Case
of the Month
Edited by Roy D. Weiss M. D.
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Case of the
Month - Third Case - Contributed by Roy D. Weiss, M.D.
FEVER OF UNKNOWN
ORIGIN
Panel 1
Fever of Unknown Origin.
Patient MN, is a 46 year old Indian male businessman, was well until 1
month ago. During a 4 week trip to Saudi Arabia, Pakistan, and India he
noted chills, fever to 40 C, malaise and total body weakness. The symptoms
started 2 weeks after leaving the US, while in India, where he was treated
with Amoxicillin for 2 days and then Ciprofloxacin for 8 days. The fever
persisted with worsening total body weakness. Upon arrival in the US he
was admitted to the hospital for evaluation of his fever. He denied cough,
ear problems, joint pain, gastrointestinal symptoms or rashes. He drank
some non-bottled water in Pakistan, but noted that his malaise preceded
this. Despite normal bowel movements and appetite, he had lost 14 pounds
in the last month.
Past Medical history was remarkable for IgA nephropathy, diagnosed by
kidney biopsy when the patient presented several years earlier with edema
and proteinura. This had resolved. There was no history of heart disease,
prior infections, malaria, tuberculosis. The patient was on no medications
and had no known allergies.
On physical examination he was an ill appearing thin,male looking his
stated age. His temperature was 38.5C, BP 136/68 mmHg, P 96, regular,
weight 71 Kg, and height was 164 cm. His exam was otherwise unremarkable.
Laboratory Evaluation:
COMPLETE BLOOD COUNT
White Blood Cell Count 9.0 x103
Hemoglobin 13.5 gm/dl
Hematocrit 39.2%
Neutrophils 78%
Lymphocytes 11%
Monocytes 11%
Platelets 258 x 103
ESR 65 mm
URINALYSIS
Normal
BIOCHEMICAL PROFILE
Glucose 93 mg/dl
BUN 16 mg/dl
Chol 128 mg/dl
Cr 1.3 mg/dl
Ca 8.8 mg/dl
Phosphorous 2.2 mg/dl
Sodium 136 mmol/L
Potassium 4.1 mmol/L
Chloride 101 mmol/L
Carbon Dioxide 26 mmol/L
The patient remains febrile.
Which test(s) would you request next?
A) Thick and Thin Peripheral blood smear (go to
2.1)
B) Psittacosis Antibody (go to 2.2)
C) Q fever Antibody (go to 2.3)
D) Tularemia Antibody (go to 2.4)
E) Brucella Antibody (go to 2.5)
F) Stool for ova and parasites (go to 2.6)
G) Blood cultures (go to 2.7)
H) PPD skin test (go to 2.8)
I) Chest Xray (go to 2.8)
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