[résolu]ABC RHUMATO PNEUMO RADIOLOGY

A 61-year-old man presents to the emergency department (ED) with fever, dyspnea, and a productive cough for 1 week that has failed to respond to outpatient antibiotics (levofloxacin). He also complains of worsening arthralgias in both lower extremities, particularly in his knees and ankles, as well as a 10-lb (4.54-kg) weight loss over the preceding 2 months. He is a former smoker with an 80-pack-year history, but there is no other significant medical history. He denies any recent travel, sick contacts, or occupational exposure to asbestos or mineral dust. His only medications include over-the-counter analgesics for joint pains, and he denies having any drug allergies.

The physical examination reveals an elderly, cachectic male who appears to be in mild respiratory distress. His vital signs demonstrate an oral temperature of 101.4° F (38.6º C), pulse of 100 bpm, blood pressure of 110/70 mm Hg, respirations of 26 breaths/min, and an oxygen saturation of 93% on room air. Auscultation of the lungs demonstrates decreased breath sounds in the right lung base, with scattered fine rales. His heart sounds are regular and without any murmurs, rubs, or gallops. Abdominal examination does not reveal any tenderness or masses. Clubbing of the digits is noted; however, there is no evidence of pedal edema, joint swelling, erythema, or joint tenderness. No skin rashes are noted.

Laboratory tests are significant for a leukocyte count of 14.0 × 103/µL (14.0 × 109/L; normal range, 3.5-12.5 × 103/µL); the remainder of the laboratory tests, including hematocrit, platelets, electrolytes, creatinine, and serum glucose, are within normal limits. A chest radiograph reveals a right lower-lobe (RLL) consolidation. The patient is started on intravenous (IV) ceftriaxone and azithromycin and he is admitted with the diagnosis of community-acquired pneumonia. Following admission, there is no improvement in his symptoms despite antibiotics, and blood cultures, sputum cultures, and legionella serology tests return negative. A computed tomography (CT) scan of the chest is obtained, which reveals emphysema as well as mediastinal lymphadenopathy in the pretracheal and subcarinal areas (see Figure 1). A moderate right-sided pleural effusion along with multiple subcentimeter nodular opacities in the right middle and lower lobe are also noted, along with septal thickening (see Figure 2).

A rheumatology consultation is obtained for his lower extremity arthralgias. There is no clinical evidence of synovitis or effusion in any of his joints, although there is evidence of mild arthritis of the knees, with suprapatellar enthesopathy seen on knee and ankle radiographs. He experiences no relief of his arthralgias with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Opiates and gabapentin are added for pain relief. Additional laboratory tests are performed, which reveal an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Rheumatologic serology was negative, including rheumatoid factor, antinuclear antibody (ANA), and antineutrophil cytoplasmic antibodies (ANCAs), as well as normal serum complements. Based on the above evaluation, a presumptive diagnosis was made.

What is the most likely diagnosis?


1--Mycoplasma pneumoniae
2--Rheumatic fever
3--Septic emboli from culture-negative endocarditis
4--Hypertrophic osteoarthropathy

I think that I can eliminate the rheumatic fever !(according to the results of biologiques tests ) and also the Mycoplasma pneumonia (he had started on intravenous (IV) ceftriaxone and azithromycin but no answer )


what about a cancer

well done