See the start of the case below…
The blood film was leucoerythroblastic with left shifted neutrophils and some red cell fragmentation in keeping with disseminated intravascular coagulation. The bone marrow is under stress. The blood film does not reveal an obvious haematological cause.
Unfortunately the patient does not improve with general measures and continues to have temperatures. Some investigations from #teamhaem have requested have returned:
- HIV – negative
- B12/folate – within reference ranges
- Hepatitis B and C – negative
- CMV IgG is positive and IgM is negative
- EMB IgG is positive and IgM is negative
- Haemoglobin high performance liquid chromatolography is normal
- Microbiology reveals negative stool and urine culture and blood cultures do not help
- Malaria screen negative
- Chest radiograph below
The patient deteriorates and needs further IVT. Intensive care have been involved but the patient does not leave further higher level support for now. His antibiotics are escalated to piperacillin and tazobactam with gentamycin.
Questions
- Does the patient have PUO?
- What further investigations would you do?
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