Asthma and epididymitis: the calm before the storm.

Case report A 17 year old Asian college student presented with a two month history of arthralgia, arthritis of his ankles and wrists, numbness of his feet and weight loss. He had a history, for the previous month, of epididymo-orchitis treated at another hospital. He had been investigated for abdominal pain and weight loss by plain abdominal radiography, abdominal ultrasound scan and rectal biopsy. Results were all normal. The symptoms were associated with a poor appetite but no history of nausea, vomiting or diarrhoea. No definite diagnosis was reached. He had a painful left ankle with associated numbness of the lateral aspect of his left foot. He felt generally weak and lethargic. He subsequently developed right ankle discomfort and swelling and bilateral wrist swelling and pain. Past medical history included allergic rhinitis and asthma, since childhood, for which he was treated regularly with beclomethasone and salbutamol inhalers. Clinical examination on presentation revealed a thin, unwell, feverish patient. He was 160 cm tall and weighed 43 kg. His fever persisted during the early stages of his admission to hospital. Hand examination revealed splinter haemorrhages, macular pigmented lesions on the palmar surface of his hands, and subcutaneous nodules at both elbows. He had a tachycardia with a soft ejection systolic murmur and his blood pressure was normal. His chest was clear and abdomen soft and non-tender with no palpable organs or masses. Central nervous system examination was normal. Peripheral nervous system examination revealed an asymmetrical subjective light touch sensory diminution in the lower limbs below the knees and absent ankle jerk reflexes bilaterally. Plantar reflexes were both flexor. There was grade 3/5 weakness of dorsiflexion at both ankles. Urine analysis was negative for blood and protein.