IN THE NAME OF GOD

A 46 Y/O MALE WITH FEVER AND WEIGHT LOSS

PI 46-year-old male patient trauma caused by lifting heavy objects with right shoulder rotator cuff tear is , One week after surgery, pain and severe swelling in both knees locked them and the difficulty in climbing stairs and inflation are both lower legs to ,One month after surgery the pain and restriction of movement both shoulders be, Weight loss up to eight to nine kilograms in two months and is accompanied by fever and night sweats mentioned above, but does not mention a history of erythema

PMH DM (-) HTN (-) IHD (-) HLP (-) Recurrent pneumonia(+) Past surgical history (+) recurrent Sinositis (+) Diarrhea(+)

DH & Habits tab pantazole 40 mg daily Tab acetaminophen ibuprofen Tab diclofenac sodium Smoking (-) Addiction (+)

PHYSICAL EXAM V/S BP: 125/80 PR: 90 RR: 16 T: 37

PHYSICAL EXAM HEAD & NEACK he is mentally alert Nl JVP LAP (-) Eye redness (-) Icter (-) Butterfly rash (-) Paleness of Conj (+) Nasal flaring (-) Oral ulcer (-)

PHYSICAL EXAM CHEST The lungs are clear in auscultation Cardiac rhythm is normal without murmurs, extra sounds, or rubs

PHYSICAL EXAM ABDOMEN Rash (-) Soft Tenderness & rebound tenderness (-) Organomegaly (-)

PHYSICAL EXAM Extrimity Rash (-) Pitting Edema : (1+) Clubbing (-) Thickening of the skin (-) Palpable purpura (-) Nl & symmetrical arterial pulses ROM: decreased in shoulders pain of motion :+ Knee effusion + , ballotman +, FABER : NL Sacroiliac Tenderness:- FORCE: NL TONE : NL

PROBLEMS Low grade fever Weight loss Recurrent infections Arthritis

DDX collagen vascular disease Malignancy MM HIV INFECTIONS immunodeficiency

WBC 8000 RBC 4600 Hb 11.9 HCT 37.3 MCV 81.1 MCH 25.9 MCHC 31.9 PLT 313000

BS 90 Urea 18 cr 0.7 Na 135 k 4.1 ca 9 p 4.4 Ast 19 Alt 23 Bilirubin direct 0.1 Bilirubin total 0.3 PTT 35 PT 12 INR 1 ESR 39 mm/h CRP positive

ANA negative Anti ds DNA 1.2 ( NORMAL < 25) HIV Ab Non reactive HBS Ag HBS Ab Hcv Ab PSA 0.7 CA19-9 17.8 (NORMAL <37 u/ml) CEA 3.6 (NORMAL < 5.5ug /l ) IgA 17 ( NORMAL 70- 400 mg/dl) IgG 3 ( NORMAL 700 – 1600 mg/dl ) IgM 2 ( NORMAL 40 – 230 mg/dl )

PROBLEMS Low grade fever Weight loss Recurrent infections Arthritis Anemia hypogammaglobulinemia

BMB & BMA Megaloblastic changes in erythroid and myeloid series with the following diff: Myeloid: 61% Erythroid :29% Lympoid : 7% Blast :2 % Plasma cell :1% Iron storage :2+ Bone marrow biopsy findings: 70% cellularity whith no definit infiltration Diagnosis : Hyper cellar marrow with megaloblastic changes

ENDOSCOPY AND BIOPSY Sections show duodenal mucosal lined by columnar epithelium, the lamina properia show modrate infiltration of lymphocyte and few pmn leukocyte and eosinophils the granular components show regenerative changes, no evidence of malignancy is seen. Diagnosis : moderate chronic inflammation

RIGHT SHOULDER MRI WITHOUT CONTRASR There is focal abnormal signal at bursal side of supraspinatus tendone infavour of partial tear , fluid not in bursa, otherwise study is unremarkable

Whole body scan Modrate and diffuse increased ratio tracer uptake is seen in humeral and femoral heads bilaterally and symmetrically suggestive of bone marrow reactive process (non specific), reminder of the skeleton is unremarkable except mild djd in knees

CXR: NL CT SCAN OF LUNG : NL

Synovial fluid: Wbc:12000 Rbc:3500 Pmn:88% Lymph:10% Monocyte:2% Culture & crystal: (-)