Endgames Case Report

An unusual cause of fever of unknown origin

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d2984 (Published 08 June 2011) Cite this as: BMJ 2011;342:d2984
  1. Janet Dua, core medical trainee year 2,
  2. Wui-hang Cheung, specialist registrar,
  3. Sabina Russell, consultant endocrinologist and general medical physician
  1. 1Chase Farm Hospital, London EN2 8JL, UK
  1. Correspondence to: J Dua janetdua3000{at}yahoo.co.uk

A 17 year old previously well black British born student was at college when he became feverish. He noticed a faint itchy rash over his arms and legs and was brought to the emergency department. He developed facial swelling and difficulty in swallowing and was admitted under the ear, nose, and throat team for suspected epiglottitis. On examination he had a faint maculopapular rash over his limbs, with submandibular lymphadenopathy and mild pharyngitis. Joint tenderness without effusions was elicited in both knees and elbows. No heart murmurs were heard. He had no family history of hereditary conditions and no history of allergy, foreign travel, or sexual relations. He had rising inflammatory markers, with a white cell count of 69×109/L (4-11), neutrophils 65×109/L (1.8-7.5), C reactive protein 163 mg/L (0-5), erythrocyte sedimentation rate 138 mm/h (3-15).

Liver function tests were deranged (alanine transaminase 577 U/L (10-40), alkaline phosphatase 117 U/L (40-129), bilirubin 50 µmol/L (1-17)). Ferritin was 50 000 µg/L (10-160). Blood cultures, malaria screen, antistreptolysin O antibody titre, hepatitis serology, cytomegalovirus, HIV, rheumatoid factor, antinuclear antibodies, and double stranded DNA were negative. Computed tomography of his neck, chest, and abdomen showed minimal reactive lymphadenopathy and 2 cm hepatomegaly. An echocardiogram was normal.

Despite four weeks of empirical antibiotic treatment he continued to have spiking fevers of more than 40°C. His rash faded away but the arthralgia was persistent.

Questions

  • 1 What are the differential diagnoses of fever of unknown origin?

  • 2 What is the most likely diagnosis in this case?

  • 3 How should this condition be managed?

Answers

1 What are the differential diagnoses of fever of unknown origin?

Short answer

The differential diagnosis of fever of unknown origin includes infections (such as tuberculosis), cancers (such as non-Hodgkin’s lymphoma), collagen vascular conditions (such as systemic lupus erythematosus), drugs, and other causes.

Long answer

Fever of unknown origin is defined as a core body temperature …

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