A 45-year-old Hispanic male physician, a nonsmoker, presented with crippling, nonerosive, seropositive, symmetrical polyarticular arthritis that involved his wrists, hands, elbows, knees, and feet. Findings included an erythrocyte sedimentation rate (ESR) of 114 mm/h (normal, lower than 23 mm/h) and a weakly positive anti–cyclic citrullinated peptide antibody result. The patient had a history of migraine and tinnitus. He had a previous diagnosis of serous otitis media with middle ear and mastoid effusions on CT scanning; he responded initially to antibiotic and corticosteroid therapy.
A diagnosis of rheumatoid arthritis (RA) was made, and the patient was treated with oral methotrexate(Drug information on methotrexate) and self-injected etanercept(Drug information on etanercept). His inflammatory arthritis with disabling musculoskeletal symptoms resolved. However, in spite of a rapid taper of low-dose prednisone(Drug information on prednisone) early in the disease course, the patient continued to self-prescribe various doses of corticosteroids for worsening headache and tinnitus; all symptoms were relieved.
The patient returned to the clinic and reported recurring eye pain; blurred vision; right-sided and pulsatile facial pain in the V2 and V3 distributions; sinusitis-like pressure; and serous ear drainage with hearing loss, tinnitus, and vertigo. The physical examination revealed sinus tenderness with serous drainage, no lymphadenopathy, normal lung sounds, no scalp tenderness or synovitis, and normal strength. Nailfold capillaroscopy showed irregularly tortuous capillaries but without dropout or dilated loops. The patient’s cerebrospinal fluid (CSF) demonstrated lymphocytosis and normal glucose and protein levels. Chest radiography and urine analysis results were normal. Serum antineutrophil cytoplasmic antibody (c-ANCA) measurement revealed an anti-proteinase 3 (anti-PR3) antibodies level of 86 U/mL and negative results for antimyeloperoxidase antibodies.
Gadolinium-enhanced coronal (top, left and right) and axial (bottom, left and right) T1-weighted MRI scans of the patient’s head were obtained.
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