LAUSR

Patient presentation: A 31-year-old Moroccan woman was admitted at the infectious diseases department because of a clinically unexplained inflammatory syndrome after recent delivery. Three weeks earlier, she had given birth to a healthy girl, during uncomplicated delivery and after unremarkable pregnancy. Obstetric history included 2 other uncomplicated pregnancies and deliveries. Medical history consisted of asthma, hypothyroidism, and frequent sinusitis episodes. Long-term treatment included levothyroxine 125 μg QD, as well as combination inhalation therapy (fluticasone furoate 92 μg and vilanterol 22 μg QD). She initially presented at the emergency department with general malaise, diffuse myalgias, arthralgias, and fever peaks. Clinical examination revealed an ill patient with symptomatic hypotension (96/48 mm Hg) and tachycardia (117 bpm) but no fever (37.8°C). Peripheral oxygen saturation at breathing room air was normal (97%) despite mild orthopnea. Cardiopulmonary auscultation revealed regular heart sounds without a murmur and bibasilar pulmonary rales. There was mild ankle pitting edema and a subtle purpura on the dorsal side of both feet. C-reactive protein level was 107.5 mg/L (normal range, 0–5 mg/L), and leukocyte count was 39.8×103/mm3 (normal range, 3.6–9.6×103/mm3) with a strong eosinophilic pattern (63.5% eosinophils; absolute value, 25.3×103/mm3). Renal, thyroid, and hepatic function were normal, as was hemoglobin concentration; troponin T levels were elevated at 1.4 μg/L (normal range, 0.000–0.005 μg/L), with creatinine kinase levels of 424 IU/L (normal range, 30–135 IU/L). Urinary sample was negative for pyuria, and serial blood cultures were taken. Contrast-enhanced thoracoabdominal computed tomography scan demonstrated a tree-in-bud pattern at the left upper lobe, suggesting bronchiolitis in the absence of clear consolidations with associated signs of pulmonary congestion. A minimal autoimmune workup consisting of antinuclear antibodies and anti-neutrophil cytoplasmic antibodies was negative. Skin biopsy of the foot lesions was performed. An urgent cardiac consultation was requested.