It's Not All in Your Head

A CLINICAL PROBLEM-SOLVING article by Kathryn Towns from University of Toronto, Ontario, Canada.
A 63-year-old man presented to the emergency department with shaking chills and drenching sweats of 4 days' duration. He reported no weight loss, arthralgias, headache, visual changes, or new skin eruptions, but he had progressively worsening bilateral anterior thigh pain of 10 days' duration.
Approximately 6 months earlier, he had had similar symptoms, in addition to myalgias and fatigue. The onset of these symptoms coincided with the initiation of minocycline for the treatment of rosacea. The minocycline was stopped, and the influenza-like symptoms resolved.
The patient's medical history was notable for benign prostatic hypertrophy, a single episode of atrial fibrillation that was successfully managed with cardioversion to sinus rhythm, gastroesophageal reflux disease, and rosacea.
On physical examination, his temperature was 39.2°C. The abdomen was soft, with mild tenderness in the right upper quadrant on deep palpation. The alkaline phosphatase level was 429 U per liter (normal range, 35 to 125). Fractionation of alkaline phosphatase indicated isoenzymes of hepatic origin.
The patient was admitted to the hospital for further evaluation. MRI of the thighs bilaterally revealed diffuse, symmetric soft-tissue, interfascial, and muscle edema. A T2-weighted image showed multiple, small, punctate foci of high signal intensity scattered within the spleen.
Over the next week, the fevers persisted. The alkaline phosphatase level increased further, to 962 U per liter. All medications were discontinued. Extensive testing has failed to yield a diagnosis. A liver biopsy was performed. [Original Article]