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A 46-Year-Old Man with Rheumatoid Arthritis and Lymphadenopathy

Presentation of Case

Viviany Taqueti (Harvard Medical School): A 46-year-old man was seen in the hematology–oncology clinic of a cancer center affiliated with this hospital because of anorexia and generalized lymphadenopathy.

The patient had a history of rheumatoid arthritis but had been otherwise well until 1 month earlier, when diffuse lymphadenopathy gradually developed in his neck, axillae, and groin, associated with sore throat and loss of appetite but not with weight loss. Approximately 1 week before this evaluation, fatigue, nausea, bloating, loose stools, and a cough productive of white sputum developed. On examination by his primary care physician 5 days before this evaluation, the patient's blood pressure was 118/70 mm Hg, the pulse 108 beats per minute, the temperature 37.3°C, and the oxygen saturation 98% while he was breathing ambient air. White lesions were present laterally on the tongue, and there were enlarged, tender lymph nodes, up to 2 cm in diameter, in the right submandibular, bilateral anterior cervical, left posterior cervical, and both axillary regions. The remainder of the examination was normal. The results of laboratory tests are shown in Table 1. Oral nystatin was prescribed. The patient returned the next day, with wheezing and purulent nasal discharge; on examination, there was tenderness over the maxillary sinuses and serous effusions behind the tympanic membranes. The lymphadenopathy had decreased slightly. The chest was clear on auscultation. A chest radiograph revealed prominence of the pulmonary hila and superior mediastinum, suggestive of lymphadenopathy, and biapical pleural thickening and bibasilar parenchymal scarring that were unchanged from a study 16 months earlier. Treatment with levofloxacin was begun.

The next day, computed tomographic (CT) scanning of the chest, abdomen, and pelvis after the intravenous administration of contrast material showed enlarged lymph nodes, ranging from 5 mm to 2.5 cm in diameter, in the bilateral supraclavicular, axillary, hilar, internal and external iliac, and inguinal regions; the mediastinum; and the retroperitoneum. Some of the axillary lymph nodes contained lucent centers, suggesting necrosis. There was basilar and biapical pulmonary fibrosis, and two subpleural pulmonary nodules on the right side, each 9 mm in diameter, were evident. A rounded density, 2.5 cm in diameter, was present posterior to the stomach, and the colonic wall was thickened. The patient was referred to a hematologist–oncologist.

The patient reported no shortness of breath or chest pain. Rheumatoid arthritis had been diagnosed 3 1/2 years earlier, manifested as morning stiffness, joint pain, and swelling mostly in the hands and feet, decreased range of motion in the hips and lumbar spine, and positive serologic tests (Table 1). At the age of 18 years, the patient had pain and swelling in the right elbow and both ankles; juvenile rheumatoid arthritis was diagnosed. The symptoms resolved spontaneously when the patient was in his early 20s. A diagnosis of ankylosing spondylitis was also mentioned to him, but he did not recall back pain, iritis, aphthous ulcers, dysuria, or rash. At the age of 32 years, an enlarged spleen (measuring 19 cm in length by ultrasonography) had been found incidentally during evaluation for acute cholecystitis; splenectomy and cholecystectomy were performed. On pathological examination, the spleen weighed 400 g, with fibrocongestive changes and reactive lymphoid hyperplasia. Pathological examination of a biopsy specimen of the bone marrow showed no abnormalities.

Symptoms of rheumatoid arthritis were controlled with prednisone, methotrexate, folic acid, nonsteroidal antiinflammatory medications, and leflunomide. Nineteen months before this evaluation, cutaneous lesions had developed on sun-exposed areas; examination of a biopsy specimen showed changes consistent with subacute cutaneous lupus erythematosus. Methotrexate was discontinued, and hydroxychloroquine was added; the skin lesions resolved. One year before this evaluation, corticosteroids were discontinued because of recurrent oral candidiasis.

Routine laboratory monitoring revealed fluctuating and intermittently low leukocyte counts (Table 1). Three months before this evaluation, the patient had been referred to the hematologist–oncologist for evaluation of neutropenia. Examination of a peripheral-blood smear revealed Howell–Jolly bodies; test results for antibodies to the human immunodeficiency virus (HIV) and hepatitis A, B, and C viruses were negative; serum levels of calcium, phosphorus, protein, and albumin and tests of liver and renal function were normal; other laboratory-test results from this earlier evaluation are shown in Table 1. Flow-cytometric analysis of peripheral-blood lymphocytes was normal. A scan of the liver and spleen showed no evidence of an accessory spleen. The neutropenia was thought to be related to the patient's medications, and he was advised to discuss possible changes in therapy with his rheumatologist.

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作者:admin@医学,生命科学    2010-10-28 05:11
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