Case history
Case history #1
A 26-year-old woman attends the emergency department with an 8-week history of daily fevers accompanied by an associated and short-lasting sore throat and non-pruritic rash. In the past 3 weeks, she has also developed painful, stiff, and swollen wrists and knees. She has had two courses of antibiotics for tonsillitis in the community with no benefit. Her only recent illness was a flu-like illness 2 months prior, requiring 4 days off work, though she recovered fully. On examination she has a temperature of 39.2°C, a salmon-pink, maculopapular rash on her trunk and shoulders and there are palpable tender cervical lymph nodes. Her wrist joints are mildly swollen and tender. Bloods show a raised WBC count (17 x 10⁹/L), raised neutrophils (12.5 x 10⁹/L), hyperferritinaemia (1200 ng/ml), and raised C-reactive protein (265 mg/mL). Rheumatoid factor, anticitrullinated protein antibody, and an antinuclear antibody screen are negative.
Case history #2
A 72-year-old man reports a 2-week history of daily high temperatures, arthralgia in both wrists, cervical lymphadenopathy, and pleurisy. In the past 2 days he has developed a central chest pain worse on deep inspiration and lying down. On examination he has a high temperature, cervical lymphadenopathy, a macular erythematous rash on his trunk and a pericardial rub heard on auscultation. ECG shows widespread ST elevation. Bloods show markedly raised WBC count (23 x 10⁹/L), raised neutrophils (18 x 10⁹/L), raised CRP (195 mg/mL), hyperferritinaemia (4600 ng/mL), and raised troponin (24 ng/L). Echocardiogram shows pericardial effusion.
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