0:01

<v ->And the third case,

0:03

is the case that I missed the diagnosis.

0:06

That is a 55 year old man

0:12

that came with ankle pain in the calcaneal region.

0:27

And we can see

0:30

enthesitis of the Achilles tendon,

0:37

inflammatory process around the tandem,

0:44

small bursitis, retro, calcaneal bursitis.

0:52

And at that time we could see

0:59

tenosynovitis

1:03

of the posterior tibial tendon,

1:07

tibialis tendon.

1:08

It maybe a small tear.

1:14

I thought at that time

1:16

that he had just a mechanical enthesitis,

1:21

cause we see just one tendon.

1:27

He used to play soccer when he was younger

1:31

and he had some pathologic tibialis tendon.

1:35

Posterior tibialis tendon.

1:38

Well,

1:40

he came back

1:42

one year later

1:45

With bilateral carpal tunnel syndrome symptoms.

1:50

I made just some images

1:54

that I'll show you now.

2:00

We have symmetrical wrist joints in synovial hypertrophy,

2:06

both sides.

2:13

We have bursitis in the flexor compartment

2:17

bilateral.

2:23

And he had no

2:26

bone erosions,

2:35

just synovial proliferation and bursitis.

2:45

At that time,

2:46

maybe

2:48

one month later,

2:51

he get

2:52

examinations of rheumatoid arthritis, positive.

2:57

Until then they didn't know

3:00

exactly what was his disease.

3:03

And obviously I made a, a mistake

3:06

in the diagnosis of enthesis in the calcaneal insertion.

3:13

So,

3:14

and

3:16

this was evolution of this case of rheumatoid arthritis.

3:23

Donald,

3:24

you have any comments?

3:25

<v ->Well, I, you know,

3:27

what we do is we learn the rules

3:32

and then we come across the exceptions to the rules

3:35

which make you always wonder.

3:37

You're showing features that look so much more like

3:41

you know, what we see with a spondyloarthropathy

3:45

than they do with rheumatoid arthritis.

3:49

Whether or not this patient later on might develop

3:53

both diseases or something.

3:55

You know, I don't know, but

3:58

it just, I certainly have seen mild enthesitis

4:04

in, in, you know, rheumatoid,

4:06

but I have never seen, you know

4:09

as a profound finding in rheumatoid.

4:12

And I think, what you're showing in this case

4:16

is a lot of tenosynovitis

4:19

before the typical compartments of the wrist

4:22

become involved,

4:23

and bone erosions haven't developed.

4:26

So there are a lot of atypical

4:28

features here that I would

4:30

imagine are difficult.

4:31

Now I'm curious,

4:32

the diagnosis of rheumatoid

4:35

were made serologically and clinically,

4:38

how did they establish them?

4:40

<v ->Serologically.

4:42

<v ->Serologically?

4:43

<v ->Yeah.

4:44

<v ->Okay, and they had no doubt that there was, you know-

4:48

<v ->He's, he's treating until now,

4:50

and he's pretty, pretty better.

4:52

<v ->Yeah. Okay.

4:54

I, I don't have an answer for cases like this.

4:57

I think

4:58

it just shows you that there are exceptions

5:01

to the rule

5:02

and you can only

5:03

apply the rules as best you can

5:06

and hope that you're not dealing with an exception.

5:10

But I would've struggled with these

5:11

with these cases, coming up with the correct diagnosis

5:14

which seems to be the comment that I'm giving you

5:17

for a lot of your cases,

5:19

that I would've struggled with them.