A 22-year-old man with cystic fibrosis (CF) developed tachypnea, fever (temperature, 38.4°C), increased cough, and dyspnea. He also complained of a sore throat, generalized myalgias and arthralgias, diaphoresis, and chills. He was treated with nebulized tobramycin sulfate and oral ciprofloxacin hydrochloride. Bilateral wrist swelling and aching had begun 3 weeks prior to his respiratory symptoms. Because his pulmonary symptoms did not improve with outpatient therapy, the patient was admitted to the hospital.
His vital signs on admission were a temperature of 36.8°C, a heart rate of 148 beats per minute, a respiratory rate of 28/min, and a blood pressure of 131/61 mm Hg. The physical examination revealed a barrel chest, diffuse crackles on auscultation, and severe clubbing of the digits. There was bilateral nontender swelling and deformity of the wrist (Fig 1).
The laboratory results showed a white blood cell count of 10.7 × 109/L with 0.59 segmented
Bokulic RE, Beckerman RC, Mulvihill D, Wood BP. Radiological Cases of the Month. Am J Dis Child. 1989;143(6):747–748. doi:10.1001/archpedi.1989.02150180129035