11/5/18 Goldstein Morning Report

Today we presented a case of a 35 year old female with no past medical history presenting with 3 weeks of fevers, rash, sore throat, weight loss and diffuse joint pain. The differential for this presentation is broad, including infection, malignancy and rheumatologic disorders. Labs were significant for very mildly elevated transaminases, mild hyponatremia and normal white count with elevated neutrophils.

– Given the constellation of symptoms, multiple infectious causes were considered including murine typhus, acute HIV, and parvovirus (the rash associated with parvovirus can intensify with warm water and showers). The patient reported eating queso fresco so Brucellosis and Q fever were also possible (chronic Q fever can present with high fevers and mild transaminitis).
– Malignancy was considered, in particular hematologic malignancy given the presence of B symptoms. However the presence of joint pain and evidence of synovitis made hematologic malignancies less likely. Rheumatologic diseases such as RA and SLE can also present with similar symptoms.

The patient was ultimately diagnosed with Adult Onset Still’s Disease after infection and other rheumatologic diseases were ruled out, and iron panel showed a ferritin of >8000. Still’s disease is a diagnosis of exclusion made upon characteristic clinical and laboratory features.
– Our patient satisfied 3/4 of the major Yamaguchi criteria (patient did not have leukocytosis >10,000 however did have a PMN predominance) and 3 minor criteria (listed below).

Image result for yamaguchi criteria

Thanks to PGY3 Alex Yang for doing a great presentation!

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