When chest percussion revealed diminished lung volumes in a 52-year-old African American woman, her diagnostic possibilities expanded. The patient, hospitalized with fever, progressive dyspnea, and diffuse joint pain, felt well until 11 months earlier. At that time, she began a course of peginterferon alfa-2, ribavirin, and boceprevir for hepatitis C acquired from a blood transfusion.
Five months into this regimen, she experienced a paroxysm of nocturnal dyspnea and presented to an outside facility, where she was found to have a pulmonary embolism. She was treated with warfarin, and her condition improved over the next month. However, she then presented to another hospital with chest pain and was found to have diffuse ST-segment elevations on electrocardiogram (ECG), an erythrocyte sedimentation rate greater than 120 mm/hr, and a C-reactive protein level exceeding 20 mg/dL; findings were consistent with pericarditis. A 5-day course of prednisone substantially improved her symptoms. She then completed treatment for hepatitis C after she was found to have a sustained virologic response to this regimen.
One month prior to admission to the Johns Hopkins Hospital, she developed intermittent fevers, progressive dyspnea on exertion, and worsening pain in her shoulders, knees, wrists, and hands. This persisted until the night of evaluation, when she awoke with severe pleuritic chest pain and dyspnea that did not remit after 6 hours. She then presented to our facility for further evaluation.
Her medical history included depression, for which she was taking citalopram. She also was taking warfarin for her previously diagnosed pulmonary embolism. She had no prior history of arthritis, alopecia, serositis, oral ulcers, rashes, or pulmonary symptoms. A retired computer analyst, she lived at home with her husband and children. Her family history was notable for a mother with bilateral pulmonary emboli and a sister with lupus nephritis.
To read this article in its entirety and to view additional images please visit our website.
–Mark L. Munoz, MD, Allan C. Gelber, MD, PhD, MPH, Brian A. Houston, MD
This article originally appeared in the August 2014 issue of The American Journal of Medicine.
