Lesley is a 53-year-old optometrist who presents with three months of pain and swelling affecting both ears.

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<p>Lesley is a 53-year-old optometrist who presents with three months of pain and swelling affecting both ears.</p><p>She has associated finger, wrist and ankle joint stiffness and swelling, and intermittent fever, conjunctivitis, tinnitus and a dry cough, which continue despite a course of amoxycillin and doxycycline.</p><p>Lesley is usually fit and well. She was born in Australia and has never travelled to TB-endemic regions.</p><p>On examination, she has normal vital signs, bilateral auricular atrophy (left ear shown), a saddle nose deformity, and tender, diffusely swollen wrists and multiple finger joints.</p><p>There is no lymphadenopathy, and cardiorespiratory examination is normal.</p><p>Investigations reveal CRP and ESR are elevated, ANA is positive at a titre of 1:160, and there is proteinuria.</p><p>FBC, kidney and liver function are normal and extractable nuclear antigen, rheumatoid factor, double stranded DNA antibodies, anti-CCP and ANCA are negative.</p>

Dr Kate Kelso is a GP and medical editor at Australian Doctor.