Persistent pulmonary lesion in a patient with rheumatoid arthritis.
Authors: F Buttgereit, K Kunzel, H J Tietz, K Sajkiewicz, K Gellert, F Hiepe, G R Burmester
Journal: Annals of the Rheumatic Diseases (1994)

Case report In June 1993 a 63 year old man attended hospital complaining of acute dizziness. He also reported a three week history of left-sided chest pain. In 1987 the patient had been diagnosed as having seropositive rheumatoid arthritis. He had initially been treated with non-steroidal anti-inflammatory drugs and gold salts, and since 1991 with prednisolone up to 10 mg daily. In June 1988 a melanoma had been totally excised from the right anterolateral chest wall. Subsequent regular follow up visits had not revealed evidence of recurrence or metastases. In March 1989 the patient was found to be suffering from refractory anaemia and a myelodysplastic syndrome was subsequently confirmed by iliac crest bone marrow biopsy. The patient was treated with regular transfusions of red cell concentrates and administration of desferrioxamine mesylate. In January 1992 the patient was diagnosed as having non-insulin-dependent diabetes. On initial examination the patient was clinically anaemic. Arthritic changes were present in the hands. Chest percussion elicited dullness at the left base, and fine to medium crackles were audible on auscultation. The patient's temperature was normal. Abdominal examination revealed marked hepatosplenomegaly. The erythrocyte sedimentation rate was 98 mm/h and the C reactive protein concentration clearly increased, at 103 mg/l. On serum electrophoresis, the O2 and y globulin fractions were relatively increased with respect to albumin. The following abnormalities were seen in whole blood: haemoglobin 6-7 g/dl, packed cell volume 21%, red cells 2-4 X 1012/1, white cells 2-0 X 109/1, platelets 113 x 109/1. The differential count showed a moderate left shift with no eosinophilia. In the chest x ray, a small effusion was seen at the left base, accompanied by infiltrate changes with no air rim in the left lower zone (fig 1). Abdominal ultrasound permitted quantification of the hepatosplenomegaly, but showed no evidence of lymphoma or metastases. After admission of the patient to hospital, the anaemia was rapidly corrected with transfusions. On the suspicion of bacterial pneumonia, antibiotic therapy was instituted with ciprofloxacin. Cultures and serological testing elicited no evidence of infection with Mycoplasma, Legionella, Chlamydia, Mycobacterium tuberculosis or other bacterial pathogens. Mycological serology was likewise negative for Candida and Aspergillus. The leftsided chest pain improved markedly in response to antibiotic treatment, and the patient felt well and remained without fever. However, the repeat chest x ray film showed an unaltered pathological appearance, and there was only a slight regression of inflammatory indices. The patient's medication was therefore changed to a combined antibacterial-antifungal regimen of piperacillin, flucloxacillin and fluconazole. Subsequently, repeated bronchoscopies showed a macroscopically unremarkable bronchial system. On thoracic computed tomography, the pneumonic infiltrate was confirmed in the 9th and 10th left segments. Samples were obtained on several occasions by bronchoalveolar lavage and CT assisted aspiration. However, apart from isolated findings of Candida albicans and Candida glabrata in small concentrations, no pathogenic organisms were demonstrated by culture or serology. No tumour cells were detected. Fontana staining for melanin, performed because of the suspicion of melanoma metastases, was consistently negative. At the last bronchoscopy, clear signs of active cytomegalovirus infection were detected in the lavage fluid. In view of this constellation of findings, with only slight radiographic improvement, the treatment was again changed, this time to itraconazole (in view of the presence of Candida glabrata and possible aspergillosis') and imipenem (because of the possibility of nocardiosis). Cytomegalovirus specific immunoglobulin was also given. Pharmacological alternatives, such as ganciclovir or amphotericin B, were withheld in view of the existing myelodysplastic syndrome.