Respiratory Distress and Nephropathy in a Young Male With Small‐Joint Polyarthritis

Abstract

History of the present illness. A 27-year-old man presented to our department with a 4-week history of worsening fatigue, malaise, and painful swelling of his wrists and finger joints. He further complained of new-onset progressive dyspnea with nonproductive cough, subfebrile temperatures, and proximal muscle weakness in his lower extremities in the last 10 days. Except for the arthritis, he had not experienced these symptoms in the past. Two months prior to admission, he was seen for the first time by a rheumatologist. At that time, he reported severe pain and stiffness in his hands, particularly at night, but no breathing or muscle difficulties. Laboratory tests at the rheumatologist's office showed increased C-reactive protein (CRP) levels and high-titer anti-cyclic citrullinated peptide (CCP) antibodies. Plain radiographs demonstrated an erosion at the fifth metatarsal head of his right foot. He was diagnosed with rheumatoid arthritis (RA) and started on oral methotrexate (MTX) and prednisone. Medical historyThe patient reported having intermittent arthralgias in his hands, elbows, and hips for the past 3 years. He had been treated with nonsteroidal antiinflammatory drugs and oral glucocorticoids as needed by his primary care provider. In the last couple of months, he increasingly experienced painful arthritis in his hands. After being diagnosed with RA, oral treatment with MTX 15 mg weekly and prednisone 50 mg daily (followed by slow tapering) was initiated, along with prophylactic pantoprazole (40 mg daily) and folic acid (5 mg weekly). He was adherent to the therapy and denied taking over-the-counter drugs or supplements. There were no other medical or surgical illnesses.Social and family history. He used to work as a gardener. His social history was negative for smoking and alcohol abuse. He denied recent travel or contact with someone with similar symptoms. His grandmother had a diagnosis of RA, but his family history was otherwise negative for autoimmune or pulmonary disorders. Review of systems.There was no history of photosensitivity, rash, sicca symptoms, Raynaud's phenomenon, back pain, hemoptysis, dysphagia, or diarrhea.Physical examination. On admission, his temperature was 37.08C, blood pressure 130/80 mm Hg, pulse 105 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation of 95% while breathing ambient air. There was no lymphadenopathy, jaundice, or cyanosis. Auscultation of the lung revealed fine bibasilar crackles. Cardiac (except tachycardia), abdominal, and neurologic examinations were unremarkable. His wrists, metacarpophalangeal, and proximal interphalangeal joints of both hands were swollen and tender with limited range of motion. There was isolated weakness of the thigh muscles (4/5), but no muscle wasting or fasciculations.Laboratory tests and imaging. Initial workup showed a hemoglobin level of 14.5 gm/dl (normal range [NR] 13.5-17.5), white blood cell count of 13.3 3 10 3 /ml (NR 4-11 3 10 3 ), and platelets of 273 3 10 3 /ml (NR 150-350 3 10 3 ). The differe...