A patient with diarrhea, arthralgias, and fever

摘要: A 28-year-old carpenter presented with diarrhea and abdominal pain for the past 4 months. He reported passage of 4-6 loose stools daily, associated crampy midabdominal bloating. also a 5-year history fever. This occurred primarily in evenings, temperatures sometimes reaching 103’F drenching sweats. In addition, there was fatigue migratory arthralgias involving proximal interphalangeal joints, wrists, elbows, knees, ankles, tarsal areas, metatarsophalangeal joints. The would usually only involve single joint at time lasting 1-4 days given area. had been treated enteric-coated aspirin up to g/day, as wel1 prednisone dose ranging from 5 10 mg excellent suppression arthralgias, although not complete relief fevers. denied use other medications. married, no sexually transmitted disease or illicit drug use. His father Italian mother German; family gastrointestina1 disease. review systems revealed gastrointestinal bleeding, weight loss, skin rash, symptoms. On examination, his temperature 36.9”C. muscular healthy appearing. vita1 signs were normal. mucous membrane examinations did reveal any abnormalities. NO pallor clubbing noted. Abdominal examination masses tenderness, recta1 There several smal1 nontender axillary nodes bilaterally less prominent inguinal nodes, but cervical lymphadenopathy. cardiac auscultation, an inconstant soft systolic click heard, murmurs rubs detected. Neurological Laboratory results fellows (normal values parentheses): hemoglobin, 9.1 g/dL (12.9-16.6); mean corpus9.2 X lO”/L (4.1-10.9) normal differential; platelet count, 593 109/L (184-370); erythrocyte sedimentation rate, 52 mm/h (0-22); reticulocytes, 1.1% (0.6-1.8); periphera1 blood smear showed microcytic red cells slight abnormalities including regenerating macrocytes, schizocytes, keratocytes stomatocytes; hemoglobin electrophoresis normal; serum iron, 9 pg/dL (50-150); total iron binding capacity, 266 (250-400); saturation, 3% (14-50); vitamin B,,, 367 ng/L (281-1079); folate, 7.0 pg/L (2-20); sodium, 137 mEq/L (135145); potassium, 4.9 (3.6-4.8); calcium, mg/dL (8.9-10.1); phosph orus, 4.6 (2.5-4.5); protein, 6.1 (6.3-7.9); glucose, 78 (70-100); alkaline phosphatase, 159 U/L (98-25 1); aspartate aminotransferase, 25 u/L (12-31); bilirubin, 0.4 (0.1-1.1); direct 0.1 (0.0-0.3); uric acid, 4.2 (4.3-8.0); creatinine, 1.0 (0.8-1.2); albumin, 3.3 g/ dL (3.5-5.0); thyroxine, 6.5 (5.0-12.5); fecal 1.6 mg/g stool (0-2); rheumatoid factor, ~30 IU/mL (0-39); antinuclear antibody negative; anti-double stranded DNA, 53 U (0-70); rapid plasma reagin nonreactive. Stool parasites some fatty crystals. Cultures urine negative. Chest spine radiographs An upper barium series esophagus stomach minimally thickened duodenal jejunal folds. enema slightly “lymphoid follicles” cecum ascending colon.