To the Editor:A 25-year-old male patient was admitted to the First Affiliated Hospital,School of Medicine,Zhejiang University with complaints of fever,cough,and knee pain.He was an overseas student and had been back f...To the Editor:A 25-year-old male patient was admitted to the First Affiliated Hospital,School of Medicine,Zhejiang University with complaints of fever,cough,and knee pain.He was an overseas student and had been back from the USA for 3 weeks,with no remarkable medical history before admission.He was initially diagnosed with a cold and given non-steroidal anti-inflammatory analgesics and oral antibiotics in a clinic.However,his symptoms were not alleviated.Swelling and pain in his left knee became worse so that normal walking was not possible.Gradually a red rash with mild pain above the epidermis appeared in the lower limbs.Then,the patient presented to a municipal hospital in Hangzhou,China,and underwent a chest computed tomography(CT)scan,which revealed highdensity areas in both the left lower lobe[Figure 1A]and left hilum[Figure 1B].Laboratory tests indicated the following results:white blood cell(WBC)count 11.6×10^9/L,neutrophils 88.2%,and C-reaction protein(CRP)70.3 mg/dL.Community-acquired pneumonia was considered first,and empirical anti-bacterial treatment(moxifloxacin injection,400 mg per day)was administered.The patient did not improve despite the use of moxifloxacin injections for 1 week but did have an elevation in liver enzymes(alanine transaminase[ALT]191 U/L and aspartic transaminase[AST]121 U/L),higher WBC count(16.6×10^9/L)and higher CRP(213 mg/dL).His left knee joint swelling progressed,and the pain worsened.A magnetic resonance imaging scan of his left knee revealed edema of the bone marrow in the distal femur as well as joint effusion[Figure 1C].Meanwhile,the skin lesions increased in number and became larger,and some of the lesions ruptured and discharged pus[Figure 1D].Bronchoscopy results revealed a neoplasm in the left lingular bronchus(B4+B5),and tissue biopsy reported suspicious spore-like substances.Because of the difficulty of diagnosis,the patient was transferred to the Respiratory Department,First Affiliated Hospital,School of Medicine,Zhejiang University on May 28th,2018.On admission,we thoroughly reviewed his medical history and learned that he had lived in Vermont,which is located in the northeastern United States.For 4 years,the patient had not traveled outside Vermont.Physical examination findings included a low fever of 37.8℃,positive floating patella test in the left knee joint,and clusters of skin lesions,presenting as swellings,pustules,ruptures,and incrustations on the lower limbs.No abnormal breathing sounds or rales were heard.展开更多
文摘To the Editor:A 25-year-old male patient was admitted to the First Affiliated Hospital,School of Medicine,Zhejiang University with complaints of fever,cough,and knee pain.He was an overseas student and had been back from the USA for 3 weeks,with no remarkable medical history before admission.He was initially diagnosed with a cold and given non-steroidal anti-inflammatory analgesics and oral antibiotics in a clinic.However,his symptoms were not alleviated.Swelling and pain in his left knee became worse so that normal walking was not possible.Gradually a red rash with mild pain above the epidermis appeared in the lower limbs.Then,the patient presented to a municipal hospital in Hangzhou,China,and underwent a chest computed tomography(CT)scan,which revealed highdensity areas in both the left lower lobe[Figure 1A]and left hilum[Figure 1B].Laboratory tests indicated the following results:white blood cell(WBC)count 11.6×10^9/L,neutrophils 88.2%,and C-reaction protein(CRP)70.3 mg/dL.Community-acquired pneumonia was considered first,and empirical anti-bacterial treatment(moxifloxacin injection,400 mg per day)was administered.The patient did not improve despite the use of moxifloxacin injections for 1 week but did have an elevation in liver enzymes(alanine transaminase[ALT]191 U/L and aspartic transaminase[AST]121 U/L),higher WBC count(16.6×10^9/L)and higher CRP(213 mg/dL).His left knee joint swelling progressed,and the pain worsened.A magnetic resonance imaging scan of his left knee revealed edema of the bone marrow in the distal femur as well as joint effusion[Figure 1C].Meanwhile,the skin lesions increased in number and became larger,and some of the lesions ruptured and discharged pus[Figure 1D].Bronchoscopy results revealed a neoplasm in the left lingular bronchus(B4+B5),and tissue biopsy reported suspicious spore-like substances.Because of the difficulty of diagnosis,the patient was transferred to the Respiratory Department,First Affiliated Hospital,School of Medicine,Zhejiang University on May 28th,2018.On admission,we thoroughly reviewed his medical history and learned that he had lived in Vermont,which is located in the northeastern United States.For 4 years,the patient had not traveled outside Vermont.Physical examination findings included a low fever of 37.8℃,positive floating patella test in the left knee joint,and clusters of skin lesions,presenting as swellings,pustules,ruptures,and incrustations on the lower limbs.No abnormal breathing sounds or rales were heard.
