Chapter 3

### Four brief histories of a ‘great pretender’

#### CASE 1

A 32-year-old housewife presented with 12 months of fluctuating symptoms of polyarthritis of the proximal (PIP) and distal interphalangeal joints (DIP) of the hand. Other symptoms included malaise, fever, mouth ulceration and Raynaud’s phenomenon. The only abnormal findings were evidence of Raynaud’s phenomenon in fingers, palmar erythema and mild fever but no deformity of the joints of the hand.

#### CASE 2

A 56-year-old farmer presented with 3 months of painful, swollen hands, wrists, feet and knees. Associated symptoms included severe fatigue, morning stiffness, intermittent grittiness of the eyes and mouth dryness. On examination he had synovial thickening and tenderness in the metacarpophalangeal and PIP joints and knees. He also had a dry mouth and conjunctivitis of the left eye.

#### CASE 3

A 17-year-old female student presented with 10 weeks of pain in her hands, wrists, knees, ankles, feet and shoulders. She also had swelling of the ankles and morning stiffness. She had been taking minocycline for acne for 12 months. Examination revealed tenderness of the left third PIP joint only.

#### CASE 4

A 30-year-old male salesman presented with 10 days of shortness of breath, cough, night sweats and chest pain. He described 12 months of mild, variable, intermittent pain of his hands, wrists and shoulders. On examination he had mild synovitis of the MCP and PIP joints of both hands and bilateral pleural effusions.

DISCUSSION AND LESSONS LEARNED

All of these four patients had systemic lupus erythematosus which is a multisystemic connective tissue disorder with a multitude of clinical symptoms and a wide variety of presentations (Hanrahan, 2001). These include dermatological, neurological, cardiovascular, haematological and obstetric manifestations. However, the two most common symptoms are joint pain and fatigue. SLE is associated with multiple drug allergies as exemplified in Case 3 (tetracyclines) and should be considered in young females with problems with the oral contraceptive pill and pregnancy. For suspected SLE the recommended approach is to perform an antinuclear (ANA) test and if positive, order dsDNA and ENA antibodies.

### The dramatic tale of ‘Hollywood Tom’—surgeon extraordinaire

Tom was a popular medical colleague who was the envy of many because of his debonair bronze surfie looks and immaculate presentation. In fact he was so suave and attractive to the ladies that we called him ‘Hollywood Tom’. He reminded me of Charles Dickens’ Dr Jobling who was described thus:

His neckerchief and shirt frill were ever of the whitest; his clothes were of the blackest and slickest, his gold watch-chain of the heaviest and his seals of the largest. His boots, which were of the brightest, creaked as he walked—and he had a peculiar way of smacking his lips and saying ‘ah’ at intervals while patients detailed ...

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