Question
I am a practicing internist in Orlando area florida. My wife, previously healthy 31 year old Asian female, G4P1A2, 18 week old female started having persistant fever about 7 days ago. Her pregnancy was complicated with moderate GERD and anorexia. No symptoms of sore throat, headache, cough, urinary sysmptoms or diarhhea. Fever of 101-103 F would come with shaking chills and barely subside with tylenol. Workup was done on 5th day by her ObGYN, including a CBC with a WBC of 5,000 and 95% neutrophils and Platelet ct of 156,000. AST was 169, with an ALT of 190 with albumin of 2.7. She was admitted to the local hospital. Her ATL jumped up to 240 and AST to 190 She developed diffuse progressive arthritis on the 6th dayalong with a maculopapular rash on her trunk and extrimities on the 7th day of the illness. Today she had mild improvement in her Alt(190) and AST(90) but an Albumin of 2.3. 24 hour urine shows protein of 500mg/dl. PT is normal. Rash is getting progressively coalescent. Arthritis is involving small and big joints and is intrestingly sparing DIPs. Rhem Wup shows a -ve ANA, Esr of 55, -ve, Anti smooth muscle antibody is -ve. RA factor is pending. The titers for CMV, coxsackie, Herpes, HIV test is pending. Question is wheather she has Still’s disease, and what tests we should order, how should we treat it and what would be the prognosis?
Answer
You clearly need a rheuamtology consultation for a thorough evaluation and treatment plan. I cannot speak specifically to your wife’s case, as I have not seen her. There are no specific tests for Still’s Disease and the diagnosis is made on clinical grounds. The usual presentation is an unexplained fever usually of several weeks duration with high daily spiking fevers often in the late afternoon (occasionally two fever spikes, in the am and pm referred to a double quotidian fever) that returns to normal or below normal. Infection must be rigorously ruled out. The fever is often accompanied by a non-specific diffuse rash and joint pain that improves when the fever resolves. Many patients have a high WBC and slight elevation in liver transaminases. A non-infectitious pharyngitis is often present. NSAIDs or aspirin often dramatically improve the fevers.
