embolism, for small-moderate pericardial effusion, and loculated pleural effusion. Echocardiography showed an EF of 60% and pericardial effusion. Physical exam with decreased breath sounds, no rales, (+1) pitting edema in bilateral lower extremity, no jugular venous distention appreciated. Patient with a constellation of symptoms including polyarthralgias, pleural effusion, and shortness of breath and an isolated finding of pericardial effusion, autoimmune workup was initiated. Workup revealed ANA positivity (1:2560, homogenous), Anti-DsDNA (+), Anti- Histone (+). Patient not on any offending agents to indicate drug induced lupus. Low C4 levels, and Rheumatology consulted and with findings consistent with acute lupus flare. Patient was started on hydroxychloroquine and prednisone. Thoracentesis was performed due to no improvement in shortness of breath and labs were consistent with
exudative effusion thus furthering confirmation of lupus diagnosis. Inpatient bronchoscopy was completed to rule out pneumonitis workup which revealed erythema throughout the tracheobronchial tree. Additional work up for HIV, hepatitis panel, fungitell and fungal immunodiffusion, and respiratory infection panel were negative. Over the course of hospital stay patient showed significant improvement in symptoms. Pt was discharged on hydroxychloroquine and prednisone with a follow up to rheumatology clinic. Discussion: Acute lupus pneumonitis is often described as being a rare manifestation of SLE, affecting 1%–4% of cases, with poor prognosis. Its clinical presentation is similar to pneumonia. Diagnosis is typically with imaging and treatment of acute lupus pneumonitis is systemic corticosteroids.
MYSTERY CASE PRESENTATIONS – RESIDENTS A 42-YEAR-OLD MALE FROM HONDURAS PRESENTED WITH WORSENING LEFT ELBOW, WRIST, AND KNEE PAIN: DISSEMINATED MYCOBACTERIUM TUBERCULOSIS
COMPLEX IN A PATIENT DIAGNOSED WITH DERMATOMYOSITIS. Carl Haupt, Danielle Aliano, Austin Tutor, Andrew Guthrie; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Disseminated tuberculosis is the clinical syndrome that results from hematogenous or lymphatic spreading and accounts for 15- 20% of cases. Biologic agents and existing immunocompromised can result in increased prevalence. Age, underlying medical conditions such as malignancy, alcohol abuse, renal disease, diabetes, pregnancy, connective tissue disease, and corticosteroid use can also increase prevalence. Case: A 42-year-old male from Honduras presented with worsening left elbow, wrist, and knee pain associated with fever and fatigue which had been intermittent for 9 months. Prior rheumatologic workup showed positive MDA5, ANA, and anti- smooth muscle antibodies. Muscle biopsy showed myopathy with necrotizing granulomas, denervation atrophy, and mitochondrial dysfunction. GMS, Gram, and AFB stains were negative. Quantiferon gold, fungitell, bartonella, brucella, and toxoplasma were negative. The patient was being treated with steroids at the time of presentation. On examination, the patient was febrile to 103°F, tachycardic to 142, and exquisitely tender in the left wrist, forearm,
and knee. X-ray of the knee showed a suprapatellar effusion. MRI of the forearm showed extensive soft tissue inflammation concerning for necrosis. Labs were notable for ALT 62 U/L (reference range, 10-44 U/L), lactate 3.2 mmol/L (reference range, 0.5-2.4 mmol/L), CRP 66.9 mg/L (reference range, 0-8.2 mg/L), ESR 57 (reference range, 0-23 mg/L), and CK 244 U/L (reference range, 20-200 U/L). Joint tap was unremarkable. Muscle biopsy showed no pathologic abnormality. Karius test was positive for mycobacterium tuberculosis complex. AFB showed mycobacterium tuberculosis complex. After a 14- day hospitalization, the patient was discharged to home isolation on rifampin, isoniazid, pyridoxine, and ethambutol with follow-up at infectious disease and tuberculosis clinics. Unfortunately, the patient has been unable to tolerate therapy resulting in repeat hospital admissions. Discussion: Disseminated TB is exceedingly rare in immunocompetent patients and accounts for 1-2% of cases.
Treatment consists of a 6-9 month regimen; generally
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