November 2007







HISTORY: A 47 year-old male was transferred from an outside hospital with fever of unknown origin, diffuse leg pain and swelling, and purpura.

He had been in his usual state of health until 5 months prior, when he began experiencing arthralgias, morning stiffness, subjective fevers, chills, and generalized malaise. He was diagnosed with rheumatoid arthritis and started on methotrexate after he was found to have a rheumatoid factor of 83. Months later, he was admitted to an outside hospital after presenting to his primary care physician with fever, hypotension, and tachycardia. He was then transferred to the ICU with pancytopenia, acute renal insufficiency, urinary retention, diarrhea, and hypocalcemia. Broad spectrum antibiotics and antifungals were given without resolution of symptoms and he was subsequently transferred to Barnes.

PAST MEDICAL HISTORY: Hepatitis C (recently diagnosed), rheumatoid arthritis (???), pancytopenia (recently diagnosed), diabetes, hypertriglyceridemia

MEDICATIONS: Methotrexate 7.5mg p.o. 2x/week, Gabapentin 300mg p.o. qhs, Metformin 500mg p.o. qhs, Hydrocodone/APAP 10/325 p.o. every six hours

SOCIAL HISTORY: The patient works as an industrial mechanic. He is in a "close relationship" with a female friend. He quit drinking alcohol 18 months ago and has a greater than 40 pack year history of smoking and quit two years ago.

PHYSICAL EXAM: diffuse purpuric plaques and edema on bilateral lower extremities

Rheumatoid factor: 109 (high), Hepatitis C antibody: positive, Hepatitis B surface antigen: negative, C4: 3.6 (low), C3: 53.6 (low), ANCA: negative, ANA: positive, 1:160 homogenous.
All blood cultures: NGTD.


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