How to manage chronic synovitis and inflammation?

Question

Hi doctor,

I am a 79-year-old female with a history of right knee pain that has lasted for six months. I was scheduled for a total knee replacement (TKR) due to osteoarthritis in my right knee. Before the surgery, I underwent an ultrasound of my abdomen and pelvis, which came back normal.

Doctors initially diagnosed me with right knee osteoarthritis with suspected chronic synovitis. During the TKR, the surgeons discovered necrotic synovial hypertrophy while operating. Because of this finding, they abandoned the TKR and instead performed a synovectomy.

The histopathology report after the surgery confirmed that I had chronic synovitis. An antinuclear antibody (ANA) test was negative, and the synovial culture showed no bacterial growth.

When I went for follow-up blood tests, my C-reactive protein (CRP) level was 13 mg/L, and my erythrocyte sedimentation rate (ESR) was 140 mm/h. Later, I began experiencing severe pain in my right knee again, along with hypoglycemia, which required emergency treatment.

The laboratory tests conducted during this time showed that my interleukin-6 level was elevated at 22 (the normal range is up to 7), my CRP was significantly raised at 172 mg/L, and my procalcitonin level was 0.08, which is low and typically indicates no sepsis.

My liver function tests were within normal limits, and my complete blood count (CBC) was normal, except for low hemoglobin levels. Both my ANA immunofluorescence and anti-CCP tests were negative.

I have been diagnosed as a person with diabetes and have been on medication for it. Since my surgery, I have had recurrent episodes of hypoglycemia leading to an admission for hypoglycemia.

My latest working diagnosis is atypical giant cell arteritis. I was started on Wysolone (a corticosteroid) and initially felt some improvement in my symptoms, but they returned after about seven days.

Now I am wondering if this could indicate a post-surgical or occult infection in my knee, even though the cultures were negative and my procalcitonin level is low, especially considering my high CRP and IL-6 levels.

I am also concerned that there might be a misdiagnosis between chronic synovitis, atypical giant cell arteritis, or another inflammatory or rheumatologic condition.

1. What diagnosis fits my situation best, considering my symptoms?

2. What are the next steps I should take for evaluation and management of my condition?

3. How should I balance my steroid use, given my diabetes and recurring hypoglycemia?

4. What should I do about the fluctuating symptoms I am experiencing?

Please guide.

Answer 1

Hi,

Welcome to icliniq.com.

I read your query and understand your concern.

I have reviewed all the tests and history (attachments removed to protect the patient’s identity).

Let us discuss the possibilities one by one.

The first possibility is a knee infection. This could explain the elevated ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) levels, which are consistent with an infection.

However, there are several points against this diagnosis: there is no redness or significant swelling at the knee joint. While there may be some swelling, it could be attributed to the surgery.

Additionally, the white blood cell (WBC) count is not elevated; typically, an infection would present with increased WBC levels. Furthermore, the culture results are also negative.

Therefore, I believe a knee infection is less likely. The more likely diagnosis is an inflammatory condition, such as giant cell arteritis or another type of inflammatory arthritis.

These conditions often present with raised ESR and CRP levels, while the WBC count usually remains normal. In giant cell arteritis, patients often experience forehead pain, and a confirmed diagnosis can be made only through biopsy.

Although it is less common, the knee joint can sometimes be affected. Regardless of the specific inflammatory condition, the treatment approach is generally the same.

Initially, steroids are administered along with DMARDs (disease-modifying antirheumatic drugs), and if there is no improvement, biological therapies may be considered.

I recommend consulting a reputable rheumatologist, as these medications should be prescribed in person.

While taking steroids, regularly monitor blood sugar levels at home. Please keep a record of these readings and check her HbA1c (glycated hemoglobin) levels every three months.

If the HbA1c is elevated, her medications may need to be adjusted.

I hope I have addressed all your questions. If there is anything else, please let me know.

Thank you.