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• W2417267989 abstract "A healthy 20-year-old female student was admitted for a short acute febrile illness associated with dysuria and loin and abdominal pain. Her physical examination, electrocardiogram, and chest x-ray study (CXR) were normal, excepting fever (39.1°C) and tachycardia (130 beats per minute). Oxygen saturation was 99% on room air. Urinalysis showed pyuria and grew Citrobacter koseri on culture. Hemoglobin was 10.9 g/dL, white blood cell count 7.0 × 103/μL (lymphocytes 0.6 × 103/μL), and platelets 228 × 103/μL, with elevated C-reactive protein 230 (later 416) mg/dL and globulins 4.63 g/dL. Within hours of admission (under ceftriaxone), she became distressed with dyspnea, tachypnea (45 beats per minute), hypoxemia (oxygen saturation 87%), and hypocarbia (PCO2 31 mm Hg). Auscultation yielded only few bilateral rales. CXR and computed tomography angiography demonstrated bilateral pulmonary alveolar infiltrates and pleural effusions (Figure). Echocardiography was normal. She was transferred to the Intensive Care Unit, oxygenated using continuous positive airway pressure, and given meropenem, levofloxacin, and oseltamivir. Extensive screening for viruses and infectious agents was negative. However, an autoantibody panel yielded an array of positive results including antinuclear antibodies (1:160, speckled); rheumatoid factor 33.9 IU/mL (N 0-15); anti-U1-ribonucleoprotein >200 (N <15); anti-Smith 27.2 U/mL (N <15); and anti-La (SSB) 61.9 U/mL (N <15). Anti-DNA antibodies and antibodies to CCP, Ro (SSA), and antiphospholipid were negative, but complement levels were consistently low: C3 0.81 g/L (N 0.9-1.8) and C4 <0.06 g/L (N 0.1-0.4). A 2-year history of Raynaud phenomenon and arthralgias (1 year) was elicited. Family history was unremarkable. Antibiotics were stopped and corticosteroids administered (1 mg/Kg prednisone) with continued improvement until her discharge (12th day) on hydroxychloquine (Plaquenil) and slowly tapering prednisone, with normal vital signs and CXR. Our patient developed sudden acute hypoxemic respiratory failure associated with bilateral interstitial pulmonary infiltrates and pleural effusions. No infectious cause could be found, and instead, a history of Raynaud's phenomenon and arthralgia was obtained, and myriad autoantibodies were found in significant titers, with associated hypocomplementemia. Thus, acute hypoxemic respiratory failure was the presenting feature of a systemic autoimmune disease that meets either American College of Rheumatology (ACR) or Systemic Lupus International Collaborating Clinics (SLICC) criteria for systemic lupus erythematosus,1Inês L. Silva C. Galindo M. et al.Classification of systemic lupus erythematosus: Systemic Lupus International Collaborating Clinics versus American College of Rheumatology Criteria. A comparative study of 2,055 patients from a real-life, international systemic lupus erythematosus cohort.Arthritis Care Res (Hoboken). 2015; 67: 1180-1185Crossref PubMed Scopus (105) Google Scholar which was likely triggered by the acute infection.2Kamen D.L. Environmental influences on systemic lupus erythematosus expression.Rheum Dis Clin North Am. 2014; 40: 401-412Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar An organ-threatening presentation in systemic lupus erythematosus is mostly related to glomerular injury or, less often, central nervous system involvement. Pleural effusion may occur in ∼17% of lupus patients on presentation, but other symptoms and signs are usually present.3Von Feldt J.M. Systemic lupus erythematosus. Recognizing its various presentations.Postgrad Med. 1995; 97 (83, 86): 79PubMed Google Scholar Although the spectrum of pulmonary involvement in the course of systemic lupus erythematosus is wide,4Min J.K. Hong Y.S. Park S.H. et al.Bronchiolitis obliterans organizing pneumonia as an initial manifestation in patients with systemic lupus erythematosus.J Rheumatol. 1997; 24: 2254-2257PubMed Google Scholar isolated autoimmune pneumonitis had been very rarely reported in the presentation,4Min J.K. Hong Y.S. Park S.H. et al.Bronchiolitis obliterans organizing pneumonia as an initial manifestation in patients with systemic lupus erythematosus.J Rheumatol. 1997; 24: 2254-2257PubMed Google Scholar and acute hypoxemic respiratory failure was not described. In patients with sudden unexplained pneumonitis, an early consideration of systemic autoimmunity and screening by antinuclear antibodies seems advisable." @default.
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• W2417267989 date "2016-09-01" @default.
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• W2417267989 title "An Unexpected Pneumonitis" @default.
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• W2417267989 doi "https://doi.org/10.1016/j.amjmed.2016.04.035" @default.
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