Case 30-2000

Abstract

A 25-year-old man was admitted to the hospital because of asthma, cardiac failure, diarrhea, and weakness of the right hand.He had been well until two years earlier, when asthma developed. It was managed with bronchodilator medications and intermittent pulsed doses of corticosteroids, including prednisone. Seven months before admission, treatment with montelukast sodium was begun. The wheezing worsened, and repeated doses of corticosteroids were administered. Four months before admission, laboratory tests were performed (Tables 1 and 2). Several weeks before admission, the dose of prednisone was tapered, but information on the specific regimen was not available.One month before admission, a dry cough developed, with orthopnea, paroxysmal nocturnal dyspnea, and night sweats, without documented fever. At about the same time, the patient had a mildly pruritic rash on the dorsum of both hands that disappeared after a few days. Ciprofloxacin, clarithromycin, albuterol, salmeterol, fluticasone proprionate, fluvoxamine, lorazepam, and lithium were prescribed. Two weeks before admission, the patient awoke during the night with severe pain in the right shoulder that radiated to the arm and wrist, with paresthesias and weakness of the right hand. The pain soon resolved, but there was persistent numbness and weakness in the first three digits of the right hand, and the patient was unable to extend the second and third digits fully. At the same time, diarrhea developed.Four days before admission, the patient entered another hospital, where examination revealed crackles at both lung bases. His temperature was normal. A stool specimen was positive (+) for occult blood. Labo-ratory tests were performed (Tables 1 and 3). The results of liver-function tests were normal. Arterialblood gases were measured (Table 4). Radiographs of the chest showed cardiomegaly and pulmonary vascular congestion. A cardiac ultrasonographic study, performed at the bedside, revealed global left ventricular hypokinesis, with an ejection fraction of 30 percent.Furosemide, digoxin, methylprednisolone, and omeprazole were administered. Montelukast and fluvoxamine were withdrawn. On the second hospital day, two units of packed red cells were transfused, and the hemoglobin level rose from 7.7 to 11.7 g per deciliter. On the fourth day, the patient was transferred to this hospital.The patient resided with his parents and was unemployed because of severe obsessive-compulsive disorder. He was allergic to birch, oak, and dust mites. He had lost 5 kg in weight in recent weeks. The temperature was 36.6°C, the pulse was 82, and the respirations were 20. The blood pressure was 110/80 mm Hg. The oxygen saturation was 98 percent while the patient was breathing oxygen at a rate of 3 liters per minute.Physical examination showed palmar erythema. The lungs were clear except for bilateral wheezes. A stool specimen was negative for occult blood. Neurologic examination showed wasting of the first dorsal interosseous muscle of the right hand; muscle strength was 4/5 in the w...