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History
The patient is a 24-year-old Asian-Indian male who initially presented to a community hospital with a 10-day history of mild hemoptysis (2 -3 tablespoons of blood per day), followed by arthralgias, joint stiffness (knees, shoulders, elbows) and myalgias of the proximal muscles. Moreover, he complained of tactile fevers but denied any rashes. He also complained of a slight occipital headache, pleuritic chest pain (right greater than left), and loose watery diarrhea without hematochezia or melena. An initial chest radiograph showed a left upper lobe infiltrate and hilar adenopathy. The patient was treated for community-acquired pneumonia with Levofloxacin, Ceftriaxone and Azithromycin. He then developed hypoxic respiratory failure requiring 100% oxygen via a non-rebreather mask. A computed tomography of the chest showed diffuse patchy, ill-defined infiltrates and increased interstitial markings at the bases. There was no evidence of pulmonary embolism. He was transferred to a tertiary care hospital.
His past medical history was significant for exercise-induced asthma, diagnosed 1 year prior to presentation. He infrequently used a short-acting β2-agonist. He was also diagnosed with ulcerative colitis 2 years prior. He presented with a single bloody stool, after which he had several colonic biopsies. Initially, these were thought to be diagnostic of ulcerative colitis. On retrospective review at the tertiary care center, the biopsies showed diffuse eosinophilic infiltration and inflammation, and were not consistent with a diagnosis of ulcerative colitis. He tested positive for c-ANCA antibody in 2006. He was treated for minimal change disease in childhood.
He denied tobacco, alcohol or illicit drug use. He denied any recent travel. He did not have any pets.
Family history was unremarkable.
His current medications included mesalamine 1600 mg twice daily and a short-acting β2 -agonist as needed.
His past medical history was significant for exercise-induced asthma, diagnosed 1 year prior to presentation. He infrequently used a short-acting β2-agonist. He was also diagnosed with ulcerative colitis 2 years prior. He presented with a single bloody stool, after which he had several colonic biopsies. Initially, these were thought to be diagnostic of ulcerative colitis. On retrospective review at the tertiary care center, the biopsies showed diffuse eosinophilic infiltration and inflammation, and were not consistent with a diagnosis of ulcerative colitis. He tested positive for c-ANCA antibody in 2006. He was treated for minimal change disease in childhood.
He denied tobacco, alcohol or illicit drug use. He denied any recent travel. He did not have any pets.
Family history was unremarkable.
His current medications included mesalamine 1600 mg twice daily and a short-acting β2 -agonist as needed.
Physical Exam
(Upon arrival to the tertiary care center):
On physical examination he was afebrile with a temperature of 97.4 °F, tachycardic with a pulse 108 beats per minute, tachypneic with a respiratory rate of 24 breaths per minute. He was normotensive. He appeared to be in mild respiratory distress but was awake, alert and appropriate. He had no oral ulcers. There was no central cyanosis. There was no palpable cervical, supraclavicular or axillary lymphadenopathy. On pulmonary examination he had dense expiratory wheezing diffusely. There was no stridor. Cardiac examination revealed tachycardia but no murmurs, rubs or gallops. Abdomen was soft with presence of bowel sounds. There was no hepatosplenomegaly. His joints were non-tender, not warm to touch and free of swelling or deformity. He had a purplish, flat, macular rash on his palms. The extremities were free of clubbing, cyanosis or edema.
Significant labs/tests from the community hospital:
White blood cell count 19,800/mm3, Hemoglobin 15.2 g/dl, Platelet count 175,000/mm3
Differential significant for 35% eosinophils
Creatinine 1.4 mg/dl, cardiac troponin 2.2 ng/ml, creatinine kinase 860 U/L, AST 214 U/L, ALT 81 U/L, Total bilirubin 0.7 mg/dl, INR 1.38 seconds
ESR 14 mm/hr, CRP 11.7 mg/dl
Urinalysis significant for 3+ amorphous sediment, 1+ protein, no blood
EKG showed sinus tachycardia with a right bundle branch block
Testing at tertiary care hospital:
On physical examination he was afebrile with a temperature of 97.4 °F, tachycardic with a pulse 108 beats per minute, tachypneic with a respiratory rate of 24 breaths per minute. He was normotensive. He appeared to be in mild respiratory distress but was awake, alert and appropriate. He had no oral ulcers. There was no central cyanosis. There was no palpable cervical, supraclavicular or axillary lymphadenopathy. On pulmonary examination he had dense expiratory wheezing diffusely. There was no stridor. Cardiac examination revealed tachycardia but no murmurs, rubs or gallops. Abdomen was soft with presence of bowel sounds. There was no hepatosplenomegaly. His joints were non-tender, not warm to touch and free of swelling or deformity. He had a purplish, flat, macular rash on his palms. The extremities were free of clubbing, cyanosis or edema.
Significant labs/tests from the community hospital:
White blood cell count 19,800/mm3, Hemoglobin 15.2 g/dl, Platelet count 175,000/mm3
Differential significant for 35% eosinophils
Creatinine 1.4 mg/dl, cardiac troponin 2.2 ng/ml, creatinine kinase 860 U/L, AST 214 U/L, ALT 81 U/L, Total bilirubin 0.7 mg/dl, INR 1.38 seconds
ESR 14 mm/hr, CRP 11.7 mg/dl
Urinalysis significant for 3+ amorphous sediment, 1+ protein, no blood
EKG showed sinus tachycardia with a right bundle branch block
Testing at tertiary care hospital:
Lab
White blood cell count 23,200/mm3, Hemoglobin 16.8 g/dl, Platelet count 214,000/mm3
Differential: 86% segmented neutrophils, 7% lymphocytes, and 5% eosinophils
Creatinine 1.1 mg/dl, cardiac troponin 18.2 ng/ml, creatinine kinase 526 U/L, AST 88 U/L, ALT 61 U/L, INR 1.2 seconds
ESR 15 mm/hr, CRP 13 mg/dl
ANA, SS-A, SS-B, c-ANCA, p-ANCA, Scl-70, ds DNA, glomerular base membrane, sm/RNP antibodies all negative
RF was mildly elevated at 49 IU/ml
C3, C4, CH50 complement levels within normal limits
Mycoplasma IgG antibody was equivocal
Legionella urinary antigen negative
IgE 2140 IU/mL (elevated)
IgG within normal limits
TSH within normal limits
Hepatitis panel negative
HIV-1/2 antibody negative
Studies:
Echocardiogram: dilated left ventricle with left ventricular ejection fraction of 20%; moderate to markedly increased wall thickness with a speckling pattern; mild to moderate mitral regurgitation; dilated left atrium; dilated right ventricle with estimated systolic pressure of 45mmHg; small pericardial effusion.
Venous duplex ultrasound of bilateral upper and lower extremities was negative for deep vein thrombosis.
Differential: 86% segmented neutrophils, 7% lymphocytes, and 5% eosinophils
Creatinine 1.1 mg/dl, cardiac troponin 18.2 ng/ml, creatinine kinase 526 U/L, AST 88 U/L, ALT 61 U/L, INR 1.2 seconds
ESR 15 mm/hr, CRP 13 mg/dl
ANA, SS-A, SS-B, c-ANCA, p-ANCA, Scl-70, ds DNA, glomerular base membrane, sm/RNP antibodies all negative
RF was mildly elevated at 49 IU/ml
C3, C4, CH50 complement levels within normal limits
Mycoplasma IgG antibody was equivocal
Legionella urinary antigen negative
IgE 2140 IU/mL (elevated)
IgG within normal limits
TSH within normal limits
Hepatitis panel negative
HIV-1/2 antibody negative
Studies:
Echocardiogram: dilated left ventricle with left ventricular ejection fraction of 20%; moderate to markedly increased wall thickness with a speckling pattern; mild to moderate mitral regurgitation; dilated left atrium; dilated right ventricle with estimated systolic pressure of 45mmHg; small pericardial effusion.
Venous duplex ultrasound of bilateral upper and lower extremities was negative for deep vein thrombosis.
Figures
Figure 1: Admission posterior-anterior (PA) chest radiograph showing bibasilar patchy opacities with obscured diaphragms and an enlarged cardiac silhouette suggesting cardiomegaly.
Figure 2: CT Sinus: showing opacified left inferior maxillary sinus.
Case Editor - Jeremy Falk
Reviewed By Clinical Problems Assembly
Submitted by
Parag B. Desai, MD
Jason Krahnke, DO
A. James Mamary, MD
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