Saman Zafar, Muhammad Ali Afzal, Nasir Khokhar.
Hyperferritinemia and pyrexia of unknown origin.
Rawal Med J Jan ;30(1):41-2.

A seventeen year old girl presented with intermittent high grade fever for 1 month. The fever would spike up to 103° F and remain so for about 12-14 hours. It was followed by drenching sweats, spontaneous resolution and recurrence every 3-4 days. The fever was associated with a pruritic pale macular rash over the trunk, sore throat, dry cough, vague arthralgias and bone pains. The submandibular lymph nodes were palpable on admission, but regressed spontaneously. Her medication history over the past month included high-dose ceftriaxone for 8 days, and appropriate full courses of Chloroquine, Artemether, Mebandazole and cefixime. Despite all this, the fever pattern and associated symptoms persisted. Examination revealed a young female with tachycardia, fever of 38°C, pallor, minimal throat congestion and a faint, macular rash over chest and upper thighs. Submandibular lymph nodes were palpable for the first 3-4 days after admission. An extensive list of investigations revealed mild microcytic hypochromic anemia and white blood cells >20,000 with neutrophilia (>70%) on repeated testing before and after treatment. ESR was in the 50-110 mm/hour range on repeated testing. Chest X-rays, abdominal ultrasounds, blood cultures, smears for malarial parasite, urine examination, echocardiography, liver and renal function tests, viral serology for hepatitis and Widal test failed to reveal any insight into the etiology of the fever. Bone marrow biopsy showed depleted iron stores and active granulopoiesis only. RA factor and ANA were negative. The serum ferritin level was 10,000 ng/ml. Applying this data to the most recently accepted criteria for the diagnosis of Adult Still`s disease revealed that all 4 major, and 3 of the 4 minor criteria were present, making a diagnosis of Adult Still`s Disease at least 93% specific in our patient.

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