Intended for healthcare professionals

Endgames Picture Quiz

Painful ears and a cough

BMJ 2009; 339 doi: (Published 29 October 2009) Cite this as: BMJ 2009;339:b4150
  1. Leena Patel, specialist registrar in rheumatology,
  2. Sonya Abraham, consultant rheumatologist
  1. 1Department of Rheumatology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London W6 8RF
  1. Correspondence to: leenapatel410{at}

    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.


    • 1 What is the diagnosis?

    • 2 What do the pictures show?

    • 3 How is the diagnosis made?

    • 4 What are the treatment options?


    Short answers

    • 1 This patient has relapsing polychondritis.

    • 2 The images show purpuric vasculitic rash (fig 3) and auricular chondritis (fig 4).

    Fig 3 Purpuric vasculitic rash on the legs (arrow)

    Fig 4 Auricular chondritis (arrow)

    • 3 The diagnosis is made on clinical grounds and is …

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