Pyrexia of Unknown Origin "Misleading First Impressions"

48 year old foundry worker from Kumta district, Karnataka (India) presented with 3 weeks history of fever, body ache, cough, weight loss (10 kg) and anorexia. Recently detected to have type 2 DM. No significant illness in the past. No history of any recent travel outside the district. O/E Temp 101.F, PR 112/min, RR-22/min BP 100/70 mm Hg Toxic looking. No pallor, icterus, clubbing, lymphadenopathy, skin lesions. Sparse crepitations heard over right lung base. Mild hepatomegaly present. No focal neurological deficit. With the above findings provisional diagnosis of

• Pneumonia

• Tuberculosis

• Enteric fever

• Brucellosis was made.

Materials and Methods:

Day-1:

TLC – 15,400/cu mm with neutrophilia, ESR – 140 mm/hr, RBS - 247 mg%, HIV, HbsAg, HCV status was negative. Tests for Dengue, Malaria, Typhoid, Leptospira, Brucella was negative. USG abdomen showed hepatomegaly and ECHO showed no vegetations. Blood and urine cultures were sent which were awaited, started on broad spectrum antibiotics in view of probable right lower lobe pneumonia.

Day-2:

Impression: tuberculosis/malignancy: Bronchoscopy showed only inflammatory cells, no endobronchial lesion, bronchial washings sent for gram stain, C&S, AFB.

Day-3:

He developed sudden onset of flaccid paraplegia with absent sensation below T8 level and urinary retention. Now the possibilties of acute myelitis, Spinal Abscess or Potts spine were considered.  Read more......