A patient with diarrhea, arthralgias, and fever.

A 28-year-old carpenter presented with diarrhea and abdominal pain for the past 4 months. He reported the passage of 4-6 loose stools daily, associated with crampy midabdominal pain and bloating. He also reported a 5-year history of fever. This occurred primarily in the evenings, with temperatures sometimes reaching 103’F associated with drenching sweats. In addition, there was a 5-year history of fatigue and migratory arthralgias involving the proximal interphalangeal joints, wrists, elbows, knees, ankles, tarsal areas, and metatarsophalangeal joints. The arthralgias would usually only involve a single joint at a time with pain lasting 1-4 days in a given joint area. He had been treated with enteric-coated aspirin up to 4 g/day, as wel1 as with prednisone in a dose ranging from 5 to 10 mg daily, with excellent suppression of the arthralgias, although not complete relief of the fevers. He denied use of other medications. He was married, and there was no history of sexually transmitted disease or illicit drug use. His father was Italian and mother German; there was no family history of gastrointestina1 disease. The review of systems revealed no history of gastrointestinal bleeding, weight loss, skin rash, or other symptoms. On examination, his temperature was 36.9”C. He was muscular and healthy appearing. The vita1 signs were normal. The skin and mucous membrane examinations did not reveal any abnormalities. NO pallor or clubbing was noted. Abdominal examination revealed no masses or tenderness, and recta1 examination was normal. There were several smal1 nontender axillary nodes bilaterally and several less prominent inguinal nodes, but no cervical lymphadenopathy. On cardiac auscultation, an inconstant soft systolic click was heard, but no murmurs or rubs were detected. Neurological examination was normal. Laboratory results were as fellows (normal values in parentheses): hemoglobin, 9.1 g/dL (12.9-16.6); mean corpus9.2 X lO”/L (4.1-10.9) with normal differential; platelet count, 593 X 109/L (184-370); erythrocyte sedimentation rate, 52 mm/h (0-22); reticulocytes, 1.1% (0.6-1.8); periphera1 blood smear showed microcytic red blood cells and slight abnormalities including regenerating macrocytes, schizocytes, keratocytes and stomatocytes; hemoglobin electrophoresis normal; serum iron, 9 pg/dL (50-150); total iron binding capacity, 266 pg/dL (250-400); iron saturation, 3% (14-50); vitamin B,,, 367 ng/L (281-1079); serum folate, 7.0 pg/L (2-20); sodium, 137 mEq/L (135145); potassium, 4.9 mEq/L (3.6-4.8); calcium, 9 mg/dL (8.9-10.1); phosph orus, 4.6 mg/dL (2.5-4.5); total protein, 6.1 g/dL (6.3-7.9); glucose, 78 mg/dL (70-100); alkaline phosphatase, 159 U/L (98-25 1); aspartate aminotransferase, 25 u/L (12-31); total bilirubin, 0.4 mg/dL (0.1-1.1); direct bilirubin, 0.1 mg/dL (0.0-0.3); uric acid, 4.2 mg/dL (4.3-8.0); creatinine, 1.0 mg/dL (0.8-1.2); albumin, 3.3 g/ dL (3.5-5.0); total thyroxine, 6.5 pg/dL (5.0-12.5); fecal hemoglobin, 1.6 mg/g stool (0-2); rheumatoid factor, ~30 IU/mL (0-39); antinuclear antibody negative; anti-double stranded DNA, 53 U (0-70); and rapid plasma reagin nonreactive. Stool for parasites was negative; there were some fatty crystals. Cultures of urine and blood were negative. Chest and spine radiographs were normal. An upper gastrointestinal barium series showed a normal esophagus and stomach but minimally thickened duodenal and proximal jejunal folds. A barium enema showed slightly prominent “lymphoid follicles” in the cecum and ascending colon.