A 43-year-old female patient without evident disease previously presented to our hospital with a 4-month history of intermittent wandering arthralgia on the left side, and also with spiking fever (the highest body temperature up to 40 C), thoracalgia and sputum for 3 months. According to the examinations of the local hospital, computerized tomography (CT) scan of the chest showed bilateral pleural effusions leading to oppressive lung parenchyma; mild inflammatory infiltration of both lungs; slightly pericardial effusion; cardiomegaly and swelling lymph nodes on the right cardiodiaphragmatic angle. Distinctive laboratory findings, as shown in Table 1, easily played a role in establishing the following diagnoses: secondary pulmonary tuberculosis; tuberculous pleuritis; tuberculous pericarditis and hyperthyroidism. Therefore, the antituberculous chemotherapy and anti-thyroid drug (methimazole) were initiated; however, a poor response was obtained. Then the patient transferred to our rheumatology ward. On physical examination, she appeared irritable, general fatigue and underweight. And palpable lymph nodes at bilateral inguinal region and supraclavicular fossa were also found. Laboratory test are shown in Table 1. According to the laboratorical results of the local and our hospital, Graves' disease (GD) was diagnosed.
Contrast-CT scan showed infection of bilateral lungs, slightly pericardial effusion and swelling lymph nodes at bilateral inguinal region and supraclavicular fossa. An abdominal ultrasound revealed splenomegaly. Thyroid ultrasonography revealed heterogeneous in echoic distribution and rich blood perfusion. Electrocardiogram showed only sinus tachycardia. A bone marrow biopsy and cytologic examination disclosed a hypercellular marrow hinting no lymphoma or other malignancies. Axillary lymph node biopsy displayed no lymphoma. According to the laboratory results, imaging studies, necessary exclusion and Yamaguchi et al. criteria, this case fulfilled the 1, 2 and 4 items of major criteria and 2 and 4 items of minor criteria, are shown in Table 2. AOSD was therefore diagnosed.
Since hospitalization in our ward, the patient had undergone an intermittent spiking fever (range from 38 C to 40.1 C) with evanescent rash. Considering the side effect of fever induced by antituberculous drugs, so stopped the treatment. According to the thyroid hormone level mentioned above, the thyroid function was improved and temporarily anti-thyroid drugs did not appear to be used by us. Although antifebrile drugs such as antondin and radix bupleuri (a traditional medicine that enable treat fever) were injected, and temperature was kept high. But when methylprednisone 30 mg per day was initiated, fever and rash gradually disappeared as well as thoracalgia. After she had received 2 weeks of therapy, the dose of prednisone tapered slowly. The secondary thyroid hormone test indicated remarkable hyperthyroidism (significantly increased FT3, FT4 and decreased TSH). Hence, methimazole was added. A week later, she was discharged with normal thyroid hormone and improved symptoms. CT re-examination demonstrated the disappearance of inflammation. During 1-year follow-up, the both diseases activity remained in remission.