An atypical cause of intestinal occlusion and hidronephrosis

Abstract

We present the case of a 56-year-old male with a history of psoriasis and occasional arthritis treated with NSAIDs and corticosteroids. Onset was days before admission, presenting poor general conditions, symmetrical arthritis (elbows, wrists and interphalangeal joints) and sustained fever of 38.5 oC accompanied by progressive dyspnea at rest, no cough, expectoration or chest pain. The exploration observed widespread psoriasis lesions, arthritis of the elbows and wrists, and hypoventilation of the base of the lungs, with rhythmic heart sounds and a pleural rub. Analytically, the patient presented hemoglobin of 11.3 g/dl, WBC 14.8×103/μl, neutrophils 13.3x103/μl, lymphocytes 1×103/μl, platelets 298×103/μl, prothrombin time 58%, activated partial thromboplastin time: 57.9 s, C-reactive protein > 9 mg/dl, ESR 83 mm/1st hour and cardiac enzymes within normal values. The electrocardiogram showed sinus rhythm at 100 beats per minute, with an axis at +30o, with no evidence of the repolarization abnormalities or signs of ischemia. The chest x-ray showed grade III/V cardiac enlargement and pleural effusion. The echocardiogram showed moderate pericardial effusion without signs of tamponade or segmental hypomotility. A chest scan was requested, which confirmed the existence of pleural and pericardial effusion (Figure 1). Suspecting sepsis of respiratory origin, empirical antibiotic therapy with ceftriaxone was begun. Blood urine and sputum cultures for bacteria and Koch bacilli were serially taken and resulted repeatedly negative. The patient had an unfavorable clinical course, with persistent fever and intestinal ileus presented as abdominal distension, diffuse pain on palpation and fecaloid vomiting, with a progressive increase of acute phase reactants. Abdominal scan were performed (Figure 2) and significant expansion of the intestine, from sigma to the stomach, was observed without an evident cause of gastric obstruction. The right kidney showed dilated caliceal groups, with grade III hydronephrosis and dilation of the initial portion of the ureter. The colonoscopy was not objective because of stenosis. Reumatol Clin. 2010;6(2):115–116