100 Cases in Clinical Medicine

CASE 78: FEVER

History

A 36-year-old man presents to his general practitioner (GP) complaining of a fever and
generalized aching in muscles around the back and legs. At first he thought that this was
probably influenza but the symptoms have now been present for 9 or 10 days. For 3 days
he had diarrhoea but this has settled now. He has complained of a sore mouth over the last
week or so which has made it difficult to eat, but he has not felt very hungry during this
time and thinks he may have lost a few kilograms in weight. Around the time that the
symptoms started he noticed a mild erythematous rash over his chest and abdomen but
this has faded.

He has visited the practice occasionally in the past for minor complaints. He has been to
the practice to obtain vaccinations for visits to Vietnam and Thailand over the last 3 years.
His last travel abroad was 3 months ago. He smokes 10 cigarettes daily, drinks 20–30 units
of alcohol weekly and takes no illicit drugs. He had no other relevant medical or family his-
tory. He works as a solicitor. He is single and lives alone. He has had a number of hetero-
sexual and homosexual relationships in the past. Twelve months ago he had an HIV test
which was negative.

Examination

He had a temperature of 38°C. Pulse rate was 94/min, respiratory rate 16/min and blood
pressure 124/78 mmHg. There were no abnormalities in the cardiovascular or respiratory
system. On examination of the mouth there were two ulcers in the oral mucosa, 5–10 mm
in diameter. There were a number of palpable cervical lymph nodes on both sides of the
neck, which were a little tender. There were no other nodes and no enlargement of liver
or spleen. There were no rashes on the skin.

Normal

Haemoglobin 14.8 g/dL 13.7–17.7 g/dL

Mean corpuscular volume (MCV) 87 fL 80–99 fL

White cell count 7.4% 109 /L 3.9–10.6% 109 /L

Neutrophils 5.1% 109 /L 1.8–7.7% 109 /L

Lymphocytes 2.0% 109 /L 0.6–4.8% 109 /L

Platelets 332 % 109 /L 150–440% 109 /L

Sodium 144 mmol/L 135–145 mmol/L

Potassium 4.4 mmol/L 3.5–5.0 mmol/L

Urea 5.9 mmol/L 2.5–6.7 mmol/L

Creatinine 73 &mol/L 70–120&mol/L

Bilirubin 13 mmol/L 3–17 mmol/L

Alkaline phosphatase 121 IU/L 30–300 IU/L

Alanine aminotransferase 25 IU/L 5–35 IU/L

Screening test for glandular fever: negative

INVESTIGATIONS

Question

• Suggest some possible diagnoses.