A 65-Year-Old Man Comes to the Office for Evaluation of New-Onset

question 343

Multiple Choice

A 65-year-old man comes to the office for evaluation of new-onset pain in the right knee.  The patient first noticed the pain 3 weeks ago after a long hike in the mountains.  The pain has not improved with acetaminophen, and he is now unable to sleep because of it.  He has also had intermittent low-grade fevers.  The patient has Paget disease of bone, which was diagnosed 10 years ago, and type 2 diabetes mellitus.  He drinks alcohol socially but does not use tobacco or illicit drugs.  Temperature is 37.2 C (99 F) , blood pressure is 120/70 mm Hg, and pulse is 80/min.  BMI is 23 kg/m².  The right knee has diffuse soft tissue swelling and a small effusion with no surrounding erythema.  The distal aspect of the thigh is tender to palpation.  X-ray of the right knee reveals medullary and cortical bone destruction with lucent areas and a surrounding periosteal elevation along the distal femur.  Which of the following is the most likely cause of this patient's knee pain?

• A)Borrelia burgdorferi-induced monoarticular arthritis
• B)Destruction and inflammation of articular cartilage
• C)Formation of stress-related microfractures
• D)Malignant proliferation of osteoid sarcomatous stroma
• E)Precipitation of calcium pyrophosphate dihydrate crystals

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