Rare oncological diagnosis presenting as ‘rheumatic fever’

Results Case report A 13-year-old Caucasian boy, while on a skiing holiday in Switzerland, developed fever, pharyngitis, erythematous skin lumps and arthralgia; investigations revealed significantly raised Anti-streptolysin-O titres. His blood count showed a transient neutrophilia and thrombocytosis. General practitioner diagnosed him with streptococcal infection and treated him with oral Penicillin; he made full recovery in few days and returned to the UK. However he continued to have episodes of fever, arthralgia associated with raised inflammatory markers for the next 5 weeks. These episodes seem to occur every 10 days, lasting 4 – 5 days. In between these episodes he would make full recovery. He was continuing oral Penicillin prophylaxis and Anti-streptolysin-O titres were improving. Acute rheumatic fever was one of the differentials, however towards the end of ‘febrile episode’, he became neutropenicwhich is not a recognised feature of acute rheumatic fever. Detailed investigations including: screen for common and rare bacterial and viral pathogens, biochemical profile, whole body isotope bone scan and urinary catecholamines, were within normal limits. Abdominal ultrasound revealed mild splenomegaly. Due to the neutropenia a bone marrow examination was performed, microscopy showed normal cellularity and maturation of the haematopoietic cells. Routine cutogenetic anaylysis was performed which demonstrated the classical Philadelphia chromosome t(9;22) BCR-ABL, thus supporting diagnosis of Chronic Myeloid Leukemia (CML). At presentation he was in the chronic phase.