Saint Elizabeth’s Hospital
Jonathan Smith - 1st year resident
Brenda Jenkins - Attending
Miss Melany Jones
28
unknown
- fever of unknown origin - past 3 months – up to 39°C - no noticeable pattern
- severe upper-back pain that limits movement – started 2 weeks after the fever
- numbness of the sole of the right foot
- difficulty holding heavy objects with either hand
- difficulty with other upper-extremity tasks (combing hair)
- productive cough (yellowish sputum) not related to posture, no diurnal variation
- significant weight loss
- bronchial asthma and chronic bronchitis - no response to multiple courses of antimicrobial treatment (amoxicillin/clavulanic acid, cefotaxime, and levofloxacin)
- 5-year history of asthma - inhaled bronchodilators, occasional aminophylline
- allergic rhinitis (preceded asthma)
- no smoking, traveling or pets.
- uncomfortable and restless
- pulse 110
- BP 110/70
- respiratory rate 25
- chest: crepitations and wheezes throughout both lung fields
- normal heart sounds without evidence of cardiac murmur or friction rub.
- back: severe tenderness of the midline cervical spine, broadening to involve both shoulders down the spine to the 2nd lumbar vertebra
- proximal weakness of both upper limbs
- normal sensory examination of the upper extremities
- normal and symmetric lower extremity sensory motor examination was
- no cervical, axillary, or inguinal lymph node enlargement
- no tenderness, rigidity, ascites, organomegaly, or masses in the abdoen
- no extremity edema
- intact dorsalis pedis, posterior tibialis, and radial pulses
- eosinophilic disorder: Löffler syndrome or chronic eosinophilic pneumonia
- vasculitic condition: Wegener granulomatosis or Goodpasture syndrome
- Churg-Strauss syndrome
CBC, ESR, liver enzymes, creatinine, BUN X-ray of the lungs, urine analysis, CT-scan of the lungs
Bloods
- hemoglobin 12.9
- platelet count 350,000
- white blood cell count 25,000, with 12% eosinophils
- ESR elevated at 65 in the 1st hour
- Liver enzyme findings unremarkable, AST of 35, ALT of 25, serum bilirubin of 0.7
- creatinine normal at 0.5, BUN of 35
- positive rheumatoid factor finding
- urine analysis - infection or proteinuria
Plain chest radiograph: multiple scattered infiltrates in both lungs
High-resolution CT scan showed interstitial lung fibrosis
Churg-Strauss syndrome
- hospitalization
- treatment with prednisolone 45 mg for remission induction
- remission maintenance: 200 mg daily azathioprine commencing with the reduction of the prednisolone therapy.
- two days after the start of therapy, dramatic improvement: sleep normally + serve herself
- back pain, respiratory symptoms, and numbness disappeared
- ESR normal in a few days
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