| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Rheumatology 2001; 40: 714-715
© 2001 British Society for Rheumatology
Letters to the Editor |
Fever and dry cough in a patient with a prosthetic heart valve. An interesting presentation of temporal arteritis
Department of General Medicine and Gastroenterology, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK
SIR, Giant cell arteritis is a common disease. Multisystem features are well described, but atypical presentation with a respiratory complaint is rare and makes diagnosis difficult. We describe the case of a patient who presented with fever and dry cough, whose arteritis also involved the colonic mesentery.
A 74-yr-old Caucasian male was admitted with a 2-month history of a dry cough. This was associated with fever, night sweats, lethargy and 5 kg of weight loss. One year previously he had undergone aortic valve replacement (bioprosthesis) and coronary artery bypass grafting. He was a non-smoker with no history of respiratory disease. His medical history was otherwise insignificant.
On examination the patient was anaemic, febrile (temperature 38.3°C) with no peripheral stigmata of infective endocarditis. He was haemodynamically stable, had a prosthetic second heart sound and a grade 2/6 ejection systolic murmur in the aortic area. The chest was clear and there were no significant abdominal or neurological findings. There was no lymphadenopathy and the patient's mental state was normal.
Initial investigation showed microcytic hypochromic anaemia (haemoglobin 7.1 g/dl). There was a neutrophil leucocytosis (8.75x109/l) and mild thrombocythaemia (610x109/l). Urea and electrolytes were normal, albumin was 26 g/l (normal range 35–55), the erythrocyte sedimentation rate was 125 mm/h and C-reactive protein 240 mg/l (normal range 0–10). Liver function was mildly deranged, with aspartate and alanine aminotransferase levels elevated to twice the upper limit of normal. Urinalysis, chest X-ray and ECG were all unremarkable and pulmonary function tests were normal.
Infective endocarditis was excluded after a normal transoesophageal echocardiogram, negative blood cultures (six sets before, then two sets on antibiotics) and repeatedly normal urine microscopy. Empirical intravenous flucloxacillin (2 g every 4 h) and gentamicin (80 mg every 8 h) were discontinued. Oral clarithromycin (500 mg every 12 h) was commenced to cover atypical pneumonia, but both serology and Legionella antigen were negative. Symptoms, fever and inflammatory indices did not change.
A computed tomography scan of the chest, abdomen and pelvis was normal. The Coombs test was positive after a blood transfusion, with no evidence of haemolysis. A repeat test 2 days later was negative. The autoantibody screen (antinuclear, antimitochondrial, anti-smooth muscle, anti-gastric parietal cell antibodies and rheumatoid factor), vasculitis screen (antineutrophil cytoplasmic antibodies) and viral serology (hepatitis A, B, C, Epstein–Barr virus and cytomegalovirus) were negative. Immunoglobulin G was reduced at 5.5 g/l (normal range 7–16) but urine was negative for Bence Jones protein and a skeletal survey was normal. Serum angiotensin-converting enzyme was normal. Flexible sigmoidoscopy and biopsy revealed a severely dysplastic polyp at the rectosigmoid junction. Barium enema showed no further abnormalities.
The history was taken on several occasions, and this eventually occurred in the presence of the patient's wife. After some prompting from her, he remembered scalp tenderness when using a comb. He subsequently admitted to jaw claudication but still denied headache, muscular pain or visual disturbance. Temporal artery biopsy on the 12th day of admission (Fig. 1
) confirmed the diagnosis of giant cell arteritis. Following treatment with oral prednisolone (60 mg once daily) the symptoms resolved completely. Three weeks later he was readmitted for surgery. After resection of the colonic lesion, histology confirmed a dysplastic polyp but showed no evidence of invasive carcinoma. The specimen also revealed a vasculitis that involved the colonic arterial supply.
|
A review of the literature has revealed that temporal arteritis has been reported as presenting with a dry cough, although this is rare [1, 2]. Pulmonary manifestations of the disease also include exudative pleural effusion and pulmonary nodules [3, 4]. The condition usually involves the medium-sized or large arteries supplying the extracranial structures of the head, neck and upper limbs. In this patient's case, histopathology also reported involvement of the mesenteric arteries supplying the resected segment of the colon. Presumably the systemic vasculitis with involvement of bronchial vasculature is the mechanism that produced the cough.
This case had evolved into a fever of unknown origin (FUO) before the diagnosis had been established. Whilst there was a strong possibility of a colorectal malignancy, and FUO is recognized in all the common malignant diseases (46 in total), we were not prepared to accept the localized rectosigmoid lesion as the basis for the gross systemic upset. Investigation was therefore continued.
Giant cell arteritis accounts for approximately 15% of diagnoses of FUO in the elderly [5]. Whilst the symptomatology in this case was not typical, the diagnosis of temporal arteritis should always be considered in an elderly patient with an unexplained fever, elevated inflammatory markers or indeed a chronic cough.
For the pathology report and photographs we thank Dr J. M. Sloan, and for performing the biopsy we thank Mr R. Kennedy of the Royal Victoria Hospital, Belfast.
Notes
Correspondence to: S. J. Walsh, c/o Wards 9 and 10 Office, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK. 
References
- Olopade CO, Sekosan M, Schraufnagel DE. Giant cell arteritis manifesting as chronic cough and fever of unknown origin. Mayo Clin Proc1997;72:1048–50.[Abstract]
-
Rischmueller M, Davies RP, Smith MD. Three year follow-up of a case of giant cell arteritis presenting with a chronic cough and upper limb ischaemic symptoms. Br J Rheumatol1996;35:800–2.
[Abstract/Free Full Text] -
Garcia-Alfranca F, Solans R, Simeon C, Gomez-Lozano A, Perez-Bocanegra C, Bosch JA. Pleural effusion as a form of presentation of temporal arteritis. Br J Rheumatol1998;37:802–3.
[Free Full Text] - Zenone T, Souquet P-J, Bohas C, Vital Durand D, Bernard J-P. Unusual manifestations of giant cell arteritis: pulmonary nodules, cough, conjunctivitis and otitis deafness. Eur Respir J1994;7:2252–4.[Abstract]
- Arnow PA, Flaherty JP. Fever of unknown origin. Lancet1997;350:575–80.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. B. Hellmann Temporal Arteritis: A Cough, Toothache, and Tongue Infarction JAMA, June 12, 2002; 287(22): 2996 - 3000. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||