Chronic fatigue, arthralgia, and malaise.

Accepted for publication 6 February 1996 Case report A 25 year old female veterinary nurse presented with a six year history of general malaise and severe fatigue. Associated with this she described frequent (monthly) episodes of polyarthralgia affecting all joints but with a predilection for the small joints of the hands and the wrists. When present this was accompanied by mild morning stiffness. In addition she experienced colicky abdominal pain, sometimes with diarrhoea, occasionally with blood mixed with her faeces. Other complaints consisted of low back pain, sore gritty eyes, and an inability to perform any physical exercise at the time of these symptoms. Her symptoms had been remarkably consistent, with no recent change to their pattern. Six years ago she had been on a working holiday at a veterinary practice situated in New York state, USA. After eating a dish made with "blue fish" she had immediately developed severe nausea, vomiting, and malaise. Although all her acute symptoms resolved, her other symptoms started on return to the United Kingdom. She was investigated twice, at different hospitals, before being referred to this department. It had been found that her symptoms were helped by treatment with 30 mg prednisolone daily for the severe episodes and a maintenance dose of 5 mg daily. Severe episodes were occurring three to four times a year. Non-steroidal anti-inflammatory drugs, sulphasalazine, and other treatments of inflammatory bowel disease had not helped her symptoms. On all occasions the examination and investigations had been reported as normal including markers of inflammation, connective tissue disease, and radiological and histological gastrointestinal studies. No blood had been seen in her faeces. No diagnosis was made other than a seronegative arthralgia. She had managed to continue her job throughout this period but was becoming increasingly unable to perform other physical activities and rested completely at weekends. She was well supported by her partner and family and had no features or history to suggest a depressive illness. She had no other relevant medical history and there were no familial illnesses. Foreign travel before the illness had only been to the United States. Subsequently she had been to Ireland, where she had also worked, and on holiday to India. On examination she was a thin but fit 25 year old with no features of connective tissue disease, fibromyalgia, or Sjogren's syndrome. There was no joint deformity, swelling, or restriction of movement, and no lymphadenopathy or splenomegaly. Investigations showed normal haematology except for a persistently raised international normalised ratio (INR) at 1-2-1-4, normal range <1-14 (lupus anticoagulant was not detected), normal biochemistry including creatinine kinase, cortisol, negative porphyria screen, and serum angiotensin converting enzyme. She had negative stool cultures (these had been negative consistently as had sigmoidoscopy, endoscopy, and associated biopsies six months previously) and a negative glycocholate breath test. Serology to borrelia, brucella, and toxoplasmosis was negative as was serology to herpes viruses, hepatitis B, enteroviruses, and parvovirus. Her HLA tissue tissue type was A2,B7,B50(2 1),DR1 5(2),DR4 (not normally associated with autoimmune disease). Her chest radiograph was normal. A full autoantibody screen, including extractable nuclear antigens, was negative. An ophthalmological review showed no evidence of an abnormality. Yersinia serology was requested and was negative to Y enterocolitica and Y pseudotuberculosis I, II, III, and V. Serology to Ypseudotuberculosis type IV was positive for IgM at a titre of 1:320. There had been no history of recent typhoid vaccination. Treatment was commenced with high dose tetracyclines for one month. After three months the serology had reverted to normal, as had her abnormal INR. Over this period the patient required no steroid medication, worked full time, and became able to exercise without restriction. She experienced occasional mild arthralgia, which resolved spontaneously.