After eating a small crayfish repeated fever, turn 20 days to find the reason!

What is the cause of repeated fever? A 74 year old woman with fever caused by a meal of crayfish was admitted to the hospital for "repeated fever for more than 20 days".20 days ago, the patient complained of fever after eating "crayfish", and went to the nearby hospital for emergency treatment. The temperature was measured at 38.6 ℃. After treatment with cephalosporins, the body temperature did not decrease significantly.chest tightness and asthma occurred the next day. Blood routine examination: WBC 20.7 × 109 / L, neu 89.6%, C-reactive protein (CRP) 11.7 mmol / L; blood biochemistry: uric acid 429 μ mol / L.1 after admission, the patient developed redness, swelling and heat pain in front of the tibia of his left lower limb, and was diagnosed as "erysipelas of the left lower limb". He received symptomatic treatment such as "Thiamphenicol". The red swelling of the left lower limb subsided without fever. The blood routine examination showed that white blood cells and neutrophils decreased to normal before discharge. After 21 weeks, the patient again had chills and fever, with the highest temperature of 39 ℃, no rash, chest tightness and asthma Blood routine examination: 8.5% monocyte, 6.5mg/l crp36.5mg/l; after 3 days, the patient developed high fever every afternoon and night, during which two blood cultures showed gram positive cocci and Staphylococcus intermedia.the patient was treated with vancomycin, levofloxacin and other drugs successively, but the patient still had repeated fever and chills, so he was hospitalized.with history of hypertension, coronary heart disease and cerebral infarction in the past, blood pressure can be controlled normally.after entering the Department, they had the following characteristics: chills and high fever at night in the afternoon, fever after taking antipyretic drugs, general fatigue when fever, no joint swelling, chest tightness, cough, frequent urination, headache, abdominal pain, diarrhea and other discomfort.no obvious rash or lymph node enlargement was found.is this fever related to the last one? What is the cause of fever? With doubts, we improved the preliminary examination: blood routine: hemoglobin 109G / L.ESR: 81mm / h; there was no abnormality in Schilling's classification.no filariasis and Plasmodium were found on blood smear, and no abnormality was found in urine routine examination.Blood Biochemistry: albumin 30.8g/l, alanine aminotransferase: 49U / L, aspartate aminotransferase: 41u / L, globulin 34g / L, procalcitonin 0.076 μ g / L.thyroid function: FT3 3.21pmol/l, T3 0.80nmol/l, t4162.47nmol/l.humoral immunity: Aso 225iu / ml, IgE 168iu / ml.autoantibodies: no abnormality was found.respiratory pathogens: weakly positive for anti Mycoplasma pneumoniae IgM antibody, 2 + for anti EB virus shell antigen IgG antibody, weak positive for anti EB virus early antigen IgG antibody, weakly positive for anti EB virus antigen IgG antibody; no bacteria were cultured in four blood cultures.chest CT: organized inflammation in the tongue segment of left upper lobe and right lower lobe, calcification in left lower lobe; calcification of mediastinum and left hilar lymph nodes, enlargement of pulmonary artery trunk and its branches; fatty liver.abdominal CT: small calcification in the lower part of the right lobe of the liver, a few exudative changes at the edge of both kidneys, and a possible left uterine fibroid.head CT: mild brain atrophy.combined with the patient's medical history and auxiliary examination, the clinical characteristics of the patient were recurrent fever, but the symptoms were relatively "carefree", no localizable signs were found, and no obvious signs of infection were found in blood routine and imaging examination.the patient had a rash on the left lower limb in the medical history and was diagnosed as "erysipelas". After anti infection treatment, the rash subsided, and whether the fever was related to the rash was doubtful. The nature of subcutaneous nodules was unknown before, but the patient did not have rash again this time, which can not be further identified; the patient had increased blood uric acid, lower limb swelling, heat and pain, but the part described by the patient was not in the typical joint site The basis of gout is insufficient, and no joint skin redness, swelling and heat pain is found in this fever; the basis of bacterial infection and virus infection is insufficient according to the existing physical examination and auxiliary examination; there is no positive sign and examination result support for malignant tumor such as lymphoma.which direction should we take for diagnosis and treatment next? We are in a dilemma.after discussion, the patient stopped taking antipyretic drugs during the fever time. Before the cause of fever was not known, we decided to let the patient stop taking antipyretic drugs and other drugs to observe the heat type and the changes of the disease.on the second day after drug withdrawal, the patient complained of lower limb pain. Physical examination: scattered nodular erythema appeared in both lower limbs (Figure 1), slightly higher than the skin, with irregular shape, unclear edge and tenderness.the clue was finally exposed, and skin biopsy was performed immediately. The biopsy report showed that there were more acute and chronic inflammatory cell infiltration in dermis and subcutaneous fat septum of "left lower limb", which was consistent with panniculitis (non-specific).the patient was diagnosed as "panniculitis". After methylprednisolone treatment, the patient's temperature dropped to normal, and the erythema of both lower limbs subsided.methylprednisolone was gradually reduced to discontinuation after discharge, and no recurrence was found after half a year follow-up.Figure 1: erythema nodosum scattered in the lower limbs of the patient.02 what disease is panniculitis? 1. Concept of panniculitis. Panniculitis is a rare disease, mainly in women. It refers to the non suppurative inflammation of subcutaneous fat layer, usually manifested as subcutaneous inflammatory nodules or plaques.the etiology of the disease is unclear, the clinical manifestations are diverse, and the specificity is poor, including a variety of subtypes, which can be associated with infection, trauma, malignant tumor and inflammatory disease, so the diagnosis is difficult.subcutaneous nodules vary in size and are distributed symmetrically. They often occur in the lower limbs, and can also be seen in the upper limbs, face and trunk. In addition to the subcutaneous nodules, common clinical symptoms include fever, chills, joint pain, fatigue, cough, chest tightness, muscle soreness and other non-specific symptoms; patients with systemic type also have visceral damage, all kinds of organs can be involved, and digestive system is the most involved Common; physical examination found subcutaneous tenderness of the nodules for panniculitis has suggestive significance.the common types of panniculitis are as follows (Table 1): Table 1: common types of panniculitis subcutaneous nodules prone sites (extracted from uptodate) Panniculitis: recognition and diagnosis) common types of panniculitis: nodular erythematosus on the extension side of the lower leg, fat skin sclerosis on the flexed side of the lower leg α 1-antitrypsin deficiency panniculitis of the buttock, side waist and thigh subcutaneous sarcoidosis of the forearm lupus panniculitis face, scalp, upper arm, breast, upper trunk, buttock and thigh 2 The key to bed diagnosis is the histopathological examination of skin biopsy, combined with comprehensive medical history collection and physical examination, to identify the subtypes of panniculitis (Table 2).most panniculitis can be classified into the following subtypes: 1. Inflammatory; 2. Infectious; 3. Traumatic; 4. Deposition; 5. Enzymatic destruction; 6. Malignant tumor.in this case, there was subcutaneous nodule, but only fever was found in the second visit, which brought challenges to our diagnosis. this also suggests that before the cause of fever is unknown, antipyretic drugs should be used carefully to avoid covering up the disease. Table 2: key medical history inquiry (from uptodate panniculitis: identification and diagnosis) common types of panniculitis key history to identify whether there is streptococcal infection or other risk factors related to erythema nodosum before inflammation? Do you have a history of connective tissue disease or symptoms suggestive of connective tissue disease? Do you have a history of chronic lower extremity edema? Is there immunosuppression in infectious patients? Is it an acute disease process? Does the patient have a history of local trauma or freezing? Is the lesion located at the site of injection or radiotherapy? Does the patient have renal failure or gout? Is enzymatic destruction suggestive of pancreatitis? Is there any early-onset emphysema (α - 1 antitrypsin deficiency)? Do you have a history of malignancy? Is the patient acute or chronic? The treatment of panniculitis includes anti-inflammatory therapy and immunosuppressive therapy. for patients with common skin type, non steroidal anti-inflammatory drugs or glucocorticoids can be given symptomatic treatment. however, some patients may relapse after drug withdrawal, so 1-2 kinds of immunosuppressants can be selected for treatment, such as hydroxychloroquine, azathioprine, thalidomide, cyclophosphamide, mycophenolate mofetil and cyclosporin; biological agents can be considered when necessary. References: 1. Division of Rheumatology and immunology of internal medicine, people's Health Press, October 2015, 1st edition. 2. Rheumatology branch of Chinese Medical Association, guidelines for diagnosis and treatment of nodular panniculitis (Draft), Chinese Journal of Rheumatology, 2004,8:253-255