Acute pneumonitis or vasculitis? A severe case with multiple organ involvement

Abstract

A 37-year-old man was admitted to our unit in June 2014 with a three-month history of fever and arthralgia, and with one transient episode of arthritis affecting the left ankle some weeks before and localized erythema of the same leg, probably erythema nodosum. He had no relevant anamnestic history apart from inhalant allergy.In March he underwent a specialist evaluation for arthralgia with the prescription of blood tests [rheumatoid factor (RF) was positive, whereas anti-CCP, ANA, ENA, native-dsDNA antibodies and HLA B27 were negative] and of thyroid scintigraphy (never performed), because echographic signs of thyroiditis and positive thyroid antibodies were found.Although he did not complain of dyspnea, he had a non-productive cough, tiredness and joint stiffness.There were right-sided crackles on respiratory examination, while other observations were normal.Chest x-ray showed perihilar pneumonitis in the right lung with a well-defined margin area.Laboratory tests revealed an increase in inflammatory markers [C-reactive protein: 15.63 mg/dL (>5 mg/dL positive)], moderate leukocytosis with eosinophilia [white blood count: 10,690/µL, eosinophils 17.76% (1900/µL)], thrombocytosis [platelets: 507,000 K/µL], positive RF [125.39 IU/mL (>20 IU/mL, positive)], ferritin 817.4 ng/mL (25-300 ng/mL), mild alteration of renal function tests (serum creatinine: 1.41 mg/dL), proteinuria (1 g/L) and microhematuria (erythrocytes 250/kL) in the urine test.We observed positive anti-neutrophil cytoplasm antibody (ANCA) and PR-3 ANCA antibodies (PR-3 ANCA >8 U/mL positive and MPO ANCA antibodies were negative).The patient was treated with large spectrum antibiotics (ampicillin/sulbactam and azithromycin), but we suspected a multisystemic disorder because of the involvement of several organs. As the first symptom was fever and then arthralgia with a transient episode of erythema nodosum, with contemporary involvement of the lung (with cough and later dyspnea) and kidney (with proteinuria and microhematuria), we decided to perform second level tests.The high-resolution chest computed tomography (CT) showed interstitial lung disease and more consolidative areas, some of which had a reverse halo sign Acute pneumonitis or vasculitis? A severe case with multiple organ involvement ABSTRACTThis report describes a case of a 37-year-old man affected by weakness, cough, fever and arthralgia for three months and a single episode of arthritis affecting the left ankle. The symptoms worsened and he was admitted to our hospital. First level blood tests showed an increase in inflammatory proteins, leukocytosis with eosinophilia, positive anti-neutrophil cytoplasm antibody (ANCA) and PR-3 ANCA antibodies, initial renal failure with elevation of creatinine and microscopic hematuria and initial proteinuria in the urine tests. As the chest x-ray revealed a perihilar pneumonitis with a well-defined margin area in the right lung, we started antibiotic therapy. The lung was studied with high-resolution chest computed tomography, which showed interstitial...