1. Dr Shrenik Shah Shrey hospital
Diagnostic dilemma
Dr Shrenik Shah
Shrey hospital

2. Case history Male/58, busy Paediatrician
Musculoskeletal pains of chronic duration-neck pain, LBP, knee, ankle, shoulder, elbow, wrist pains and extensor tenosynovitis of left hand
h/o of chikungunia
No medical illness in past
Treated with NSAIDs and allopurinol with partial relief
Investigations normal except transient rise in serum uric acid

3. Clinical pictures

4. Shoulder Xrays

5. USG SHOULDER

6. Xrays

7. IS IT GOUT?
S URIC ACID
Clinical picture of joint pains of unexplained etiology
Clinical response to NSAIDs and/or allopurinol?
Xray  arthritic changes

8. Gold standard Aspiration and demonstrated crystals
If negative revise the diagnosis
JAPI-feb Post-Chikungunya Chronic arthritis-our experience with DMARDs over 2 yr f/u

9. Post chikungunya chronic arthritis (PCCA)
Onset- febrile polyarthritis
H/o affection of multiple family members
DIP joint involved
Typical soft tissue pain
Edema hands and feet
Seronegativity in majority
Synovial biopsy- nongranulamatous chronic synovitis
JAPI-feb Post-Chikungunya Chronic ar-our experience with DMARDs over 2 yr f/u

10. PCCA Treatment NSAIDs for symptom relief
Low dose steroids – for control of synovitis and edema of hands and feet
HCQ and SSZ combination
MTX added- majority showed good improvement
JAPI-feb 2011 PCCA -our experience with DMARDs over 2 yr f/u

11. RESULT