The Wolf at the Door

A CLINICAL PROBLEM-SOLVING article by Benjamin Uttenthal, from Royal Free and University College Medical School, London in United Kingdom.
A 29-year-old man presented with a 1-week history of fever, night sweats, reduced appetite, and left upper abdominal pain exacerbated by inspiration.
Eight years previously, the patient had an episode of fever, with raised inflammatory markers that persisted for 12 weeks. He underwent evaluation for cancer and infection, including tuberculosis, but no cause was identified. Joint pains subsequently developed, and he had a positive antinuclear antibody test, at a low titer; he was treated with oral glucocorticoids over a period of 2 months, with resolution of his symptoms.
It was unclear whether the patient's present illness represents a relapse of his prior condition or was unrelated.
Current clinical examination confirmed a temperature of 38.2°C, but the patient appeared well. Laboratory results showed pancytopenia with a low reticulocyte count which indicated a low bone marrow output. The activated partial-thromboplastin time was markedly raised, and failed to normalize with the addition of normal plasma.
The patient was treated with intravenous amoxicillin and clavulanate but continued to have spiking fevers daily, with peak temperatures of more than 38.5°C. Over the next 2 days, headaches, confusion, and muscle cramps developed, as well as proteinuria, and he was transferred to a tertiary care hospital. Laboratory results revealed a very high ferritin level.

Drenching Night Sweat（盗汗） の鑑別診断

• Abscess
• Brucellosis
• HIV
• Lymphoma
• Malaria
• Malignancy
• Menopause
• Subacute bacterial endocarditis
• Tuberculosis