A case of persistent fever

Abstract

Objective: Clinical case report. Methods: Description of a clinical case of a patient with dragged febrile syndrome and whose diagnosis was challenged by an unusual feature. Results: A male patient of 36 years old, with personal history of psoriasis (located on the scalp and nails) is followed in consultation of autoimmune diseases for psoriatic arthritis on suspicion. He was previously admitted in 2004 because of a febrile syndrome (axillary temperature between 38–39 °C), which lasts 10 days and is accompanied by arthritis. Other complaints were denied. Several exams were made, of which stood out: negative blood cultures, sputum bacteriological examination (including negative culture for Koch's bacillus), negative selorogies for HBV, HCV, HIV, CMV, Weil-felix, Huddleson, EBV, Widal and VDRL; normal lumbar punction; negative Antinuclear Antibodies (ANAs); abdominal ultrasound revealed discrete liver enlargement; echocardiography: slight pericardial effusion with mild mitral regurgitation; thoracic CT: fibrotic changes in the upper lobe of the right lung; bone scintigraphy that revealed high uptake of the sacroiliac joints, especially at the level of the tarsus, and 5th distal inter phalange joint. A probable diagnosis of psoriatic arthritis is established due to the presence of sacroiliitis and began therapy with methotrexate 15 mg per week, salazopyrin 5 g per day and deflazacort 6 mg per day. Four years later, by keeping the same complaints of poly-arthralgias, began etanercept with mild improvement. Ten months after restart the fever and arthritis, this time accompanied by evanescent, salmon-colored, macular eruption and odynophagia, there by establishing the diagnosis of Adult Still's disease. He initiated treatment with anakinra 100 mg per day having good results. Conclusion: Sacroiliitis is a typical manifestation of psoriatic arthritis, but may be present in a small percentage of patients with Adult Still's disease.