A 73-year-old man with a history of gastroesophageal reflux disease and Raynaud disease but no history of cigarette smoking presented to the emergency department with 4 weeks of dysphagia and a 4.54-kg (10-lb) weight loss over 3 months. He had no nausea, vomiting, abdominal pain, melena, or hematochezia but reported a cough productive of yellow sputum, dyspnea on exertion, and fatigue. The patient had been treated for presumed pneumonia with 3 courses of azithromycin over the prior 3 months due to infiltrates on a chest radiograph. He reported no known ill contacts or recent travel outside the US. At presentation, his heart rate and blood pressure were normal, and oxygen saturation was 95% on room air. Physical examination revealed a maculopapular rash over his neck and chest (Figure, left panel) and bibasilar crackles on lung auscultation. Laboratory testing showed a white blood cell count of 14.3 × 103/μL (reference, 4.2-9.1 × 103/μL); creatine kinase level, 2060 U/L (34.40 μkat/L) (reference, 44-196 U/L [0.73-3.27 μkat/L]), aldolase level, 18 U/L (0.30 μkat/L) (reference, <8 U/L [<0.13 μkat/L]), C-reactive protein level, 30 mg/L (reference, <8 mg/L), and erythrocyte sedimentation rate, 35 mm/h (reference, <20 mm/h). Antinuclear antibody immunofluorescent assay findings were positive. Results from testing for HIV, hepatitis B, and hepatitis C were negative. A barium swallow study showed no visualized aspiration. Endoscopy revealed clean-based esophageal and duodenal ulcers and nonspecific gastritis. Chest computed tomography (CT) showed bibasilar pulmonary consolidations and ground glass opacities (Figure, right panel).
Please finish quiz first before checking answer.
Read the answer below and download your certificate.
Read the discussion below and retake the quiz.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Priya Agarwala, MD, NYU Langone Health, 259 First St, Mineola, NY 11501 (Priya.agarwala@NYUlangone.org).
Published Online: July 27, 2023. doi:10.1001/jama.2023.13766
Conflict of Interest Disclosures: None reported.
Additional Information: We thank the patient for providing permission to share his information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
You currently have no searches saved.
You currently have no courses saved.