75-Year-Old Man With Fever, Weight Loss, and Diarrhea

Abstract

75-year-old retired farmer came to our institution because of anorexia, fever, weight loss, diarrhea, and occasional right upper quadrant pain. Three months ear­ lier, the patient had noticed decreased appetite and energy. A month later, coughing and expectoration of yellowish sputum were treated with an orally administered macrolide antibiotic. Despite completion of the course of antibiotic, fever (temperatures up to 38.9°C) developed, occurring primarily at night. One month before admission, the pa­ tient had diarrhea, with production of up to seven brown liquid stools per day without hematochezia or mucus; these bouts resolved spontaneously in 3 to 4 days. At that time, he was admitted to another hospital with the diagnosis of right lower lobe pneumonia, for which he received ceftriaxone, 1 g intravenously every 24 hours, and erythro­ mycin, 500 mg intravenously four times a day, for 8 days, after which he was dismissed with a 10-day oral regimen of antibiotics. Two days after completion of the antibiotic therapy, another episode of diarrhea occurred, with up to seven brown liquid stools per day, again without mucus or hematochezia. Four days later, he was admitted to our institution with the diagnosis of dehydration. Throughout this period, the patient continued to have nightly fevers (temperatures up to 40°C) with occasional drenching night sweats. The patient had a history of a monoclonal gammopathy of undetermined significance (MGUS) for at least 9 years, with low levels ofIgA, IgG, and IgM and an M peak in yof 0.8 g/dL (IgG K type). He had hypothyroidism and had also undergone a coronary artery bypass grafting procedure 2 years earlier. He had a history of farmer's lung and chronic obstructive pulmonary disease, with frequent use of antibi­ otics during the past few years for recurrent upper respira­ tory tract infections. Additionally, he had a history of paroxysmal atrial fibrillation, for which he was receiving