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Case 25 

Case 25
Chapter:
Case 25
Author(s):

Joel David

, Anne Miller

, Anushka Soni

, and Lyn Williamson

DOI:
10.1093/med/9780199587506.003.0025
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date: 19 August 2019

A 72-year-old Caucasian female presented with rapid-onset, painful, and disabling dactylitis of both second toes (Fig. 25.1). She had a past history of mechanical low back pain. Since the development of dactylitis she suffered general malaise, pain all over, and night sweats. On examination she was distressed and anxious, afebrile, and normotensive, with widespread hyperalgesia but no significant abnormality apart from dactylitis of both second toes. In particular, there were no skin, hair, or nail lesions. During the following few months the dactylitis migrated between different toes, but was always present in at least two toes. The pain, fever, and malaise troubled her to such an extent that she became depressed. She was treated with paracetamol, NSAIDs, amitriptyline, and morphine sulphate, all of which were ineffective. Intravenous methylprednisolone had a transient effect on the inflammatory response. DMARDs (methotrexate, leflunomide, and sulfasalazine) were also ineffective.

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