Case 1: Fever and lymphadenopathy

Abstract

A previously well nine-year-old girl was transferred to her local tertiary paediatric centre after 15 days of fever and lymphadenopathy. Her symptoms started with fever and headache, resulting in several visits to her family doctor and eventually a prescription for cefprozil. Despite antibiotic therapy, the fever persisted, with increasing malaise and the development of ‘lumps’ on the left side of her neck. She was brought to her local emergency room on day 9 of her illness. Assessment in the emergency room noted the above symptoms plus a complaint of myalgias, particularly when her temperature was at its highest. She also described persistent ‘backache’ localized to her spine. The review of her systems noted the absence of rashes, gastrointestinal symptoms, weight loss, anorexia or other constitutional symptoms. The patient’s medical history was unremarkable, noting only attention-deficit hyperactivity disorder treated with methylphenidate. She had no known allergies, and her immunizations were up to date. The patient lived at home with her parents, step-sister and pet cat. All members of her family were well, with no contributory medical history, and none of whom had similar symptoms. She had not travelled outside of eastern Canada, where she was born, nor had tuberculosis or other sick contacts. On initial examination, the patient was thin with a temperature of 38.8°C. She had a 0.5 cm lymph node in her left posterior auricular chain, and several shotty lymph nodes bilaterally. Her physical examination was otherwise normal. A complete blood count revealed a white blood cell count of 14.2×109/L (neutrophils 50%, bands 18%, lymphocytes 25% and monocytes 6%), with erythrocyte sedimentation rate elevated at 105 mm/h and C-reactive protein at 76 mg/L. The remainder of her complete blood count, electrolytes, liver enzymes, lactate dehydrogenase and urinalysis were within normal limits. Her blood cultures, monospot, rheumatoid screening and spine x-rays were all negative, as were her serological tests for cytomegalovirus and toxoplasmosis. She remained febrile over the next five days, with her temperature spiking to 40°C, and was transferred to the IWK Health Centre (Halifax, Nova Scotia) for further diagnostic evaluation. The only new finding on transfer was progression of the lymphadenopathy in her left-sided cervical nodes. A laboratory test definitively made the diagnosis.