A 28-year-old African-American female with a past medical history of Crohn's disease and associated arthritis was evaluated for chest pain of 5-month duration that had become worse over the previous week. Her past medical history was significant for Crohn's disease diagnosed 7 years earlier when she presented with nonbloody diarrhea after a trip to Kenya. She underwent a colonoscopy that confirmed the diagnosis, and she was treated with mesalamine and steroids for 1 year at an outside institution. She had one flare of her bowel disease 2 years later, which required hospitalization for 2 days and was treated briefly with oral steroids. She also underwent a liver biopsy because of abnormal liver enzymes. This revealed primary sclerosing cholangitis which was not specifically treated at that time.Ten months prior to this presentation, the patient was admitted with a threatened abortion at 13 weeks of gestation along with an asymmetric polyarthritis of the fingers, wrists, elbows, shoulders, and ankles. During her hospitalization, she was noted to have a rash, characterized as minute follicular pustules, on the right side of her face and right upper extremity. She did not have any bowel symptoms at this time. Diagnostic workup revealed antiproteinase 3 (anti-PR-3) antibody of 536 AU/ml (normal <19 IU), rheumatoid factor (RF) of 24 IU/ml (normal 0-20 IU), erythrocyte sedimentation rate (ESR) of 139 mm/h (normal 0-20 mm/h), and C-reactive protein of 11.9 mg/dl (normal 0.30-0.80 mg/dl). A skin biopsy of the rash demonstrated vesiculopustular pyoderma gangrenosum consistent with her underlying Crohn's disease. Antinuclear antibodies, anti-double-stranded DNA antibodies, anti-streptolysin O antibody, viral hepatitis serologies, anticyclic citrullinated peptide, and human immunodeficiency virus testing were negative. She was started on 100 mg intravenous (IV) hydrocortisone three times daily for 3 days followed by 60 mg oral prednisone which was tapered off over the next 4 weeks. She also received two doses of 5 mg/kg infliximab 2 weeks apart.Six weeks later (gestational week 19), the patient presented with chest pain, arthritis, temperature of 38.7°C, and pulse of 130 beats per minute. A workup to reveal a source of infection was performed and was found to be negative. Also, an electrocardiogram, echocardiogram, and HSSJ
