Grace Elta and Robert J. Fontana, Section Editors A 44-Year-Old Patient With Fever, Night Sweats, and Arthralgia Thomas Karlas, 1,2 Joachim Mössner, 2 and Volker Keim 2,3 1 Leipzig University Medical Center, IFB Adiposity Diseases, 2 University Hospital Leipzig, Department of Internal Medicine, Dermatology and Neurology, Division of Gastroenterology and Rheumatology, and 3 University Hospital Leipzig, Interdisciplinary Ultrasound Unit, Leipzig, Germany Question: A 44-year old man presented with fatigue, intermittent fever, and night sweats. His symptoms started 10 days earlier. Furthermore, he reported painful knee joints after physical exercise for the last week. He experienced similar, self-limiting episodes of arthralgia 1 and 2 years ago. The patient stopped smoking 10 years earlier (20 pack-years). Further personal medical and travel history were uneventful. On admission, physical examination was unremarkable, except for a slight swelling of both knees. C-reactive protein level was 160 mg/L (normal, <5) and both alanine and aspartate aminotransferases were elevated (174 and 120 U/L; normal, <51). Alkaline phosphatase was 145 U/L (normal, <129); gamma-glutamyl transferase and bilirubin were within normal ranges. Hemoglobin was 7.9 mmol/L (normal, >9.2) and there was mild thrombocytosis (465 Gpt/L). The further blood count was within normal limits. A chest x-ray and urinalysis did not reveal any pathological findings. Abdominal ultrasound detected a central liver lesion (23 19 mm) with a hyperechoic halo (subcostal view, Figure A). Alpha-fetoprotein, carbohydrate antigen 19-9, carcinoembryonic antigen, prostate-specific antigen, and liver autoantibodies were within normal limits. Serology and polymerase chain reaction were negative for HIV, hepatotropic viruses (hepatitis B and C; herpes simplex, varicella, Epstein–Barr virus, and cytomegalovirus), mycoplasma and Borrelia burgdorferi. The clinical suspicion of malignancy was supported by predominant arterial tumor perfusion and lack of perfusion in the portal venous phase in contrast-enhanced ultrasound (Figure B, C, respectively). Whereas on computed tomography (CT) barely any lesion was detectable (Figure D), magnetic resonance imaging (MRI) showed a signal decrease in the late phase after injection of contrast agent (T1 20 minutes after gadoxetate disodium injection; Figure E). Positron emission tomography (PET) revealed an intense glucose Electronic Clinical Challenges and Images in GI GASTROENTEROLOGY 2013;145:e1–e3
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A 44-Year-Old Patient With Fever, Night Sweats, and Arthralgia
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