Fever, weight loss, and night sweats: infection or malignancy?

Case report (Dr A Winter) A Peruvian man in his 30s was admitted as an emergency with a 3 week history of fluctuating temperatures and rigors, a worsening sore throat, and a 4 day history of non-bloody diarrhoea without significant abdominal pain. On further inquiry he denied respiratory, neurological, or urinary symptoms, but admitted to night sweats for the past 4 months and some 20 kg weight loss in the past year. The patient had lived in the United Kingdom for 10 years. He had just arrived back from a 1 week cruise around the coast of Spain. He could not recall any insect bites and had not slept on land. Nine months before admission he had visited the coastal region of northern Peru and had made several previous visits to the Amazon basin without adequate antimalarial prophylaxis. He denied previous exposure to tuberculosis, smoked 20 cigarettes a day, and drank about 20 units of alcohol weekly. He lived with his regular male sexual partner of 5 years, but admitted to multiple male sexual partners in Spain in the 1980s. Ten months before admission he had presented to the genitourinary clinic with perianal warts but after counselling had declined an HIV test. He did not know the HIV status of any of his previous partners. Nine months before admission he had presented to his general practitioner with indigestion and was found to be seropositive for Helicobacter pylori with a normal upper gastrointestinal endoscopy. Four months before this admission he had presented with an ischiorectal abscess which had required incision and drainage twice, yielding Escherichia coli on the first occasion, and a mixed growth of Staphylococcus aureus and Bacteroides on the second. A sterile pyuria had been noted on both occasions but had not been further investigated. Two weeks before admission he had undergone an anal stretch procedure for a fistula in ano and had subsequently received courses of flucloxacillin, ciprofloxacin, co-amoxiclav, and metronidazole. On examination he was surprisingly well in spite of intermittent rigors. The temperature was 38°C, the pulse 100/min, and the blood pressure 140/75 mm Hg. He had mild oral candidiasis and oral hairy leucoplakia. There was a soft systolic ejection murmur. The liver was palpable 3 cm below the costal margin. The spleen and lymph nodes were impalpable. The perianal area was intact with no sign of an abscess. The respiratory and neurological systems were normal and there was no rash. Funduscopy revealed a small (and transient) flame haemorrhage in the right eye but was otherwise normal. Oxygen saturation was 98% and did not fall on exercise. The haemoglobin was 11.0 g/dl, total leucocyte count 2.9 × 10/l (neutrophils 1.7 × 10/l, lymphocytes 1.0 × 10/l), and platelet count 144 × 10/l. The erythrocyte sedimentation rate was 99 mm in the first hour. The serum albumin was 28 g/l, and the alkaline phosphatase (ALP) was 482 IU/ml (normal 70–320) but the bilirubin and transaminases were normal. Serum creatinine was 84 (μmol/l). The urine contained more than 100 leucocytes/ml, red cells, and casts but was sterile. The patient agreed to HIV testing and was found to be HIV seropositive. He was naturally immune to hepatitis B (HBsAg negative and total anti-HB core antibody positive) and seropositive for cytomegalovirus (CMV) IgG. Anti-CMV-IgM was detected but CMV DNA could not be amplified from the blood by polymerase chain reaction (PCR). Serological tests for toxoplasma (IgG and IgM), hepatitis C, hepatitis A IgM, syphilis, and parvovirus IgM were negative. He had serological evidence of past Epstein–Barr virus (EBV) infection, but was negative for IgM EBV viral capsid antibody and a Paul Bunnell test was negative. A test for serum cryptococcal antigen was negative. No malaria parasites were found in multiple thin and thick blood films. The chest radiograph was normal. Nine sets of aerobic and anaerobic blood cultures were sterile. Five stool cultures were negative for pathogenic bacteria, cysts, and parasites (including cryptosporidium) and C diYcile toxin. A perianal swab grew Staphylococcus aureus and Candida. The sputum grew Candida but no acid fast bacilli were seen. No pathogenic bacteria or viruses were isolated from a throat swab. Blood and urine was sent for mycobacterial culture. The patient was anergic to tuberculin. There was hypergammaglobulinaemia but complement levels were normal. An autoantibody screen revealed antineutrophil cytoplasmic antibody (ANCA) at a titre of 1:25 with a cytoplasmic pattern and antismooth muscle antibodies. Hepatosplenomegaly was demonstrated by ultrasound which also revealed two nodules near the femoral vessels. By computed tomography the liver measured 21 cm, the spleen 14 cm, and a few paracaval and aortic lymph nodes up to 1 cm diameter were noted. The mediastinum and chest were normal. Although there was thickening of the rectal wall no perianal abscess was seen. Sex Transm Inf 1998;74:439–444 439