Thinking Inside the Box

A CLINICAL PROBLEM-SOLVING article by Peter Jessel from University of Michigan Medical School, Ann Arbor.
A 62-year-old woman presented to a community hospital with nausea, vomiting, diarrhea, and fever, all of 1 week's duration.
Her medical history included psoriasis and psoriatic arthritis, hypertension, hyperlipidemia, possible fibromyalgia, and degenerative lumbar disk disease. Her medications included the tumor necrosis factor (TNF) inhibitor infliximab (500 mg intravenously every 8 weeks), methotrexate, folic acid, atenolol, diltiazem, hydrochlorothiazide, aspirin, simvastatin, and gabapentin, as well as oxycodone for chronic pain.
Chest radiography revealed a small pleural effusion on the right side, with no infiltrate. Two sets of blood cultures were negative. CT of the chest, abdomen, and pelvis revealed a hazy infiltrate in the left midlung and small, bilateral pleural effusions.
The patient's fever persisted despite ceftriaxone therapy. On the 13th hospital day, the patient reported chest tightness. Cardiac catheterization revealed nonobstructive coronary artery disease. A transthoracic echocardiogram revealed an ejection fraction of 15% and a mobile, multilobulated soft-tissue mass, 7 mm by 25 mm, attached to the midpoint of the interventricular septum in the left ventricle.
This case demonstrates the need for extraordinary vigilance should patients who are being treated with TNF inhibitors present with symptoms suggestive of infection. However, this patient's unusual presentation and the negative results on initial blood cultures hindered a timely diagnosis. [Original Article]

タイトルは、添付文書の枠組みされた警告文"boxed warning"と型通りの考え方をすること"think inside the box "を掛けたものとなっている。