### 35 years old lady presents to OPD with fever daily since last 6 years. Associated with rigor on and off. Associated with generalized weakness and loss of appetite. She looks ill. Took medications OTC and from doctors also but in vain. She even got IV antibiotics (Inj. Xone, as per her talks) but no improvement. Her MP Optimal is negative and her Widal test is also negative. Her WBC count is within normal limits. But her ESR is raised much. Her DLC is within normal limits in one report and in another report her Eosinophil count is raised, RBC count is decreased (but Hb normal) and PCV decreased slightly. RE Urine is also within normal limits. Her serum uric acid and RBS are also within normal limits. She also complains of passage of white discharge per vagina. Also she complains of dry cough. How to approach and manage this case ??? What might be the diagnosis ??? What further investigations should be recommended to arrive at the diagnosis for proper treatment of this case ???

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** DDs of the case may be.... 1. PULMONARY TUBERCULOSIS : Cough, Feverishness, decreased appetite, raised ESR favour this Diagnosis. Confirm by CXR, Sputum ZN stain +/- CBNAAT. 2. CONDITIONS RELATED TO IMPAIRED IMMUNITY (eg. Cryptosporidiosis, Pneumocystis Jerovecii Pneumoni) : Take h/o chronic steroid therapy, Check for HIV status. If so then advice CXR or CT Chest, Stool exam. 3. HEPATITIS A : Test for Bilirubin and SGPT. If suggestive then see for Hepatitis viral serology. 4. ASTHMA /ALLERGIC CONDITIONS : Test for Serum Total IgE. 5. PERIPHERAL EOSINOPHILIA : Give a trial of Diethyl Carbamazine 100 mg TDS for 3 weeks. 6. ABDOMINAL TB : However it can't explain of cough here. May be cough and white discharge are separate entity. Advice USG /CT abdomen. 7. ATYPICAL INFECTIONS : Rikettsia or Other atypical infections to be ruled out. May give Doxycycline as presumptive therapy. 8. PID : White discharge and fever may be due to this. But it can't explain cough. 9. IRON DEFICIENCY ANAEMIA : Feverishness, loss of appetite, weakness are may be the presenting symptoms. R/O by advising CBC, Serum Iron, Ferritin. 10. UNDIAGNOSED MALIGNANCY : CT abdomen and Chest, Peripheral blood smear can rule out these. ** Investigations : Advice.... 1. Blood for CBC, PBS, TSH, Total IgE, HIV,Bilirubin, SGPT as primary tests . Anti Hep A IgM, Serum Fe, Ferritin if needed. 2. Sputum ZN Stain +/- CBNAAT. 3. CT Scan Chest and Abdomen. ** Emperic treatment : Meanwhile treat with... 1. Tab Monteleukast + Levocetrizine 1Tab ODHS for 1 month. 2. Tab Diethyl Carbamazine 100 mg TDS for 21 days. 3. Deworming with Albendazole 400 mg two doses two weeks apart. 4. Tab Doxycycline 100 mg BD for 1 week. 5. Tab Secnidazole 2 gm Stat dose. 6. Tab Fluconazole 400 mg weekly for 4 weeks. 7. Treat fever with PCM SOS and Cough with cough syrup containing CPM. 8. Adequate hydration and Carbohydrate diet.

Wow... What a marvellous explanation !!! Appreciated
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35 years old female with daily fever since 6 years. It is unbelievable. Patient needs evaluation As ESR is significantly raised . 1 infections - tuberculosis, chronic pyelonephritis., Ascending cholangitis. Typhus fever . Investigations- blood and urine culture. , slide test for M.P. Weil felix test for typhus and for borrellia recurrentis Ultrasound abdomen X- ray chest 2.Connective tissue disorders 3.Neoplasms 4.endocrine abnormalities 5.CNS lesions 6.hypothalamic diseases. Also think of Pel- Ebstein fever of hodgkin's lymphoma

Very nice explanation Sir... Thank you so much
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Go for ANA screening test sir. Can be a case of SLE . FEVER may be the only symptom of SLE as it begins. SLE is basically based on two hit hypothesis - infection or ocp usage can also can cause the second hit. From the history there is decrease in RBCS . Investigations to be done - Coombs test - ANA test If positive ANA test go for dsDNA ab test to confirm .

Thank you so much for your beautiful explanation !!!
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Any chronic fever wit h no localising sign is suggestive of rhematic conditions wrf to our country and so is the teaching infec tive endocarditis is the definitive possibility .

Which investigation should be recommended ??? @Dr. Sampathi Bashyam Aravamudhan
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Blood and urine culture and sensitivity test Slide method for MP. Iv antibiotic anti antipyretic. Multivitamins and antioxidants orally.

Thanks Dr Anowar.
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Urine and blood cultures Pap smear test Aso titre, CRP Cxr pa view Sgot sgpt,hbsag USG of whole abdomen ELISA for k.azar

Thank you so much for your beautiful explanation
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widal test is no longer done . advsd blood culture&sensitivity &report

Any fever of chronic duration may be heart related.for eg infective endocardititis(subacute bacterial endocarditis)ECHO is the most important diagnostic modality in arriving at a conclusion.admit the pt.Widal test is no longer performed.Blood c/s must be done in a case of enteric fever which is unlikely in this case.

six year fever age 35 white discharge.... PID blood and urine culture and sensitivity pap smear... USG abdomen and pelvis SOS pet scan.....symptomatic treatment till report come ....

Look for spemomegaly kale azar multiple myeloma etc further look for MP serum albumin globulin B12 level etc but I said it's not proper history given hear

What further history needs to be extracted in this case ??? Please explain
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