Fever, rigors and sweats in an immunocompromised male.

A 63-yr-old male presented with a 20-day history of fever with chills, rigors, sweats and fatigue. He resided in the countryside and there was no history of recent travel to other countries. He had a past medical history of idiopathic pulmonary fibrosis (usual interstitial pneumonia confirmed by surgical biopsy) and the last 2 yrs he was taking daily azathioprine 100 mg per os and methylprednisolone (actually) 12 mg per os. On physical examination he was pale, with a body temperature of 39.5uC, blood pressure 130/90 mmHg, pulse rate 90 beats per min and respiratory rate 24 breaths per min. There were no skin rashes, petechiae or ecchymoses. The abdomen was soft, without tenderness or rigidity and the spleen was enlarged 3 cm below the costal margin. The auscultation revealed "velcro" rales at the lower lung fields bilaterally. There were no heart murmurs. Laboratory investigations revealed the following values: haemoglobin 1.271 mM (78 g?L); total leukocyte count 1.54610?L, with differential count 56% polymorphonuclears, 39% lymphocytes and 4% monocytes, and 57610?L platelets. The prothrombin time and activated partial thromboplastin time were within normal range. The blood urea was 16 mM the creatinine 97.2 mM, total bilirubin 42.75 mM with a indirect fraction 27.36 mM, aspartate aminotransferase 1500 nM?s alanine aminotransferase 866.8 nM?s. Peripheral blood smear showed no parasites. Cultures of blood and urine failed to yield any significant growth, and induced sputum was negative for Pneumocystis carinii. Mantoux and sputum test for acid-fast bacilli were negative. Serology for human immunodeficiency virus (HIV) and urine Legionnella antigen were negative, while the results of serological tests for mycoplasma, chlamydia, ricketsiae, malaria, leishmania, brucellosis and common virus were pending. Chest roentgenogram (fig. 1a) and computed tomography scan have shown no apparent changes compared with past films (12 months previous). An upper abdomen film is visible in figure 1b. A bone marrow aspirate was performed; the findings are shown in figure 2.