CASE 20: FEVERS AND FATIGUE
History
A 33-year-old woman is admitted to hospital because of general fatigue, fever and weight
loss. She has lost 5 kg in weight over the last 3 months. She has felt increasingly fatigued
and has a poor appetite. Over the past few weeks she has felt as if she was feverish and
has developed night sweats. She has no chest pain or shortness of breath. She and her two
children, aged 4 and 6 years, have come from Nigeria to visit her husband who has been
in this country for 2 years. She has visited the UK twice before. She has had occasional
fevers over the last 10 years and these have been treated presumptively as malaria with a
good response. She has been otherwise well, although her periods have been irregular over
the last 3 months. She has had no other serious medical illnesses. She is a non-smoker and
drinks no alcohol. The ward receptionist has suggested that she is not entitled to NHS
treatment.
Examination
She is thin and looks unwell. Her temperature is 38.2°C. There are no abnormalities in the
cardiovascular or respiratory systems and there are no lymph nodes palpable. Her con-
junctivae look pale. Physical examination is otherwise normal.
NormalHaemoglobin 8.6 g/dL 13.3–17.7g/dL
Mean corpuscular volume (MCV) 85 fL 80–99 fL
White cell count 12.0% 109 /L 3.9–10.6% 109 /L
Neutrophils 10.6% 109 /L 1.8–7.7% 109 /L
Lymphocytes 0.9% 109 /L 0.6–4.8% 109 /L
Platelets 97 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate 87 mm/h !10 mm/h
Sodium 134 mmol/L 135–145 mmol/L
Potassium 4.5 mmol/L 3.5–5.0 mmol/L
Urea 4.4 mmol/L 2.5–6.7 mmol/L
Creatinine 87 &mol/L 70–120&mol/L
Bilirubin 15 mmol/L 3–17 mmol/L
Alanine transaminase 26 IU/L 5–35 IU/L
Alkaline phosphatase 244 IU/L 30–300 IU/LBlood film: immature red cells/nucleated red cells present
Serum electrophoresis: normal
Urinalysis: no protein; no blood
Blood and urine cultures: negative
A chest X-ray is shown in Fig. 20.1.