[Clinical reasoning and decision-making in practice. A patient with fever and pancytopenia].

Abstract

An 82-year-old man was admitted with a 1-week history of chilling fever and dry cough. Laboratory tests revealed pancytopenia and elevated levels of C-reactive protein and lactic dehydrogenase (LDH). Screening for infectious diseases was negative. A bone marrow biopsy showed aspecific findings. The combination of pancytopenia, persistent fever, elevated LDH and hepatomegaly (demonstrated by ultrasound examination of the abdomen) was suggestive of the haemophagocytic syndrome. This was confirmed by very high levels of ferritin and soluble interleukin-2 receptor in the blood. In addition, re-examination of the bone marrow showed several haemophagocytic histiocytes. A polymerase chain reaction for Epstein-Barr virus (EBV) revealed a very high viral load. Since the patient had a history of an increased level of anti-EBV immunoglobulin-G, this was explained by a reactivation of the EBV infection. On the sixth day in hospital the patient developed signs of bilateral pneumonia and subsequent multiple organ failure. Despite intensive treatment the patient died. Autopsy revealed no haematological or other malignancies, but did show haemophagocytosis in many organs. It was then concluded that the patient had a virus-associated haemophagocytic syndrome, due to a reactivation of EBV, for which no underlying cause was found.

• Authors: W K Lam-Tse, L van den Berg, L Dawson, H H van Ravenswaay Claasen, W Hart, E Maartense
• Journal: Nederlands tijdschrift voor geneeskunde (Ned Tijdschr Geneeskd) Vol. 152 Issue 11 Pg. 606-14 (Mar 15 2008) ISSN: 0028-2162 [Print] Netherlands
• Vernacular Title: Klinisch denken en beslissen in de praktijk. Een patiënt met koorts en pancytopenie.
• PMID: 18410020 (Publication Type: Case Reports, English Abstract, Journal Article)

Chemical References

• C-Reactive Protein

Topics

• Aged, 80 and over
• C-Reactive Protein (analysis)
• Epstein-Barr Virus Infections (blood, complications, diagnosis)
• Fatal Outcome
• Fever of Unknown Origin (etiology)
• Herpesvirus 4, Human (isolation & purification)
• Humans
• Lymphohistiocytosis, Hemophagocytic (blood, complications, diagnosis)
• Male
• Pancytopenia (etiology)