Pneumonia With an Enlarged Cardiac Silhouette

A 52-year-old woman with COPD and a 20-month history of rheumatoid arthritis presented to an outside hospital with several days of fever and cough productive of thick, dark sputum. This followed 2 to 3 months of progressive dyspnea, night sweats, and chest pain. She had required prednisone, methotrexate, and azathioprine alone or in combination for control of her articular symptoms. At the time of the admission, the chest roentgenogram revealed a dense alveolar infiltrate of the lower lobe of the right lung and mild cardiomegaly. A presumptive diagnosis of pneumonia was made, and she was treated first with IV and then oral broad-spectrum antibiotics. Blood and sputum cultures were negative. An echocardiogram demonstrated a moderate pericardial effusion with mild right atrial and right ventricular diastolic collapse. No additional therapy was prescribed and no further evaluation was performed at that time.