This patient had recently experienced intermittent fevers, malaise and myalgias, as well as swelling in his left knee and one testicle; both conditions had spontaneously resolved. A HEENT examination showed a significant right inferior nasal quadrant visual field defect and signs of papillitis. He had reduced muscle strength in his right upper extremity and increased sensation to light touch over the fourth and fifth digits of his right hand. He also had an elevated white blood cell count and immunoglobulin index. An autoimmune workup was negative for antinuclear antibody (ANA), even when tested twice, as well as anti-Smith and anti-RNP antibodies. He showed higher than normal levels of anti-ds-DNA antibody.
He was initially presumed to have ANA-negative systemic lupus erythematosus, but further lab testing was positive for exposure to the bacterium Brucella melitensis, leading to a diagnosis of central nervous system-related vasculitis secondary to neurobrucellosis. He had eaten unpasteurized cheese while visiting Mexico, causing brucellosis that may have led to a false-positive ds-DNA test result. Fever, arthritis, orchitis, petechial rash and papillitis are all features of systemic brucellosis infection.
Unusual Myalgias & More
Other cases at this year’s Thieves Market may not have won the top prizes, but elicited audience applause nonetheless. They included:
Red Rice-Related Myopathy
Ariane Barbacki, MD, a resident at McGill University/Montreal General Hospital in Quebec, Canada, shared the case of a 57-year-old woman who presented to the hospital with diffuse myalgia, generalized weakness and dysphagia so severe she had to eat pureed food. She said she hadn’t taken any medications or nutritional supplements. A highly elevated creatine kinase of 9,653 stood out. Testing for myositis autoantibodies and a muscle biopsy confirmed a diagnosis of anti-HMGCR myopathy, which prompted her doctor to ask her about her diet. This health-conscious woman had consumed large amounts of camargue red rice, a food marketed as a natural way to lower cholesterol. This rice, high in plant sterols, can mimic statins in the blood and trigger myositis.
Strange Breast Lesions
Nadine Mbuyi, MD, a fellow at Brown University Alpert Medical School in Providence, R.I., shared “The Case of the Red Herring,” the story of a 48-year-old woman who presented to the hospital with painful, bilateral breast lesions with underlying edema. On one breast, the patient had a large, necrotic area surrounded by petechiae and purpura, and her right breast was firm and tender. Formerly obese, she had recently lost 200 lbs. She had been diagnosed with hepatitis C virus, but hadn’t yet undergone treatment. She had been taking calcium, vitamin D and vitamin B-12 supplements, but no anticoagulants. Her most notable laboratory test result was a positive cryoglobulinemia.
