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Answers on p 723.
A 49 year old woman presented in June 1998 with left sided pleuritic chest pain, fever, night sweats, flitting arthralgia, and loss of appetite of three weeks' duration. She also complained of episodic numbness of her fingertips and later her toes and oral ulceration.
She was known to have had asthma for the past 24 years and to have had four episodes of arthralgia involving large joints in the last year.
On general examination, she was pyrexial (37.5°C) with evidence of digital vasculitis affecting the left index and middle finger nails (see figs 1 and 2). She had oral ulceration. There was no rash or any evidence of inflammatory arthritis. Examination of the peripheral nervous system revealed reduced power of her right plantar flexion and inversion of right foot. There was diminished sensation over the sole of the right foot and sensory loss affecting all fingertips.
Investigations on admission gave the following results: white cell count 21.3 × 109/l, eosinophils 5.4 × 109/l, neutrophils 13.1 × 109/l, haemoglobin 128 × g/l, platelets 200 × 109/l, serum C reactive protein 145 mg/l, and erythrocyte sedimention rate 74 mm/hour. Her biochemical profile was normal, except for a moderately raised alkaline phosphatase of 176 IU/l and creatinine kinase of 202 IU/l with normal creatinine kinase myocardial bound isoenzyme.
Chest radiography showed diffuse patchy consolidation of both lungs. Spiral computed tomography of her chest showed a little patchy consolidation of upper lobes suggestive of vasculitis. An echocardiogram was normal.
Urinalysis revaled microhaematuria and proteinuria. A renal biopsy and angiogram were normal. Her latex, antineutrophil cytoplasmic antibodies, antinuclear antibodies, anticardiolipin antibody titres, and hepatitis B surface antigen were all negative. A ceretec scan was normal.
- What is the most probable diagnosis?
- What is the treatment?