Fulminant pneumonitis: a clue to autoimmune disease.

were heard over the lower third of the right lung, without reduced air entry or dullness on percussion. Pitting edema of both lower extremities was present. Otherwise, the physical examination was unrevealing. Her blood tests showed mild anemia (hemoglobin 11 g/L, mean cell volume 78 fl), normal number of white blood cells and platelets, normal level of serum electrolytes, urea and creatinine; reduced albumin (2 g/dl, normal > 3.5 g/dl) and elevated lactate dehydrogenase (365 U/L, normal < 225). Erythrocyte sedimentation rate was 40 mm/hr (normal < 20 mm/hr) and C-reactive protein was 65 U/L (normal < 5 U/L). Chest radiographic findings were similar to those of the previous examination. Blood and sputum cultures were sterile. immunodeficiency virus, Epstein-Barr virus, cytomegalovirus and parvovirus were negative. Antibiotic therapy was changed to levofloxacin with no ameliora-w e report a 65 year old woman who presented with a 2 week history of fever, dry cough and dyspnea, and developed severe interstitial lung disease. High titers of antinuclear antibodies, anti-SS-A, anti-SS-B, and hyperglobulinemia strongly support the fact that her fulminant pneu-monitis was probably due to previously unrecognized Sjogren's syndrome. Similar cases of severe interstitial lung disease as the first presentation of autoimmune conditions are discussed. Patient descriPtion A 65 year old woman presented to our emergency department with a 2 week history of fever up to 39ºC, dry cough and shortness of breath. Her medical history included hypertension, nephrolithiasis with right nephrectomy (performed 20 years ago) and asthma treated with a long-acting beta agonist/corticosteroid inhaler. The patient denied a history of rash, arthralgia, arthritis, aphthea or a family history of connective tissue disease. Clinical and chest radiographic findings were suggestive of right lower lobe pneumonia. Despite oral antibiotic therapy, her fever, dry cough and dyspnea persisted; she also developed leg edema and was admitted to hospital. On admission her respiratory rate was 20 breaths per minute and oxygen saturation was 95% in room air. Fine crackles tion of dyspnea and fever. She developed an erythematous maculopapular rash on the right calf. Chest computed tomog-raphy disclosed ground-glass opacities, multiple peripheral nodular interstitial infiltrates and small pleural effusions [Figure]. Considering the progressive respiratory failure and radiologic deterioration despite wide-spectrum antibiotic treatment, the diagnosis of bronchiolitis obliterans with organizing pneumonia was suspected. Prednisone 40 mg/day was started, followed by disappearance of the rash but appearance of arthritis in the knees, elbows and ankles. Fundus examination of her …