Case history

A 24 year old man who was studying immunology at a postgraduate medical school presented to this hospital's casualty department in July 1995 with a 17 day history of high fevers, night sweats, dry cough, and myalgia. He also complained of pain and discharge from a lower left molar tooth. He had no medical history and was taking no regular drug treatment. A travel and occupational history showed that he had lived in Himachal Pradesh in northern India until March 1995, when he moved to London. He had previously qualified as a veterinary surgeon, before studying for a microbiology degree between 1993 and 1995. During this time he had performed regular experiments on the products of conception from cattle and sheep to investigate possible infectious causes of abortion.

On examination at admission the patient had a fever of 38.5°C, a solitary cervical lymph node measuring 1 cm × 0.5 cm in size, a resting tachycardia of 110 beats per minute, and a palpable splenic tip. Examination of his mouth showed pus discharging from the lower left third molar tooth.

Initial investigations showed raised inflammatory markers (erythrocyte sedimentation rate 34 mm in the first hour and C reactive protein concentration of 84 U/l) and white cell count of 4.8 × 10⁹/l. Three blood films for malaria parasites were negative. Standard liver function tests yielded abnormal results (with a raised serum alkaline phosphatase concentration of 405 U/l, a raised (gamma)-glutamyltransferase concentration of 410 U/l, and a raised serum aspartate aminotransferase concentration of 248 U/l); the serum bilirubin concentration was at the upper …