lead to end-stage kidney disease in around 40% of cases. A renal biopsy is also crucial for diagnosing IgA nephropathy in patients with or without another autoimmune disease. Focal crescent formation, a histological feature observed in this case, helped exclude several diagnoses, such as lupus nephritis or pauci-immune glomerulonephritis. The primary goal of treating IgA nephropathy is to prevent disease progression. Initial treatment includes controlling blood pressure, reducing proteinuria, and implementing lifestyle modifications. Corticosteroid therapy may be considered if supportive care is insufficient.
ABSTRACT
Nontuberculous mycobacterial tenosynovitis is a rare entity that is often misdiagnosed as bacterial or inflammatory tenosynovitis. We present a case of a 64-year-old man who presented with pain and swelling of his right wrist for several weeks. Magnetic resonance imaging (MRI) of his right upper extremity showed findings consistent with prominent tenosynovitis in the right extensor digitorum tendon sheath. Surgical debridement showed reactive histopathology with negative Gram stain, culture, and acid-fast bacilli stain; after which, steroids were started along with methotrexate and hydroxychloroquine, which was later changed to anti-tumor necrosis factor (anti-TNF) therapy. Due to minimal improvement, repeat operative debridement was done showing macroscopic rice bodies with pathology revealing chronic granulomatous inflammation with necrosis. However, repeated infectious work-up remained negative. After his symptoms progressed to involve his right index finger, his tenosynovium was sampled again, which was positive for acid-fast bacilli (AFB) staining for rare mycobacterial organisms, with cultures growing faint transparent colonies that were sent to the state laboratory for speciation. He was started on empiric therapy with clarithromycin, ethambutol, and rifampin following which his wound fully healed. This case illustrates the insidious course of nontuberculous mycobacteria (NTM) tenosynovitis leading to delayed diagnosis along with unwarranted treatments that could be harmful. Open tissue biopsy is important in the context of a lack of clinical response to common treatment modalities, in the absence of an alternative diagnosis with a similar clinical picture.
ABSTRACT
BACKGROUND: Advanced osteoarthritis and total joint replacement (TJR) recovery are painful experiences and often prompt opioid use in developed countries. Physicians participating in the philanthropic medical mission Operation Walk Boston (OpWalk) to the Dominican Republic have observed that Dominican patients require substantially less opioid medication following TJR than US patients. We conducted a qualitative study to investigate approaches to pain management and expectations for postoperative recovery in patients with advanced arthritis undergoing TJR in the Dominican Republic. METHODS: We interviewed 20 patients before TJR about their pain coping mechanisms and expectations for postoperative pain management and recovery. Interviews were conducted in Spanish, translated, and analyzed in English using content analysis. RESULTS: Patients reported modest use of pain medications and limited knowledge of opioids, and many relied on non-pharmacologic therapies and family support to cope with pain. They held strong religious beliefs that offered them strength to cope with chronic arthritis pain and prepare for acute pain following surgery. Patients exhibited a great deal of trust in powerful others, expecting God and doctors to cure their pain through surgery. CONCLUSION: We note the importance of understanding a patient's individual pain coping mechanisms and identifying strategies to support these coping behaviors in pain management. Such an approach has the potential to reduce the burden of chronic arthritis pain while limiting reliance on opioids, particularly for patients who do not traditionally utilize powerful analgesics.
