We admitted a 72-year-old woman to the internal medicine service.She had weight loss of 18 kg over 2 years, decreased oral intake, and recent onset of anasarca, with a history of seronegative inflammatory arthritis.Her musculoskeletal symptoms began 4 years prior with migratory arthralgias and morning stiffness, initially affecting the right metacarpophalangeal and proximal interphalangeal joints, followed by wrist tenderness, right elbow swelling, and bilateral knee pain.Shortly after the symptoms started, a rheumatologist started the patient on methotrexate and later prescribed disease-modifying antirheumatic drugs (DMARDs) and biological agents, including leflunomide, hydroxychloroquine, abatacept, and tocilizumab.However, her arthritic symptoms did not improve and after 3 years, she discontinued all DMARDs and biologic agents.She continued to experience gastrointestinal (GI) symptoms (anorexia, early satiety, and generalized abdominal pain), persistent weight loss, and fatigue.She denied diarrhea, vomiting, or change in bowel movements.Her worsening GI symptoms were attributed to her antirheumatic medications.When admitted to hospital, the patient was cachectic and reported exertional dyspnea.She had grade 4 bilateral lowerextremity edema extending to the abdominal wall, no ascites, normal heart sounds with a faint systolic murmur, and a normal jugular venous pressure.She had no joint or neurologic abnormalities and no peripheral stigmata of infective endocarditis or chronic liver disease.Blood tests showed hypoalbuminemia of 13 (normal 30 to 45) g/L, a normal 24-hour urine albumin level, and a C-reactive protein (CRP) level of 66.2 (normal < 8) mg/L.Abdominal computed tomography showed focal thickening of the right hemicolon.We performed esophagogastroduodenoscopy (EGD) and colonoscopy to rule out gastritis and colitis; we noted duodenitis (Figure 1A), but the rest of the examinations were normal.Three separate sets of blood samples cultured during the first 7 days of admission were negative.We ordered transthoracic echocardiography (TTE) to
Khan et al. (Sun,) studied this question.