Cases from the Osler Medical Service at Johns Hopkins University

Abstract

Presenting featuresA 58-year-old man presented to the Johns Hopkins Hospital complaining of a 9-month history of malaise, fevers, night sweats, and weight loss. His fevers were episodic in nature with periods of constant fevers reaching high peaks (104°F) during the day from 5 to 7 days followed by an afebrile period 3 to 4 weeks. A typical fever curve of these episodes is shown in Figure 1 Note that the patient’s temperature rarely drops below the febrile range, <38°C. Review of symptoms was noteworthy for the lack of headache, pharyngitis, sinus congestion, cough, abdominal pain, diarrhea, arthritis, rashes, dysuria, urinary frequency, or neurologic symptoms. He had been placed on numerous courses of antibiotics, including levofloxacin and clarithromycin, during the months before ad-mission without a change in his symp-toms. Past medical history was unremarkable. He was on no medications. He denied recent travel, exposure to farm or exotic animals, or illicit drug use. He had been monogamous with his wife.His admission physical examination was notable for a temperature of 104.4°F and firm enlarged (1.5 to 2 cm) cervical and axillary lymph nodes. Admission laboratory data were notable for elevated liver function enzyme (aspartate aminotransferase 50, alanine aminotransferase 73, alanine phosphatase 274), and pancytopenia with a white blood cell count of 1300/mm3 (but a normal white cell differential), hematocrit level of 26, and platelet count of 103.000/mm3. To elucidate the etiology of his febrile episodes, a diagnostic procedure was performed.What is the diagnosis?