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A 27-year-old male traveller was admitted to hospital in the Netherlands because of fever and weight loss. He travelled in Africa from north to south during 9 months. He started in Morocco, crossed the Sahara and continued via Nigeria to Zimbabwe. Four months before admission he developed fever, headache and muscle aches; he went to a local laboratory and was found to have a positive blood film for malaria. He was treated with an antimalarial drug after which the fever disappeared. Two months before admission he had an episode of diarrhoea with some blood admixture; there was no fever. He used some tablets from his travel companion (‘against diarrhoea’) and improved. One month before admission he developed fever and muscle aches that continued until admission; later there was also right upper quadrant abdominal pain.

He had been adequately vaccinated for diphtheria, tetanus, poliomyelitis (DTP -booster), typhoid fever, yellow fever, hepatitis A and B and rabies; he used mefloquine as malaria prophylaxis, albeit intermittently.
After returning home, he had persistent intermittent fever, abdominal pain, right shoulder pain and generalized weakness. There was slight non-productive cough. He had lost 5 kg of weight since the start of the fever. He was admitted to hospital.

Physical examination

Ill looking; not jaundiced; not pale.
Vital signs: blood pressure 130/85 mm Hg; pulse rate 95/min, regular; respiratory rate 24/min; temperature 39.5 C.
Head and neck: no abnormalities.
Lungs: dullness right lower zone; normal breath sounds.
Heart: apex beat not displaced, not enlarged on percussion; heart sounds S1 S2, no pericardial rub.
Abdomen: tenderness right upper quadrant, liver enlarged 3 cm, tender, smooth surface, sharp edge.
Spleen not palpable.
Extremities: no oedema.
Skin: in the anterior axillary line at the upper abdomen/lower chest: swelling, redness and tenderness with peau d’orange appearance.

Laboratory results

ESR 60 mm/hr
Hb 8.1 mmol/L
TWC 13.3 x 10⁹/L; differential count: 80% neutrophils
Platelet count: 173 x 10⁹/L
Bilirubin 16 mmol/L
AST 14 U/L
ALT 23 U/L
Alkaline Phosphatase 110 U/L (n< 75)

Questions

1 What is the differential diagnosis?
2 What diagnostic procedures would you do?
3 What is the likely diagnosis?
4 What is the preferred treatment?

Answers on page 15