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47 ‐year ‐old man with ankylosing spondylitis was admit‐ ted with fever of unknown origin. diagnosis of ankylosing spondylitis was made 14 years ago based on occurrence of inflammatory back pain, bilateral sacroileitis and HLA B27 positivity. the patient was treated with non ‐steroidal anti‐inflammatory drugs; treatment with TNF alpha inhibi‐ tor (adalimumab 40 mg s.c. every other week) had been started ten months before admission. four months ago the patient started to be subfebrile or febrile (38 °c, sometimes with chills), he suffered from night swelling, fatigue, weight loss (5 kg during the last month) with normal appetite and without changes of bowel movements. the treatment with adalimumab was stopped two months ago. Before admis‐ sion, several tests and imaging methods were performed, however, the origin of the fever remained unclear (normal chest X ‐ray, abdominal ultrasonography, scintigraphy of the skeleton, otorhinolaryngologic examination, antinuclear fac‐ tor and anti dsdna antibodies as well as quantiferon tB gold were negative). with persistent fever he was admitted to our department of Rheumatology. Laboratory markers of inflammation were elevated (eryth‐ rocyte sedimentation rate 101mm/hour, cRp 110 mg/l), blood count and differential leukocyte count were nor mal, urine examination showed significant microsco‐ pic erythrocyturia (++++) and increasing proteinuria (0.74 g/day...1.2 g/day...2.64 g/day), serum creatinine was ini tially normal, subsequently the values were increasing (83...113...146...189...212 μmol/l). Paraprotein was not detected either in blood or in urine. infectious aetiology was not found (blood cultures repeatedly negative, as well as other cultures, also Mycobacterium species pcR in serum and urine negative). However, a significant titre of PRO3 anca antibodies (136.8 U/ml) was detected. high resolution ct (hRct) of the lung excluded a pneu‐ mopathy, but displayed a mediastinal mass in posterior mediastinum (190 × 32 × 53 mm), located perivertebrally, saddle shaped, in contact with dorsal aortic wall. fluoro‐ dexyglucose pet/ct revealed hypermetabolism of this mediastinal mass (figs. 1–3); another similar mass was found in the aortic arch area (20 × 8 mm, fig. 4), and still another under the bifurcation of abdominal aorta (30 × 35 × 10 mm, fig. 5). a ct ‐guided biopsy of the mediastinal mass was performed, followed by a kidney biopsy.

acta medica

Case 1‑2012: ANCA Associated Glomerulonephritis in Combination with IgG4 Positive Mediastinal Mass in a Patient with Ankylosing Spondylitis Treated with TNF Alpha Inhibitors