It's the Presentation, Stupid: A Patient Is Not a Lab Test
The patient was quite well and active until December 2011, when he developed severe fatigue and low-grade fever. In January 2012, he developed right shoulder and right upper-quadrant abdominal pain; he described the former as if he had a nail being driven into his shoulder. He also developed left wrist pain and swelling. This pain has been persistent throughout his illness.
At the end of January 2012, the right abdominal pain resolved, and the same pain occurred in the left abdominal area; the patient also developed pain in his chest radiating from the shoulders. In February 2012, he was unable to lie down owing to severe pressure and pain in his chest. He had trouble getting out of bed and had to use a heating pad daily.
Because of the severe anterior chest pain, the patient was seen in an emergency department in February 2012. Chest radiography and CT of the chest and abdomen done at that time were negative. He was treated with codeine without improvement. By the next morning, the patient developed severe chest pain; he was seen in another emergency department and was admitted to the hospital for 4 days for the treatment of jaundice, fever, and chest pain.
His temperature was 103°F, and echocardiography showed mild pericarditis that was thought to be related to a viral syndrome. Over the next week, the patient's condition improved, with decreased pain and fever, but he was still fatigued.
On March 19, 2012, doctors removed 1.5 L of pleural fluid from the left lung area. Cytologic examinations were negative. Liver enzyme levels were elevated, but CT of the chest, abdomen, and pelvis was negative. Bone scan was negative. Erythrocyte sedimentation rate was 84 mm/h, and the C-reactive protein level was 10.6 mg/L. The hemoglobin level was 9.7 g/dL, white blood cell count was 15,000 cells/μL, and platelet count was 220 × 10 cells/µL.
In April 2012, the patient was seen by a rheumatologist, who thought he might have an autoimmune problem. A liver biopsy on April 16, 2012, showed fatty liver and stage IV cirrhosis and changes consistent with autoimmune hepatitis. During hospitalization, the patient's white cell count was as high as 15,000 cells/μL, with a mildly elevated proteinase 3 antibody level, a hematocrit of 36%, and an erythrocyte sedimentation rate of 60 mm/h. Antinuclear antibody (ANA) testing was negative and a perinuclear antineutrophil cytoplasmic antibody (ANCA) titer was positive.
Two weeks after discharge, the patient developed severe left-groin tenderness with testicular pain, swelling, and hardness. He was seen in a local emergency department and was then admitted because of masses in both testicles. Over the next few days, the patient's pain in his testicles improved significantly; he took only ibuprofen during this time and was not prescribed antibiotics. On April 25, 2012, he was seen by a urologist at a cancer hospital; this specialist thought that the swelling in the testicles was cystic and inflammatory in type. The patient then was given a 1-month course of ciprofloxacin, with improvement.
Currently, the patient has severe fatigue and general muscle and joint pains, with left wrist discomfort in particular. He does not have fever. He has never had Raynaud phenomenon, red or painful eyes, dry eyes or dry mouth, mouth or nasal sores, difficulty swallowing, psoriasis, or colitis. He lost 30 lb between January and April 2012.
Case Presentation
The patient was quite well and active until December 2011, when he developed severe fatigue and low-grade fever. In January 2012, he developed right shoulder and right upper-quadrant abdominal pain; he described the former as if he had a nail being driven into his shoulder. He also developed left wrist pain and swelling. This pain has been persistent throughout his illness.
At the end of January 2012, the right abdominal pain resolved, and the same pain occurred in the left abdominal area; the patient also developed pain in his chest radiating from the shoulders. In February 2012, he was unable to lie down owing to severe pressure and pain in his chest. He had trouble getting out of bed and had to use a heating pad daily.
Because of the severe anterior chest pain, the patient was seen in an emergency department in February 2012. Chest radiography and CT of the chest and abdomen done at that time were negative. He was treated with codeine without improvement. By the next morning, the patient developed severe chest pain; he was seen in another emergency department and was admitted to the hospital for 4 days for the treatment of jaundice, fever, and chest pain.
His temperature was 103°F, and echocardiography showed mild pericarditis that was thought to be related to a viral syndrome. Over the next week, the patient's condition improved, with decreased pain and fever, but he was still fatigued.
On March 19, 2012, doctors removed 1.5 L of pleural fluid from the left lung area. Cytologic examinations were negative. Liver enzyme levels were elevated, but CT of the chest, abdomen, and pelvis was negative. Bone scan was negative. Erythrocyte sedimentation rate was 84 mm/h, and the C-reactive protein level was 10.6 mg/L. The hemoglobin level was 9.7 g/dL, white blood cell count was 15,000 cells/μL, and platelet count was 220 × 10 cells/µL.
In April 2012, the patient was seen by a rheumatologist, who thought he might have an autoimmune problem. A liver biopsy on April 16, 2012, showed fatty liver and stage IV cirrhosis and changes consistent with autoimmune hepatitis. During hospitalization, the patient's white cell count was as high as 15,000 cells/μL, with a mildly elevated proteinase 3 antibody level, a hematocrit of 36%, and an erythrocyte sedimentation rate of 60 mm/h. Antinuclear antibody (ANA) testing was negative and a perinuclear antineutrophil cytoplasmic antibody (ANCA) titer was positive.
Testicular Involvement
Two weeks after discharge, the patient developed severe left-groin tenderness with testicular pain, swelling, and hardness. He was seen in a local emergency department and was then admitted because of masses in both testicles. Over the next few days, the patient's pain in his testicles improved significantly; he took only ibuprofen during this time and was not prescribed antibiotics. On April 25, 2012, he was seen by a urologist at a cancer hospital; this specialist thought that the swelling in the testicles was cystic and inflammatory in type. The patient then was given a 1-month course of ciprofloxacin, with improvement.
Currently, the patient has severe fatigue and general muscle and joint pains, with left wrist discomfort in particular. He does not have fever. He has never had Raynaud phenomenon, red or painful eyes, dry eyes or dry mouth, mouth or nasal sores, difficulty swallowing, psoriasis, or colitis. He lost 30 lb between January and April 2012.