A 76 year old man was seen in the rheumatology clinic with a rash (fig 1⇓), monoarthritis of the right wrist, and fatigue. He also had bilateral painful ears (fig 2⇓), an intermittent hoarse voice, and hearing loss. He had a history of gout and was a non-smoker.

Six months before presentation, the patient had an episode of anterior uveitis. One year before presentation, he had a prolonged episode of central pleuritic chest pain and an associated dry cough. At this time he was diagnosed with severe atypical pneumonia or possible early interstitial lung disease. He did not respond to three courses of antibiotics, but his symptoms spontaneously improved within six months.

At presentation his erythrocyte sedimentation rate was 110 mm (normal range 0-10 mm) in the first hour, C reactive protein was 154 mg/l (0-10 mg/l), haemoglobin was 86 g/l (125-170 g/l), and albumin was 23 g/l (33-34 g/l). Audiometry showed right sided sensorineural hearing loss. Atypical pneumonia, viral serology, and autoimmune serology were negative. High resolution computed tomography of the chest showed mild non-specific fissural nodularity, with minor basal reticulation. Transbronchial biopsy had shown a mild chronic inflammatory interstitial infiltrate and mild fibrosis, but no granulomas or vasculitis. Pulmonary function tests were normal.