From the Departments of Pediatrics and Radiology, University of Utah School of Medicine, Salt Lake City.
A 14-YEAR-OLD GIRL was referred for evaluation of a fever of unknown origin. She was in good health until 2 months previously, when she abruptly developed an elevated temperature and back pain. A urine culture was sterile. She had an elevated white blood cell count and a Westergren erythrocyte sedimentation rate of 116 mm/h. A chest radiograph and abdominal ultrasound were normal. Sinus radiographs indicated sinusitis. She was treated with azithromycin without improvement. A radionuclide bone scan demonstrated increased tracer uptake in the calvarium, left ninth rib posteriorly, and both knees. Results from radiographs of the skull and knees were normal. Serum antinuclear antibodies were positive with a level of 1:80. Several blood and urine cultures were sterile. Results of a serologic study for Epstein-Barr virus suggested a distant infection. A cytomegalovirus serologic study was negative.
The patient had a temperature of more than 40°C daily and had migratory arthralgias, occasional frontal headaches, and intermittent nausea and anorexia. She had lost 5.85 kg during this illness. The patient lived in a metropolitan area and had not traveled recently. The family had 2 cats and the patient also reported exposure to a hamster, dogs, and a lizard. She reported multiple insect bites in the preceding several months. She denied consumption of unpasteurized milk. The family history was unremarkable.
On physical examination, the girl was pale and appeared ill. Her temperature was 38.3°C and her blood pressure was 130/75 mm Hg. The oropharynx was slightly erythematous with no exudates. The first and second heart sounds were normal. A third heart sound and intermittent gallop were audible with no cardiac murmurs noted. An epigastric bruit was present. The results from the remainder of the physical examination were normal.
The total leukocyte count was 10.9 × 109L, with a normal differential. Hematocrit was 0.26 and platelet count was 725 × 109/L. The Westergren erythrocyte sedimentation rate was 98 mm/h. The C-reactive protein level was elevated to 149 g/L, and the serum electrolyte, blood urea nitrogen, creatinine, albumin, uric acid, and lactic dehydrogenase levels were normal. Serum alanine aminotransferase level was elevated at 69 U/L (normal, 4-46 U/L), but aspartate aminotransferase and bilirubin levels were normal. A urinalysis showed trace hemoglobin. Blood and urine cultures were sterile and stool cultures isolated only normal enteric flora. Serologic testing for coccidioidomycosis, toxoplasmosis, syphilis, hepatitis A virus, hepatitis B virus, and human immunodeficiency virus was negative. Purified protein derivative skin testing was negative, and Candida and tetanus antigen tests were positive.
A chest radiograph (Figure 1) was performed. Results of an echocardiogram showed mild aortic regurgitation. Magnetic resonance imaging of the thorax (Figure 2, left and right) followed.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Pediatrics editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Purchase Online Access to this article for 24 hours
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 2
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.