Sometimes, several attempts at an accurate history are necessary before questioning elicits crucial information. The diagnosis for a 34-year-old woman with type 1 diabetes remained elusive until she provided a missing detail. She was transferred from an outside hospital, where she originally presented with a 5-month history of quotidian fevers up to 104°F (40°C). These were accompanied by lethargy, malaise, and significant weight loss. A review of systems was otherwise negative. The patient, an accountant, had no significant past surgical or family history. She was maintained on insulin and denied any use of alcohol, tobacco, or illicit substances. Initial laboratory findings were significant for an erythrocyte sedimentation rate of 140 mm/hr and severe anemia of chronic disease (hemoglobin, 8.3 g/dL).
Empiric antibiotic treatment produced no response. The patient continued to be febrile with no clear infectious source. Specialists in rheumatology and infectious disease were consulted, and extensive specialty-based studies were performed. Aside from a mildly elevated smooth muscle antibody titer (1:160), the workup remained negative for rheumatologic and infectious causes. Computed tomography of the chest, abdomen, and pelvis was significant for hepatomegaly plus enlargement of retroperitoneal and inguinal lymph nodes. Further evaluation included a lymph node biopsy, which showed reactive hyperplasia. Liver and bone marrow biopsy results were nondiagnostic.
The patient was again transferred, this time to our tertiary referral center for further evaluation of a fever of unknown origin. Upon arrival, her vital signs were stable except for a temperature of 104°F (40°C). Physical examination was significant for hyperpigmented, indurated plaques on the bilateral external thighs. The plaques were exquisitely warm and tender (Figure 1). Significant bilateral inguinal lymphadenopathy was also present.
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— Jenna R. Bordelon, BS, Syeda U. Abbas, MD, Arsalan Q. Shabbir, MD, PhD, Andrew L. Ross, MD
This article originally appeared in the September 2015 issue of The American Journal of Medicine.
