CONTINUING MEDICAL EDUCATION
CASE REPORT

Fever, sore throat and myalgia

P Ive^I; M Mendelson^II; S Dlamini^III

^IFCP (SA); Division of Infectious Diseases and HIV Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
^IIPhD, FRCP; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
^IIIFCP (SA), Cert ID (SA) Phys; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

Correspondence

ABSTRACT

A 20-year-old man presented with a severely sore throat and myalgia, which were unresponsive to antibiotics. He was admitted to a regional hospital with an ongoing painful throat, generalised myalgia, fever and a transient, recurring, salmon-pink rash on his hands and trunk. He did not respond to ceftriaxone and had a continual significant fever daily.

A 20-year-old man presented with a severely sore throat and myalgia, which were unresponsive to antibiotics. Ten days into his illness he was admitted to a regional hospital with an ongoing painful throat, generalised myalgia, fever (38.5°C) and a transient, recurring, salmon-pink rash on his hands and trunk. He did not respond to ceftriaxone and had a continual significant fever daily. Shotty cervical lymphadenopathy was noted. The relevant laboratory investigations are shown in Table 1.

On admission to tertiary care, an aetiological differential diagnosis for the pyrexia of unknown origin (PUO)^[1] (Table 2) included retropharyngeal abscess, Lemierre's syndrome, HIV seroconversion, and adult-onset Still's disease (AOSD). A slightly enlarged left adenoid was noted that exuded a small volume of pus on biopsy, while histology revealed lymphoid hyperplasia. A fourth-generation HIV enzyme-linked immunosorbent assay (ELISA) was negative. A computed tomography (CT) scan and Doppler test excluded retropharyngeal abscess and Lemierre's syndrome. The patient fulfilled the Yamaguchi criteria^[2] (Table 3) for AOSD,^[3] with a good clinical and laboratory response to prednisone 80 mg once daily.

When the aetiological diagnosis eludes the clinician, patients with PUO are often diagnosed as having AOSD. As steroids suppress fever and inflammation, idiopathic PUO would respond to this treatment because its natural history is to abate. However, the key findings in this case of unrelenting quotidian fever, evanescent rash, marked neutrophilia, and ferritin >10 000 μg/L are highly suggestive of AOSD. A low percentage of glycosylated fraction of ferritin is another pointer to the diagnosis, but it cannot be determined in most laboratories in South Africa.^[4]

References

1. Petersdorf RG, Beeson PB. Fever of unexplained origin: Report on 100 cases. Medicine (Baltimore) 1961;40:1-30.         [ Links ]

2. Yamaguchi M, Ohta A, Tsunematsu T, et al Preliminary criteria for classification of adult Still's disease. J Rheumatol 1992;19:424-430.         [ Links ]

3. Gerfaud-Valentin M, Jamilloux Y, Iwaz J, Sève P. Adult-on set Still's disease. Autoimmun Rev 2014;13:708-722. [http://dx.doi.org/10.1016/j.autrev.2014.01.058]        [ Links ]

4. Fautrel B, Le Moël G, Saint-Marcoux B. Diagnostic value of ferritin and glycosylated ferritin in adult onset Still's disease. J Rheumatol 2001;28(2):322-329.         [ Links ]

Correspondence:
P Ive
prue.ive@gmail.com