Follow up DFASM3 4 – Fever of unknown origin

Where?

Saint Elizabeth’s Hospital

Doctors’ names and Positions

Jonathan Smith - 1st year resident
Brenda Jenkins - Attending

Patient’s name:

Miss Melany Jones

Age:

28

Marital status:

unknown

Presenting complaint:

-          fever of unknown origin - past 3 months – up to 39°C - no noticeable pattern
-          severe upper-back pain that limits movement – started 2 weeks after the fever
-          numbness of the sole of the right foot
-          difficulty holding heavy objects with either hand
-          difficulty with other upper-extremity tasks (combing hair)
-          productive cough (yellowish sputum) not related to posture, no diurnal variation
-          significant weight loss

Past medical history:

-    bronchial asthma and chronic bronchitis - no response to multiple courses of antimicrobial treatment (amoxicillin/clavulanic acid, cefotaxime, and levofloxacin)
-    5-year history of asthma - inhaled bronchodilators, occasional aminophylline
-    allergic rhinitis (preceded asthma)
-    no smoking, traveling or pets.

O/E:

-    uncomfortable and restless
-    pulse 110
-    BP 110/70
-    respiratory rate 25
-    chest: crepitations and wheezes throughout both lung fields
-    normal heart sounds without evidence of cardiac murmur or friction rub.
-    back: severe tenderness of the midline cervical spine, broadening to involve both shoulders down the spine to the 2nd lumbar vertebra
-    proximal weakness of both upper limbs
-    normal sensory examination of the upper extremities
-    normal and symmetric lower extremity sensory motor examination was
-    no cervical, axillary, or inguinal lymph node enlargement
-    no tenderness, rigidity, ascites, organomegaly, or masses in the abdoen
-    no extremity edema
-    intact dorsalis pedis, posterior tibialis, and radial pulses

Differential diagnosis:

-    eosinophilic disorder: Löffler syndrome or chronic eosinophilic pneumonia
-    vasculitic condition: Wegener granulomatosis or Goodpasture syndrome
-    Churg-Strauss syndrome

Further investigations:

CBC, ESR, liver enzymes, creatinine, BUN X-ray of the lungs, urine analysis, CT-scan of the lungs

Results:

Bloods

-          hemoglobin 12.9

-          platelet count 350,000

-          white blood cell count 25,000, with 12% eosinophils

-          ESR elevated at 65 in the 1st hour

-          Liver enzyme findings unremarkable, AST of 35, ALT of 25, serum bilirubin of 0.7

-          creatinine normal at 0.5, BUN of 35

-          positive rheumatoid factor finding

-          urine analysis - infection or proteinuria

 

Plain chest radiograph: multiple scattered infiltrates in both lungs

High-resolution CT scan showed interstitial lung fibrosis

Diagnosis:

Churg-Strauss syndrome

Treatment:

-    hospitalization
-    treatment with prednisolone 45 mg for remission induction
-    remission maintenance: 200 mg daily azathioprine commencing with the reduction of the prednisolone therapy.

Prognosis:

-    two days after the start of therapy, dramatic improvement: sleep normally + serve herself
-    back pain, respiratory symptoms, and numbness disappeared
-    ESR normal in a few days

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Fever of unknown origin

 

 

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