Dr Chan 日記

I just like a little boy in a small boat.......... in a big big sea... don't know where I am and don't know how to do......
Over the past 1 week, I have great problem in managing a girl with PUO. She presented with prolonged fever for 20 days with the symptoms of sore throat and multiple tender cervical lymphadenopathy for 1 week followed by skin rash of limbs and trunk. She was given antibiotics of Unasyn for 10 days since Day 7 of her illness. There was no other symptoms of cough, runny nose, nausea, vomiting nor diarrhoea. There was no history of travel and there was no history of insect bite and she did not kept any pets at home. There was no history of recent weight loss and there was no family history of autoimmune disease, tuberculosis.
Physical examination showed multiple small non-tender cervical lymph nodes with generalised maculopapular rash over the body with prominent involvement over the distal part of the limbs. There was no hepatosplenomegaly.
Investigations results showed there was persistent leukopenia with the lowest white cell counts of 1.5 x 10^9/l. L/RFT were normal with moderate increase in LDH to 538. Microbiological investigations showed no growth on blood culture, negative malarial screen, Widal test, Weil-felix test, Mantoux test. Rubella IgM, Measles IgM, EBV IgM, Dengue fever IgM were all -ve. Autoimmune markers of ANA was -ve and the C3 and C4 level were normal. Inital CRP was normal 9.9 and subsequent CRP raised to 16. ESR was 35 on admission and raised to the latest of 50 today.
She had been given 7-day-course of iv cefotaxime without apparent response.
I have run into diagnostic difficulty and requested for skin biopsy, lymph node biopsy and bone marrow examination. I feel particular annoyed when I found that there was not much helpful input from my senior. Anyway, I continue with my discussion among our junior collegues and I start to look up the possible causes through the medline search. I found that there was an uncommon condition that may involve South East Asia girl with skin rash, fever, leukopenia and cervical lymphadenopathy and the diagnosis may rely on the skin biopsy that will be scheduled tomorrow. I hope this may help in making the correct diagnosis so as to alleviate my stress in my work.....
Hope everything would be fine and hope the girl will be able to recover soon......