A young man with multiple joint pains and fever: A case with the importance of accurate history taking

A 38yearold Japanese man presented to the outpatient department of orthopedics with sudden onset of back pain without radiation for 4 days followed by a 3 week history of multiple joint pains. The joint pains were involved with the major joints, including left ankle, left wrist, right knee, and right second proximal interphalangeal joint of the foot. The pains became worse with movement. Due to increased joint pains along with plantar pain, he gradually developed difficulty in walking. During this period, the patient also had intermittent fever with a range of 3738.6°C at daily maximum temperature. He had no significant past medical history such as diabetes, hypertension, hyperlipidemia, asthma, trauma, or major surgery. He worked as a system engineer. For 17 years, he had been smoking one pack of cigarettes and drinking two cans of beer a day. He had no known drug or food allergy. Multiple etiologies should be considered for multiple joint pains and fever. These include infectious diseases, crystalinduced arthritis, endocrine disorders, collagen vascular diseases, or seronegative spondyloarthropathies. Regarding infectious diseases, viral, bacterial, fungal, or parasitic diseases can cause multiple joint pains and fever. Crystalinduced arthritis includes gout or pseudogout, although these diagnoses at this age are not common. Endocrine disorders include hyperthyroidism, hypothyroidism, or hyperparathyroidism. For collagen vascular diseases, rheumatoid arthritis, systemic lupus erythematosus, various vasculitis, or adult Still’s disease are possibilities. Seronegative spondyloarthropathies include psoriatic arthritis, ankylosing spondylitis, enteritisassociated arthritis, or Behcet disease. Among these extensive causes, infectious diseases, such as bacterial arthritis, should be considered first, as they may cause sepsis, or rapid joint destruction. Thus, taking detailed history is necessary, focusing especially on exposures to potential pathogens, including sexual history. Review of systems is mandatory for gathering additional important information. The patient lives in Kanto area with his parents. Family history showed the absence of collagen vascular diseases or traits of hereditary diseases. He denied any contacts with animals, people with tuberculosis, sick people, or sexual contacts in the past half year. He had no recent travel history or exposure to wildness. In review of systems, chills, night sweat, or weight loss were negative. The patient also claimed that he did not have a sore throat, rhinorrhea, a headache, chest pain, abdominal pain, cough, dyspnea, vomiting, diarrhea, dysuria, or skin rash. Negative exposure history cannot exclude infectious diseases. Concrete sexual history should be included into social history especially for adolescent men with suspected infectious diseases. Absence of skin rash cannot eliminate collagen vascular diseases. Physical examination should differentiate between inflammatory arthropathy and noninflammatory arthropathy by inspection and palpation on the entire joints. Presence of swelling, redness, local heat, or tenderness of the points indicates inflammatory arthropathy. He was alert and oriented, and vital signs were normal, including the blood pressure of 112/66 mm Hg, the pulse of 95/min, the respiratory rate of 18/min, and the temperature of 36.1°C. There were no skin rash, conjunctival injection, or superficial lymphadenopathies. Heart sounds were normal without murmurs, gallops, or rubs. The lungs were clear to auscultation. Abdominal examination was normal. Examination of joints showed mild swelling and tenderness of left ankle, left wrist, right knee, and right second proximal interphalangeal joints. Although there was no tenderness over the spinous processes in the cervical, thoracic, and lumbar spines, the