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Endgames Case Review

Polyarthralgia in a young woman

BMJ 2017; 358 doi: (Published 31 August 2017) Cite this as: BMJ 2017;358:j3561
  1. Raju Vaishya, senior consultant, orthopaedics1,
  2. Amit Kumar Agarwal, consultant, orthopaedics1,
  3. Sujeet Kumar Singh, deputy director general2,
  4. Vipul Vijay, consultant, orthopaedics1,
  5. Raman Sardana, senior consultant, microbiology1
  1. 1Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
  2. 2Ministry of Health and Family Welfare, Government of India, Nirman Bhawan, New Delhi, India
  1. Correspondence to AK Agarwal amitorthopgi{at}

A 22 year old Indian woman presented to the orthopaedic clinic with excruciating pain and swelling in multiple joints (knee, ankle, wrist, and elbow) for the past two weeks. She also had on and off high grade fevers for the past month, associated with a rash all over her body. There were no ophthalmic or urinary symptoms. Investigations on presentation to the clinic showed anti-chikungunya immunoglobulin M and G antibodies. She had been managed with simple analgesia.

At the current presentation, on examination, her joints were mildly swollen and tender (fig 1). Plain radiographs of the hand, knee, and ankle did not show any juxta-articular osteopenia or bone erosion.

Fig 1

Asymmetrical swelling of knees (right more than left)

The results of a full blood count showed a haemoglobin of 120 g/L (reference range 135-180 g/L), total leucocyte count of 8700 cells/µL (3500 to 10 500 cells/µL). Her erythrocyte sedimentation rate (15 mm/h) and C reactive protein (0.5 mg/L) were found to be within normal limits. Rheumatoid arthritis factor, antibodies against the cyclic citrullinated protein, antinuclear antibodies, and human leucocyte antigen B27 were also negative.


  • 1. What is the differential diagnosis for polyarthralgia in a patient with a recent history of fever and rash?

  • 2. What is the differential diagnosis of …

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