When I met him nine years ago, Johann was the kind of patient that family physicians dread taking on. He looked twice his 28 years, thanks to a long history of polysubstance abuse, including alcohol, cocaine, and heroin. In addition, he suffered from asthma, anxiety, depression, irritable bowel syndrome and hepatitis C.

Tragically, he was also the father of a two-year-old, HIV-positive boy who had become infected in utero by his mother. Frankly, Johann was not my cup of tea, but I agreed to look after him as a favour to his hepatologist, who is a good friend of mine.

One year later, Johann’s girlfriend left him, taking their son to another province. Johann, without any significant source of income with which to travel, has never seen him again. Despite this and other setbacks in his life, Johann has surprised me with his resiliency, finally even stopping his self-abusive behaviour.

Two years ago, at age 35, Johann developed significant pain in his back, hands and ankles over 6 months. There were no radicular symptoms. Johann had been born with congenital club feet. Radiographs of the affected joints showed considerable osteoarthritis. Serological tests were negative. Liver function tests were, of course, elevated (mildly), the platelets were slightly reduced, and the ESR was 16.

On examination, his face and body showed significant scarring and light bruising. He had very poor oral hygiene and had had a number of dental procedures. There was a soft systolic murmur heard over the prechordium and the neurological exam was normal other than his vision, which had declined significantly over the past two years. Does this constellation of symptoms point to any unifying diagnosis?