Case presentation A 52-year-old man is evaluated in the emergency department for a 2-week history of progressive fever and malaise with gradual onset of shortness of breath, pleuritic chest pain, myalgia, arthralgia, and rash. He reports no cough. He has a 15-year history of rheumatoid arthritis, which is well controlled with methotrexate and etanercept; his last flare was one year ago. He has also been taking naproxen and folic acid.
Physical examination Temperature: 39.0°C (102.2°F) Blood pressure: 148/94 mmHg Pulse rate: 90 bpm Respiration rate: 22/min The cardiac examination is normal. Pulmonary examination reveals a left pleural friction rub. There is a synovial thickening of the wrists and metacarpophalangeal and proximal interphalangeal joints bilaterally, as well as small bilateral knee effusions. A non-blanching purpuric rash is noted over the distal lower extremities.…
