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4. 1 and 3
Given high suspicion for the diagnosis and concerns about poor wound healing, biopsy of sural nerve or kidney to confirm vasculitis was not performed. He was started on tenofovir daily and prednisolone 20mg daily (low dose given concern for precipitating mania given his of bipolar disorder for which he is not currently on therapy). While evidence is limited, most experts would agree that for his mild disease without evidence of major organ involvement, high dose glucocorticoids and antiviral therapy is appropriate for initial treatment to induce remission, though many patients do require a second immunosuppressive agent to maintain remission. He was scheduled for follow-up with rheumatology and gastroenterology. He was discharged home.
Two days later he represented to the ED with severe abdominal pain, nausea, and shortness of breath.
He was tachycardic to a heart rate of 120 beats per minute and tachypnea to 32 breaths per minute. His brain natriuretic peptide was 57,000 pg/mL and his lactate was 10 mmol/L. Portable chest x-ray is shown below (Figure 1).
Figure 1. Initial chest x-ray from second admission.
What is your differential diagnosis? (Click on the correct answer to proceed to the sixth and final page)