Test your rheumatology
Try to make sense of seemingly unrelated symptoms
A 58 year old white man presented with a six month history of arthralgia that affected his shoulders, hands, ankles, and feet, associated with early morning stiffness and intermittent joint swelling. Two weeks before he had developed ulceration on his elbow and tongue. He also reported weight loss, fevers with profuse sweating, haemoptysis, nasal stuffiness, and a six month history of intermittent deafness.
On examination, he had an ulcer over his right elbow measuring 2 × 3 cm (fig 1) and two small ulcers over the left side of his tongue. The second, third, and fourth metacarpophalangeal joints of his right hand were swollen, as was his left ankle. A urine dipstick showed a trace of protein and blood.
(1) What is your differential diagnosis?
(2) What investigations would you perform to establish the diagnosis?
Immunological tests showed a strongly positive classical antineutrophil cytoplasmic antibody with a titre of 1/1024