Uncovering Sternoclavicular Arthritis, Suspected Pseudogout, in a Fever of Unknown Origin by Whole-Body MRI

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Abstract
An 89-year-old male developed a persistent high fever (around 39 °C) approximately two weeks following endoscopic reduction of sigmoid volvulus. He had no history of hypercalcemia but was using diuretics and proton pump inhibitors. Renal and thyroid status were normal. He was largely bedridden and asymptomatic except for fever. Laboratory tests demonstrated elevated C-reactive protein (4.75 mg/dL), but some tumor markers (including CEA, CA19-9, and CA125), anti-nuclear antibodies, MPO-ANCA, PR3-ANCA, β-D-glucan, and interferon-gamma release assay were all negative. Urinalysis was unremarkable. Blood cultures obtained from two sets were negative. Chest–abdomen–pelvis contrast-enhanced computed tomography (CT), and echocardiography did not reveal any evident neoplastic lesions or focal sites of infection. Despite various antibiotic therapies, the patient’s spike fever persisted for nearly one month, leading to a diagnosis of fever of unknown origin (FUO). The patient experienced partial symptomatic relief with corticosteroid therapy, though mild fever continued. Two months after the volvulus onset, diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) was performed, revealing hyperintensities at the right sternoclavicular joint, leading to a diagnosis of sternoclavicular arthritis. Neck CT revealed calcification in this joint. Despite difficulty in joint fluid analysis, low infection risk and the patient’s prolonged bedridden state and advanced age led to suspicion of pseudogout. Nonsteroidal anti-inflammatory drugs relieved fever and normalized inflammatory markers. DWIBS may be a valuable tool for detecting potential focus sites in FUO.

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