Case history

A 34 year old man developed a mild sore throat on 29 October 1995. This became more severe during the following week, when he consulted his general practitioner and was given a seven day course of penicillin V. The patient discontinued the antibiotics after two days because of nausea. During the subsequent fortnight he developed myalgia and arthralgia, followed by drenching night sweats and rigors.

After four weeks he was unable to get out of bed without help because of the severity of the myalgia and arthralgia, and he had lost over 10 kg. He was admitted to his district general hospital in November 1995. He appeared pale and unwell with a fever of 40°C. He complained of weakness and intense myalgia of his shoulder and pelvic girdle muscles, arthralgia of his left knee and right elbow, and left sided pleuritic chest pain. He had no medical history of note and no history of recent foreign travel. Physical examination was unremarkable: there was no palpable lymphadenopathy; no organomegaly; and no stigmata of infective endocarditis.

Laboratory data on admission showed a blood haemoglobin concentration of 81 g/l with normochromic normocytic indices, a raised leucocyte count of 21.85x10⁹/l with a neutrophil count of 19.65x10⁹/l and a raised platelet count of 648x10⁹/l. His erythrocyte sedimentation rate …