A 61-year-old man with arthritis and an 80-pack-year smoking history presented with fever, dyspnea, and productive cough of a week’s duration that did not respond to outpatient treatment with levofloxacin. He also had worsening arthralgias in both lower extremities, particularly in his knees and ankles, accompanied by a 10-lb weight loss over the 2 months before presentation. Physical examination findings included digital clubbing and decreased breath sounds on the right side with scattered fine rales.
The patient was admitted with the diagnosis of right lower lobe (RLL) pneumonia on the basis of RLL consolidation on his radiograph. He was treated with intravenous ceftriaxone and azithromycin. However, there was no improvement in his symptoms despite treatment with the antibiotics; therefore, a CT scan of the chest was obtained. It revealed emphysema and mediastinal lymphadenopathy in the pretracheal and subcarinal locations (Figure 1). A moderate right-sided pleural effusion and multiple nodular opacities (measuring less than 1 cm) in right middle and lower lobes with septal thickening were noted, suggesting a lymphangitic tumor (Figure 2).
The patient underwent mediastinoscopy and lymph node biopsy, which confirmed poorly differentiated non–small-cell lung cancer. Thoracentesis with aspiration of the effusion also confirmed malignancy. Meanwhile, a rheumatology consultation was sought for his leg pain. There was no clinical evidence of synovitis or effusion in any of his joints, although there was evidence of mild arthritis in the knees with suprapatellar enthesopathy on knee and ankle radiographs. He had minimal relief with NSAIDs. Opiates and gabapentin were added for pain relief.
Laboratory findings were significant for an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level. Results of serological tests for rheumatoid factor, antinuclear antibody, and antineutrophil cytoplasmic antibodies were negative; levels of serum complements were normal.
Chemotherapy with cisplatin and etoposide was started, and the patient had some improvement in his arthralgic symptoms.
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