Infectious Disease
Case 9: A Young Man with a Fever of Unknown Origin
CASE
A 25‐year‐old labourer had an 8‐week history of feeling unwell. His symptoms initially started with right‐sided otitis media which did not resolve with antibiotics; he then developed right‐sided Bell's palsy with minimal improvement with prednisolone and aciclovir. During this time he experienced intermittent fevers, night sweats and lost 6 kg in weight. He presented to A&E with a 2‐day history of breathlessness, haemoptysis and a fever. There was no history of foreign travel.
On examination he was found to be febrile and hypoxic with a PaO2 of 8 kPa on air. He had a complete right VII nerve palsy and reduced hearing on the right; the rest of the CNS examination was normal. There were no vesicles in his external auditory canal. Bronchial breathing was heard bi‐basally and his heart sounds were normal.
The following results were obtained:
Hb 13 g/dL WCC 17 × 109/L(80% neutrophils) Platelets 240 × 109/L CRP 240 mg/L ESR 90 mm/h Clotting Normal U&Es Normal LFTs Normal
Chest radiograph: multiple coin‐shaped cavitating lesions in both lung fields
Sputum analysis: negative for acid‐fast bacilli
HIV test: negative
Blood culture: no growth
Urinalysis: blood ++
c‐ANCA: positive (high titre)
QUESTION 1
Your score this session: 0 of 0
What is the likely cause of his fevers?