A 61-year-old woman with a history of hypertension, hypercholesterolemia, non-insulin-required type 2 diabetes mellitus.
It began in December 2008 with a clinical picture of myalgias in the scapular and pelvic girdles with proximal predominance plus febricula in the context of rosuvastatin 20 mg/day, with a negative antibiotic headache hisdinopha
She was admitted in January 2009 due to the persistence of symptoms associated with fever with pyrogenemia and left pleuritic pain.
Her physical examination was normal, with no lymphadenopathy, no visceromegaly, and normal temporal arteries.
At the laboratory level, white blood cell count was 18.800 per mm3 predominantly polymorphonuclear, haematocrit 38%, platelet count 418.000 mm3, creatininemia 0.9 mg/ dl reactive calcium SGdl
Protein electrophoresis with slight alpha 2 increase.
Urinalysis was normal.
ECG and chest X-ray were normal.
Three blood cultures and one urine culture were negative.
A computed axial tomography (CAT) of the neck, chest and abdomen showed left pleural thickening with mild pleural effusion, without pulmonary thromboembolism and other without particularities.
Empirical treatment was started with ceftriaxone covering probable respiratory focus.
The transesophageal echocardiogram showed no vegetations.
Despite antibiotic treatment, she continued with isolated febrile records, so approximately 20 days later she began meprednisone 60 mg/day and intravenous gammaglobulin at doses of 400 mg/ kg/day serological studies continued for 5 days before.
Serologies for HIV, syphilis, toxoplasmosis, cytomegalovirus (CMV) (IgM serology and antigenemia pp65), Chagas, par-vovirus B19, Huddleson, Herpes
Immunological studies: Antinuclear factor, Latex, anti DNA, anti Ro and La, RNP, Sm, ANCA c and p, anticardiolipin antibodies, CH50, C3 and C4 normal or negative
Other studies: Vitamin B12 and folic acid were normal.
Despite the treatment with steroids, fever records were still present, mainly at night, and pyrogenemia added to the analytical classification of pancytopenia with platelet count 2,000 mm3, anemia with leucocytes 26%,000 mm.
Ferritin was requested to be 2,000 μg/l (VN: men 30-400 and women 15125), triglycerides 301 mg/dl and fibrinogen 109% (normal from 200 to 400%).
It was decided to perform puncture aspiration of bone marrow (PAMO) which reported: 50% medullary cellularity, megakaryocytic hyperplasia with dissimilar changes, hemophagocytic phenomena are evident.
Based on these findings, the clinical picture was interpreted as an HS secondary to a possible infectious versus autoimmune cause.
It was decided to start treatment with cyclosporine 0.2 cc (200 mg) every 12 h and rotate methylprednisolone to dexamethasone O mg every 12 h.
The patient responded well to treatment, with no further fever records and normalization of blood count and platelets.
In the subsequent week, CMV PCR was performed, which was positive (> 5OOO copies; VN: less than 5O copies), adding to previous treatment, improvement of viral load and worsening of symptoms.
A gradual decrease of steroids was carried out and cyclosporine was suspended two months after starting.
The clinical picture was interpreted as an HS secondary to CMV.
After 1 year the patient is asymptomatic.
