The Journal of Emergency Medicine, Vol. 49, No. 3, pp. e85–e86, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.01.039

Visual Diagnosis in Emergency Medicine

YOUNG MAN WITH HOARSENESS AND DYSPNEA Shu-Yung Lin, MD, Sheng-Yuan Ruan, MD, and Chong-Jen Yu, MD, PHD Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei, Taiwan Reprint Address: Sheng-Yuan Ruan, MD, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 10002, Taiwan

CASE REPORT A 22-year-old man presented to the Emergency Department (ED) with hoarseness, dry cough, and progressive dyspnea. He had no fever, and the symptoms had fluctuated during the last 3 months. The patient was treated with bronchodilator therapy initially; however, his symptoms rapidly progressed to the development of air hunger with stridor followed by impaired consciousness. Endotracheal intubation was attempted immediately, but it failed due to severe laryngeal edema. Neuromuscular blockade was not used because the patient had been unconscious during the intubation procedure. Fiberoptic intubation was not available. After 10 min of intubation attempt, he received an emergency tracheostomy by an otolaryngologist in the ED. However, the patient’s course was complicated with a circulatory collapse. He did not regain consciousness after cardiopulmonary resuscitation. Episcleritis and auricular inflammation were noticed after admission (Figure 1). Gallium-67 scintigraphy showed active inflammation of auricular, laryngeal, costal, and nasal cartilages (Figure 2). Computed tomography scan of the thorax showed laryngotracheal wall thickening, and serological studies for connective tissue diseases were unremarkable. Serial evaluations suggested the diagnosis of relapsing polychondritis. DISCUSSION Relapsing polychondritis is an immune-mediated disease characterized by recurrent episodes of inflammation of

Figure 1. Episcleritis and auricular inflammation.

RECEIVED: 2 October 2014; FINAL SUBMISSION RECEIVED: 8 January 2015; ACCEPTED: 11 January 2015 e85

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Figure 2. The hot spots on Gallium-67 scintigraphy indicating active inflammation of involved cartilaginous structures (arrows).

cartilages, and frequently affects the cartilaginous structures of the ears, nose, eyes, and large airway (1). Gallium imaging is useful in the evaluation of infections and inflammation, and the structures affected by relapsing polychondritis can be detected by a whole-body Gallium scan. There is no test that is specific for relapsing polychondritis, and McAdam’s criteria are often used to establish the diagnosis (2). The six McAdam’s criteria are as follows: recurrent chondritis of both auricles, nonerosive inflammatory polyarthritis, chondritis of nasal cartilages, inflammation of auricular structures, chondritis of respiratory tract, and cochlear or vestibular damage. The diagnosis of relapsing polychondritis requires meeting at least three of the criteria. The clinical manifestations of relapsing polychondritis vary considerably from patient to patient. Although the most common presenting feature is

external ear inflammation, a large cohort study reported that airway symptoms were the first manifestation of this disease in half of patients (1,3). For the cases with airway symptoms as the initial presentation, the disease may be misdiagnosed as asthma or upper airway infection. Recognizing the pattern of multiple cartilaginous involvements is crucial for early diagnosis of this disease. REFERENCES 1. Trentham DE, Le CH. Relapsing polychondritis. Ann Intern Med 1998;129:114–22. 2. McAdam LP, O’Hanlan MA, Bluestone R, Pearson CM. Relapsing polychondritis: prospective study of 23 patients and a review of the literature. Medicine 1976;55:193–215. 3. Ernst A, Rafeq S, Boiselle P, et al. Relapsing polychondritis and airway involvement. Chest 2009;135:1024–30.

Young Man With Hoarseness and Dyspnea.

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