A 66-year-old white woman with a history of gastrointestinal bleeding due to peptic ulcer at 42 years of age, osteoporosis, dorsolumbar arthrosis, dyslipidaemia, abscess, and abscess is referred for outpatient treatment.
The patient was under treatment with rabeprazole 10 mg/24 hours, crushed on demand.
associated with pain and rigidity in the proximal areas of the limbs of 1 year of evolution and in the last 3 months accompanied by fever, asthenia, anorexia, weight loss of about 8 kg and a depressive organic syndrome
Physical examination showed good general condition with Ta 37.5 oC, normal blood pressure, skin dryness and cardiorespiratory auscultation was normal.
Analyses revealed a hemoglobin level of 10.8 g/dL, MCV 88.1, SGA level of 75 mm, CRP level of 94 mg/dL, and voluntaries level D 400 ug/l.
Biochemical examination revealed a GGT 139 U/L, alkaline f 217 U/L, iron 19 ug/dL, ferritin 436 ng/ml, glucose, creatinine, calcium, phosphorus, cholesterol, triglycerides.
Rheumatoid factor was negative.
Normal thyrotropin. b2 microglobulin, CEA and CA 19.9 were normal.
Blood cultures were negative.
Urine sediment was normal.
The fecal occult blood was negative.
The chest X-ray showed a residual fibrous tract in the right lower lobe.
Gastroduodenal transit was normal.
Abdominal ultrasound and abdominal CT were normal.
Gastroscopy was normal.
Biopsy of the temporal artery showed only signs of atherosclerotic disease.
With the diagnosis of polymyalgia rheumatica, treatment was initiated with consolidation rate 30 mg/24 hours, improvement and normalization of hemoglobin, CRP and VSG.
There was a reduction in the number of episodes started and treated at 7 months. The patient was asymptomatic and followed up on a progressive dose of 6 mg tape measure every day.
When the patient was 69 years old, she was being treated with gabapentin at levels 6 mg/24, paroxysmal 20 mg/24, gabapentin at 400 mg/12 h, vomiting 20 mg/24, lormetazepam 1 mg/24.
A routine follow-up was performed 6 months before, the patient was asymptomatic and her hemoglobin, ESR and CRP were normal.
Febrile fever and sometimes fever of 38.5 °C of evening predominance without apparent focus, dry cough, anorexia, and diffuse abdominal pain.
Physical examination was normal.
Analyses showed hemoglobin 10.4 g/dL, Hto 31.9% (MCV, MCH and RDW normal).
ESR 109 mm and CRP 93 mg/dL.
Biochemical analysis showed GGT 220 U/L, GPT 45 U/L, GOT 44 U/L, and ALP 153 U/L, iron 20 ug/dL, and ferritin 441.6 ng/ml.
CK.
Proteinogram normal.
Normal thyroid hormone and folate levels.
Direct negative Coombs test.
Dry urine.
Blood cultures were negative.
Serologies of Toxoplasma, Cytomegalovirus, Euep confirmed Salmonella B tiphy negative and paraffin CF, Brucella, Coxiella burnetti, adenovirus, respiratory syncytial virus, FC3
Serology HIV virus, hepatitis B and C negative.
Sputum negative ZN.
The Mantoux test was negative.
CEA and beta-2-microglobulin were normal.
Ig G 10.60, IgA 1.76, IgM 2.55.
Complement C3 and C4 normal.
Rheumatoid factor, ANA, AMA, ANCA and anti-LKM negative.
Faecal occult blood was negative.
The chest X-ray showed cardiomegaly.
The x-ray showed a zone of consolidation and level of L4 that in CT lumbar spine corresponded to a bone infarction in L4.
Abdominal ultrasound showed no significant findings.
Chest-abdominal computed tomography showed only one pericardial effusion.
Gastroscopy was normal and diverticula, internal hemorrhoids and diverticula were observed.
1.
The ECG showed sinus rhythm Fc 90 x'q in DIII and AVF and lack of septal vector activation.
An echocardiogram showed an anteroposterior severe pericardial effusion associated with a pattern of poor ventricular relaxation, without hemodynamic compromise.
Pericardiocentesis was performed, obtaining approximately 200 cc of fluid sero tiny dye solution 68 mm3, gelatinous cytology, gelatinous character 18 cc of mesocardial fluid showed glucose mesoDH with negative leukocytes / dL.
The cardiac study was completed with myocardial perfusion scintigraphy, which showed no perfusion alterations suggestive of ischemia or myocardial necrosis.
Temporal arterial biopsy revealed a transmural inflammatory infiltrate consisting of a mixture of polymorphonuclear cells, lymphocytes and giant cells. The infiltrate was accompanied by internal elastic fracture.
The patient improved to 60 mg/day with symptoms in a few days and the pericardial effusion resolved in 3 months.
