Fever, fatigue and chest ...

A 54-year-old man with H/o smoking, past pulmonary tuberculosis and recent seropositive and erosive RA associated with Sjögren’s syndrome presented to our hospital with fever, fatigue and chest pain that had started one week prior. 

Physical examination found a BP of 100/60mmHg in both arms. He had tachycardia, with a high temperature of 38.5°C. Movement of the elbows, wrists and shoulders was painful. He had rheumatoid nodules on the external side of both elbows. In addition, he had a dislocation of the right ulnar styloid. The rest of the physical examination was regular. An electrocardiogram showed atrial fibrillation with 115 beats per minute associated with diffuse ST-segment elevation with upward concavity.

Blood tests showed hyper leucocytosis at 11000/mm3, CRP of 117 mg, ESR of 118mm and cholestasis. A chest X-ray revealed a flask-shaped enlarged cardiac silhouette. A non-compressive large posterior pericardial effusion was confirmed by Transthoracic echocardiography. CT scan showed pericardial effusion with enhancing the pericardium, compatible with pericarditis, and regular parietal hypodense circumferential thickening of the aortic arch and supra-aortic arterial trunk root, confirming aortitis as shown n figure. There was evidence of emphysema in the pulmonary parenchyma but no active tuberculosis on chest CT. Liver biopsy indicated peliosis with no sign of auto-immune hepatitis nor auto-immune biliary cholangitis.