Abstract
A 62-year-old Caucasian female ex-smoker presented to the emergency department with
progressive shortness of breath with associated pleuritic chest pain, new arthralgias, and muscle
weakness
for two months.She had already beentreated with two courses of antibiotics for
suspected
community acquired pneumonia with no improvement in her respiratory symptoms.
This is a case that
illustrates the eventual diagnosis of antisynthetase syndrome, a subtype
of theidiopathic inflammatory
myopathies. The current standard of diagnostic criteria and treatment for this autoimmune
condition will also be discussed.
A 62-year-old Caucasian female ex-smoker presented to the
emergency department with progressive shortness of breath
with associated pleuritic chest pain, new arthralgias, and muscle
weakness for two months.She had already beentreated with
two courses of antibiotics for suspected community acquired
pneumonia with no improvement in her respiratory symptoms
(Figure 1). She denied any recent travel, remarkable environmental
or occupationalexposures. She had no history of fever, weight
loss or other constitutional symptoms. Her past medical history
included hypertension, irritable bowel syndrome, and previous
diverticulitis. She took no medications. Her brother had severe
rheumatoid arthritis.
Upon initial assessment, she was hypoxic (oxygen saturation
85% on room air and on exertion). Physical examination
revealed bibasilar inspiratory crackles, rosacea, tender wrists
and metacarpophalangeals (MCPs) bilaterally and symmetrical
proximal muscle weakness in both upper and lower extremities.
Her laboratory investigations showed elevated creatinine kinase
levels of 3373 U/L (peak 4795 U/L; Normal range <149U/L), and
an erythrocyte sedimentation rate of 40 mm/hr (Normal 0–20
mm/hr). She had a mildly elevated troponin level of 0.18 ug/L
(Normal <0.07ug/L) with an electrocardiogram (ECG) showing
evidence of left ventricular hypertrophy but no ischemia and a
normal bedside echocardiogram.
Computed tomography (CT) of the chest showed a peripheral
and basilar pattern of bilateral pulmonary opacities favouring
organizing pneumonia (Figure 2). Subsequent pulmonary
About the Author
Dr. Stephanie Lapinsky, MD, is with the University of Toronto, Department of Obstetrics and Gynecology. Jessica Leen,
MD is with the Scarborough and Rouge Hospital, General Internal Medicine. Jessica Mak, BSc. Pharm (Hons), RPh, MD
Candidate is with the Faculty of Medicine at the University of Toronto. Dr. Mohammed A. Shafiee MD, MSc, FRCPC, Toronto
General Hospital, Division of General Internal Medicine
Correspondence can be directed to: jessica.mak@utoronto.ca
Submitted: March 20, 2018. Accepted: June 10, 2018. Published: February X, 2019. DOI: 10.22374/cjgim.v14i1.278
A Challenging Case of Non-resolving
Pneumonia: Keeping Antisynthetase
Syndrome in the Differential Diagnosis
Dr. Stephanie Lapinsky MD, Dr. Jessica Leen, MD, Jessica Mak, BSc. Pharm (Hons), RPh, MD Candidate.
Dr. Mohammed Shafiee, MD, MSc, FRCPC
Figure 1. Chest radiograph with opacities and pulmonary edema
Case Study
Canadian Journal of General Internal Medicine
Volume 14, Issue 1, 2019 25
Resume
Une ex-fumeuse caucasienne âgée de 62 ans s'est présentée à la salle d'urgence avec un essoufflement progressif
accompagné de douleurs pleurétiques à la poitrine, de nouvelles arthralgies et une faiblesse musculaire datée deux
mois. Elle avait déjà été traitée par deux fois à l’aide d’antibiotiques pour une pneumonie communautaire présumée
sans amélioration de ses troubles respiratoires. Il s'agit d'un cas qui illustre le diagnostic éventuel du syndrome de
l'anti-synthétase, un sous-type des myopathies inflammatoires idiopathiques. La norme actuelle des critères
diagnostiques et du traitement pour cette maladie auto-immune sera également discutée.