Case 36-2008

Dr. Adam B. Cohen (Neurology): A 59-year-old man was admitted to the neurology service of this hospital because of chronic daily headache, fever, and myalgia. Approximately 6 months earlier, the patient had begun having headache, accompanied by muscle spasms, generalized myalgia, weakness, fatigue, difficulty sleeping, and anxiety. The headache was constant, affected both temporal and frontal regions, and was not affected by posture. The temperature rose daily but remained below 37.8°C. Five months before admission to this hospital, he saw his internist at another hospital. The physical examination was normal. Amitriptyline at bedtime was prescribed, without improvement. The patient took ibuprofen every 4 hours and oxycodone–acetaminophen intermittently, with transient improvement in the headache. Three months before admission, computed tomography (CT) of the head without contrast material revealed increased density and possible thickening of the dural and subdural spaces along the frontal lobes. Results of liver-function tests were normal; other results of laboratory tests are shown in Table 1. On follow-up evaluation, the patient reported difficulty sleeping and night sweats, dry mouth at night, polydipsia and polyuria (urinating up to 25 times per day and up to 6 times per night), and pain in the jaws when chewing. His wife noted that he snored at night, but she had not observed choking or apneic episodes. Approximately 30 years earlier, for several years, he had had annual episodes of fever, sweats, and myalgia of 1 week’s duration, each of which had resolved after the use of antibiotics. Twenty-three years earlier, a mediastinal mass, 7.5 cm by 10 cm, was resected, and pathological examination reportedly revealed caseating granulomas within a lymph node. Testing for tuberculosis was negative. The annual febrile episodes had ceased after the surgery. On physical examination, there were enlarged nasal inferior turbinates and discomfort in the maxillary areas with pressure and percussion. A thoracotomy scar was present. The remainder of the examination was normal. Chest radiography showed calcified right hilar and paratracheal lymph nodes that were slightly more Case 36-2008: A 59-Year-Old Man with Chronic Daily Headache