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case_images: Chest computed tomography hospitalizations in gastroenterology (A, C) and rheumatology (B, D). Both showed a large amount of pericardial effusion and a small amount of pleural effusion. Red arrow indicate pericardial effusion.
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case_images: In the department of gastroenterology of our hospital, chest computed tomography (CT) showed a large amount of pericardial effusion and a small amount of bilateral pleural effusion, with multiple small nodules in both lungs ( Figures 1A, C ). In the rheumatology department, chest CT showed a large amount of pericardial effusion and a small amount of left pleural effusion, multiple small nodules in both lungs, and disseminated inflammation of the middle lobe of the right lung and the lower lobes of both lungs ( Figures 1B, D ).
case_images: Submandibular gland ultrasound showed that large low echo nodules can be detected, with clear boundaries, less uniform internal echoes, and blood flow signals. Red arrow indicates the submandibular gland nodules.
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case_images: Submandibular gland ultrasound showed that large low echo nodules can be detected in the submandibular gland, with clear boundaries, less uniform internal echoes, and blood flow signals. ( Figure 2 ).
case_images: Positron emission tomography computed tomography on August 25, 2020. Positron emission tomography computed tomography showed that medium pericardial effusion which corresponding to an increased area of FDG uptake (A). Bilateral pharyngeal tonsil, submandibular gland (B), small lymph nodes in the right side of sternal bone and mediastinum (C) and the wall of ascending aorta (D) all showed increased metabolism. Red arrow indicates positron emission tomography (CT) scans showing an increase in FDG uptake area in the central envelope effusion.
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case_images: Moreover, small lymph nodes were observed at the right side of the sternal bone, and the mediastinum and the wall of the ascending aorta all showed increased metabolism ( Figure 3 ).
case_images: Pathological morphology and immunohistochemistry of the right submandibular gland. (A, B) HE showed hyperplasia of interstitial fibrous tissue and lymphoid tissue hyperplasia, formation of lymphoid follicle, infiltration of a large amount of lymphocyte and scattered plasma cells and eosinophils; (C, D) Immunoglobulin (Ig) G positive plasma cells could be seen by immunohistochemical staining; (E, F) IgG4-positive plasma cells could be seen by immunohistochemical staining; The IgG4/IgG ratio was greater than 40%. HE, Hematoxylin and eosin stain; Ig, Immunoglobulin.
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case_images: Three days after admission, a biopsy of the right submandibular gland was performed ( Figure 4 ).