A Tricky Case of Arm Pain and a Swollen Ear

Stephen Paget, MD

Disclosures

July 27, 2016

Patient Profile

I recently saw a 52-year-old woman who had presented to her local doctor 3 months earlier with significant swelling, redness, and tenderness of the upper aspect of the right ear that lasted a few days and eventually resolved.

During the previous year, she experienced intermittent episodes of pain without redness, warmth, swelling, or significant functional limitation in the fingers, toes, and right sternoclavicular joint. She is also affected by mild fatigue and has to take a nap in the middle of the day.

The possibility of polychondritis was considered, but the patient has had no recurrence and has experienced no nasal, tracheal, internal ear, or eye inflammation.

When I first saw the patient, her physical examination was normal and the following laboratory tests were negative or normal: chemistry screen, complete blood count, thyroid-stimulating hormone, C-reactive protein, erythrocyte sedimentation rate, antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide antibodies to extractable nuclear antigens. The test for anti-Sjögren syndrome A was weakly positive.

The patient returned 1 month later with intermittent joint pain, particularly in the shoulders, without redness, warmth, or swelling of the wrists, hands, ankles, or feet. She had some mild redness on the outside of her ears, more prominently on the left ear, but it was nowhere near the acute inflammation she had experienced in the past. She took ibuprofen on an as-needed basis for her ear and joint symptoms.

The next month, the patient returned and reported increased intensity and frequency of short-lived episodes of redness, tenderness, and warmth of both ears, not involving the lobules. She had developed a parvovirus B19 infection after her son became infected, which she characterized as the presence of a "slapped cheek" rash on her face and a lacy red rash on her arms and legs. Four days after the onset of the rash and increased symmetrical joint pain and swelling of the hands, wrists, ankles, and feet, she developed severe burning, searing, and incapacitating pain in her left shoulder, upper arm, and neck. She tried ibuprofen, acetaminophen, Percocet®, Vicodin®, and gabapentin because of the intensity of pain in her left shoulder and arm. She reported a slow improvement in pain by about 50% and in the development of left upper extremity weakness. MRI of the brachial plexus and shoulder showed intramuscular denervation changes involving one or more muscle groups of the shoulder girdle. Most involved were the supraspinatus and infraspinatus muscles.

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