Case Study: Kevin Presents Arthritis, Diabetes, Angina
Kevin was a 58-year-old disabled tree faller who presented with several health problems including stable angina, diabetes mellitus, rheumatoid-like arthritis, and a generalized fatigue that was not relieved with rest.
Kevin’s problems began when he underwent carpal tunnel syndrome repair at age 53. During the procedure, he had a minor heart attack which resulted in extended hospitalization. During this time, it was discovered that Kevin’s blood sugars were elevated. He was placed on oral medication for diabetes mellitus as well as on nitroglycerin and a beta-blocker medication for his heart.
Over the next few years, Kevin noticed progressive pain, stiffness, and swelling in his knuckles, shoulders, knees, and ankles. He was referred to a rheumatologist who diagnosed a rheumatoid-like arthritis (previous blood tests were negative for actual rheumatoid arthritis). Kevin then was placed on a powerful drug to stop the inflammation in his joints; nevertheless, he was still unable to carry a bag of groceries because of the pain in his hands. Unfortunately, during the five years before I met Kevin, he developed angina (pain in his chest on exertion, relieved by rest or nitroglycerin spray). He now found that he was able to walk only one-half block before the onset of symptoms.
In the past, Kevin had been generally healthy and very active, and had enjoyed working as a tree faller. He was a nonsmoker and his blood pressure had never been elevated. His cholesterol had always been in the normal range, though several relatives on his father’s side had experienced heart attacks in their 50s and 60s. Mercury seemed not to be an issue (partly – but not only -- because Kevin had all his teeth extracted several decades previously).
When I examined him, Kevin appeared tired and seemed older than his 58 years of age. His skin was a pale gray color, he had evidence of mild chronic swelling of his knuckle joints, and he found it hard to elevate his arms above his shoulders. His knees also appeared chronically swollen. Otherwise, his examination was unremarkable.
I ordered iron indices and was somewhat taken aback at how high the levels were. Transferrin saturation was 65 per cent with normal being 20-55 per cent. Ferritin (the storage form of iron) was 2600 ug/L, with normal being 30-300. Interestingly, Kevin’s serum iron level was 20 umol/L, with normal being 10-33, and if I had ordered only his serum iron level, I would have missed the diagnosis.
- Dr. J.Cline, MD BSc