This odd case, shared by a Perth-based GP, can use a bit of your wisdom. Test your skills and share your opinion on this baffling case.
Challenge
A 60-year-old man presented with 1 week history of muscle pains after returning to Great Southern WA from a 4-week holiday in coastal NSW. The patient was initially diagnosed with poly myalgia rheumatica and commenced treatment with steroids.
Initial results showed that the patient’s Erythrocyte sedimentation rate (ESR) was normal and there was a mild elevation in C-Reactive Protein (CRP), with elevated lymphocytes (Known CLL stage 0).
The following week, the patient returned with increased levels of pain, swinging fever and a maculopapular rash on the chest. At this point, the patient said his condition was like typhus diagnosed years ago.
No focus for infection found, but the rash resembled typhus.
The patient was commenced on amoxicillin and doxycycline and sent off serology and blood cultures. Liver function test and a creatine kinase (CK) test were normal.
Three days later, the patient returned with increasing muscle pain and developed 2 more rashes:
- Urticarial rash all over body
- Small vesicular rash in clusters on upper body and upper arms.
The patient also began complaining that his voice sounded like a robotic voice to him. No audible change in voice detected by me or the patient’s family.
Antibiotics were stopped, as a presumed cause of urticaria. The vesicular rash was swabbed for Herpes simplex.
The patient continued to have Pyrexia of Unknown Origin symptoms, and increased self-reported “robotic voice”. Muscle and limb pain also increased.
Now, 14 days since initial presentation to the GP, the patient has started to develop leg weakness and is unable to stand up from a squat. On clinical examination the patient lost knee and ankle reflexes. No other neurological signs detected.
On the basis of these findings only, what is the most probable diagnosis?
- Guillain-Barré syndrome secondary to Infection Rheumatoid nodule
- Rickettsial Illness
- Disseminated herpes simplex.
- Something else?
Please send your answers, ideas or suggestions to: karl@mforum.com.au. All GPs are welcome to share their odd cases.