Fever, weakness, malaise

A 58-year-old woman presented with continuous high-grade fever (38.6°C±0.2°C) of 4-month duration associated with generalised weakness and malaise. No other localising symptoms were present. There was no significant history. She did not have pets at home but had history of intake of unpasteurized milk for 30 years. She was evaluated at a local hospital; however, the aetiology of fever remained elusive. She was referred to our institute for further evaluation and management.

At presentation, she was febrile (38.8°C) with stable vitals. Pallor was present; rest of the general and systemic examination was essentially normal. Initial blood investigations revealed normocytic, normochromic anaemia with reversal of albumin: globulin ratio, high erythrocyte sedimentation rate and increased serum alkaline phosphatase levels. Workup for typhoid, malaria, leishmaniasis, dengue, scrub typhus, leptospirosis and histoplasmosis was negative. Immunoglobulins for brucella (IgG and IgM), and antinuclear antibody were negative. A contrast enhanced CT of chest and abdomen did not reveal any nodules or lymphadenopathy. Bone marrow examination was not suggestive of atypical cells or parasites. Two-dimensional echocardiography was normal. An 18F-FDG-PET/CT scan revealed atypical heterogenous uptake in bilateral renal cortex. A repeat ultrasonogram and MRI of abdomen did not reveal any renal or hepatic abnormality. Urine routine examination showed no pyuria. On 18F-FDG-PET/CT scan image findings, three early morning urine samples were sent for acid-fast bacilli stain along with GeneXpert and liquid culture for urine. The GeneXpert result was positive.