A 60 y.o. white male with rheumatoid arthritis was admitted to Munson Medical Center for syncope.

This was the patient's third hospitalization within the previous two months related to an undiagnosed systemic illness. This illness began approximately three months prior to the current hospitalization and was originally characterized by pulmonary symptoms (cough and shortness of breath) treated with a course of prednisone. The illness later came to be more prominently characterized by high irregular fevers, wt loss, malaise, and intermittent prostration. The two previous hospitalizations were for a prior syncopal spell and a left lower extremity deep venous thrombosis respectively.

He had suffered from rheumatoid arthritis for the previous ten to fifteen years. Previously treated with methotrexate, he had experienced significant relief of his symptoms since therapy with Humira was initiated five or six months prior to his current hospitalization. He lived in rural northern Michigan on family property where there was an old barn frequented by pigeons. He had not traveled beyond the Midwest recently but had been to Indianapolis to visit a son a month or so before he became ill.

In his previous evaluations he had undergone an extensive work up for infectious diseases, malignancy, and hypercoagulability without conclusive results. Studies had included blood cultures, serologies and CT Scans (chest CT had shown areas of interstitial and nodular infiltrates). A bone marrow biopsy done for thrombocytopenia had shown granulomas, but no organisms were seen on AFB or fungal stains. Admitting labs included WBC 5.2, Hgb 12.9 (L), Plts 145 (L), AST 35, ALT 74 (H). On examination he appeared ill and had high fever but had no focal findings except for buccal ulcers (see upper left).

While undergoing evaluation he experienced diarrhea and had an abrupt fall in hemoglobin with evidence of intestinal bleeding. He underwent upper and lower gastrointestinal endoscopy and was found to have ulcers throughout his intestinal tract including stomach, small bowel and colon. A representative colon ulcer is pictured at lower left.

Multiple biopsies were taken from ulcers in the upper and lower gastrointestinal tract, and he had a repeat bone marrow biopsy.