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A 72 year old woman living in Namuen District, Nan Province, was referred from a local hospital for having two years of fever and back pain. Her symptoms started with feeling malaise, intermittent fever with chills and body ache. All the symptoms got worse at night making her unable to sleep. She also experienced back pain all day night in additon to anorexia. She had no cough, petechia or abnormal bleeding. After having had medical consultations at a local hospital, no definite cause of her suffering was found. She then underwent various further investigations including a bone marrow examination at a local university hospital which did not reveal any malignant conditions. She was referred back to her home town hospital. However, she still suffered from recurrent high pyrexia, anorexia, progessive weight loss, etc. leading to many more hospital admissions. One year later, her symptoms, including fever and back pain, seemed to get worse and she was once again admitted to the hospital. The laboratory tests at that time revealed hematocrit 27%, white blood cell count 21,600 / mL, neutrophil 95%, lymphocyte 5%, platelet 563,000 /mL, ESR 120 mm/hr., Ca 7.6 mg/dl, phosphorus 4.5 mg/dl, BUN 14 mg/dl, Cr 0.9 mg/dl, Coomb's test megative. T3 179 ng/dl, TSH 1.27 mU/ml. Echocardiography showed LVEF 66% without evidence of infective endocarditis. An abdominal ultrasound revealed a mild degree of renal parenchymal disease, normal size liver with homogeneous parenchymal disease and a normal-appearing spleen. Gastroscopy was also performed without any significant finding. Because the clinical scenario was so obscure, she was referred to Siriraj Hospital Medical School for further management on May 6, 2003. There was no significant chronic medical condition prior to this agonic episode. She neither smoked nor drank alcohol. Her adult children ran a family business within her home so she was closely looked after by her daughter and did not have any financial difficulties.
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