ABSTRACT
Felty syndrome (FS) and infective endocarditis (IE) can present with similar signs and symptoms. FS is a diagnosis of exclusion, which poses a challenge for the clinician since accurate diagnosis is required to treat this condition effectively. A 52-year-old woman with a 15-year history of rheumatoid arthritis (RA) was admitted due to dyspnea and pain in the right ankle and left arm for two weeks. She was hemodynamically stable and afebrile. Physical examination revealed right ankle swelling and tenderness, left forearm tenderness, abdominal distension, and swan-neck finger deformities. Laboratory tests were notable for pancytopenia with a white blood cell (WBC) count of 2900 × 103/µL (absolute neutrophil count (ANC) of 1800/µL). Rheumatoid factor and anti-cyclic citrullinated peptide tests were positive. Synovial fluid analysis of the right ankle showed no crystals or bacteria, and a WBC count of 192 × 103/µL. Left upper extremity computed tomography (CT) revealed two abscesses, in the forearm and elbow, respectively. CT chest and abdomen revealed a wedge-shaped consolidation in the left upper lobe, multiple bilateral pulmonary nodules, and splenomegaly. Abdominal ultrasonography showed portal hypertension with no clear findings of cirrhosis. Blood cultures were negative. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed no vegetation. Incision and drainage were performed for the right ankle swelling, and left forearm and elbow abscesses. Left forearm abscess culture revealed Staphylococcus hemolyticus. Transbronchial needle aspiration and culture of the left upper lobe lesion showed acute and chronic inflammation with no signs of malignancy or microbial growth. Repeat TTE and blood cultures were negative. Bone marrow biopsy and flow cytometry showed no evidence of large granular lymphocytic (LGL) leukemia. The patient was diagnosed with FS complicated by disseminated infections and pulmonary necrobiotic nodules. Empiric ceftriaxone and vancomycin were initiated. The patient was discharged after the resolution of her symptoms. FS is a rare extra-articular presentation of RA with a triad of a > 10-year history of RA, neutropenia (ANC < 2000/µL), and splenomegaly. IE can also present with disseminated infections and splenomegaly. Repeat TTE and blood cultures were performed due to concerns regarding the high mortality rate of IE and the possibility of false-negative echocardiography results. LGL leukemia also presents with RA and neutropenia, which was deemed less likely in our patient based on unremarkable bone marrow biopsy and flow cytometry results. FS is a rare condition. Therefore, it is important to keep its possibility in mind in the setting of RA while performing workup for the most likely conditions.
