Seeking an Expert Interpretation

Abstract

A 32-year-old woman had been evaluated one month earlier for low-grade fevers and malaise. Her temperature at that time was 37.9°C (100.2°F), but her history and physical examination were otherwise unremarkable. She was told that she probably had a viral syndrome, and she was treated supportively. She returned one week later with the same symptoms, and on the basis of a distant history of sinus problems, she was given a one-week course of amoxicillin for possible sinusitis. Her fever persisted.This patient has a subacute febrile illness. Initially she was told she had two conditions: a viral syndrome and sinusitis. Both disorders are often ill documented and self-limiting. There is little evidence of a viral syndrome; the patient certainly does not have many symptoms characteristic of a viral infection. Sinusitis is often diagnosed in patients with respiratory symptoms, yet it is uncommon for patients to have respiratory symptoms and documentable sinus disease. It does not surprise me that her nonspecific illness did not get better.The patient reported a history of childhood asthma and occasional exercise-induced cough. She had received a course of antibiotics six months earlier for uncomplicated cystitis. She uses oral contraceptives and takes acetaminophen for occasional joint pains that she attributes to exercise. She had no relevant travel history and no risk factors for human immunodeficiency virus (HIV) infection or tuberculosis, and she used no other medications. Her blood pressure was 90/60 mm Hg, with a temperature of 38.4°C (101.2°F) and a pulse of 112. The remainder of her examination was unremarkable. The patient was admitted to the hospital.The history of joint pains is intriguing but nonspecific. If she had had overt arthritis I would be interested in examining her for rheumatic diseases. With respect to HIV, it is important to remember that because the traditional risk factors do not necessarily hold true anymore, anyone who has had sexual exposure could be at risk. The most salient feature of her history so far is her hypotension and tachycardia. The most common cause of these findings is dehydration or hypovolemia, though she has no history of fluid losses or physical findings to suggest volume depletion. I am always concerned about adrenal insufficiency in patients with a chronic illness and unexplained hypotension. At this point, though, I would still want to see the results of basic laboratory tests before ordering more specific tests.The patient's blood pressure returned to normal, but she continued to be febrile and had occasional temperatures as high as 38.8°C (102°F). Urinalysis was normal. The white-cell count was 10,300 per cubic millimeter with a predominance of lymphocytes. The hematocrit was 36 percent, and a peripheral-blood smear showed no abnormal cellular forms. Electrolyte levels were normal. Liver-function tests revealed an aspartate aminotransferase level of 54 U per liter, an alanine aminotransferase level of 45 U per liter, an alkaline phosphatase level of 118 U per liter, an...