Journal articles: 'Arthromyalgia'

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Mariette, Xavier. "Hepatitis C virus, arthritides, and arthromyalgia." Joint Bone Spine 70, no. 4 (August 2003): 246–47. http://dx.doi.org/10.1016/s1297-319x(03)00071-x.

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Madland, Geir, Charlotte Feinmann, and Stanton Newman. "Factors associated with anxiety and depression in facial arthromyalgia." Pain 84, no. 2 (February 2000): 225–32. http://dx.doi.org/10.1016/s0304-3959(99)00210-9.

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Stewart, A., and M. Harris. "Acquired anterior open bite and facial arthromyalgia: possible aetiology." British Journal of Oral and Maxillofacial Surgery 34, no. 2 (April 1996): 174–80. http://dx.doi.org/10.1016/s0266-4356(96)90373-3.

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Peoples, C. E. "Acquired anterior open bite and facial arthromyalgia: Possible aetiology." Journal of Oral and Maxillofacial Surgery 55, no. 2 (February 1997): 201. http://dx.doi.org/10.1016/s0278-2391(97)90256-1.

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Verhoeven, Frank, Xavier Guillot, Mickaël Chouk, Clément Prati, and Daniel Wendling. "Polymyalgia Rheumatica Revealing a Lymphoma: A Two-Case Report." Case Reports in Rheumatology 2016 (2016): 1–3. http://dx.doi.org/10.1155/2016/2986297.

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Introduction. Polymyalgia rheumatica (PMR) is one of the most common inflammatory rheumatism types in elderly population. The link between cancer and PMR is a matter of debate.Methods. We report two cases of PMR leading to the diagnosis of lymphoma and the growing interest of PET-TDM in this indication.Results. A 84-year-old man known for idiopathic neutropenia presented an inflammatory arthromyalgia of the limb girdle since one month. Blood exams highlighted the presence of a monoclonal B cell clone. Bone marrow concluded to a B cell lymphoma of the marginal zone. He was successfully treated with 0.3 mg/kg/d of prednisone, and response was sustained after 6 months. A 73-year-old man known for prostatic neoplasia in remission for 5 years presented arthromyalgia of the limb girdle since one month. PET-CT revealed bursitis of the hips and the shoulders, no prostatic cancer recurrence, and a metabolically active iliac lymphadenopathy whose pathologic exam concluded to a low grade follicular lymphoma. He was successfully treated with 0.3 mg/kg/d of prednisone.Conclusion. These observations may imply that lymphoma is sometimes already present when PMR is diagnosed and PET-CT is a useful tool in the initial assessment of PMR to avoid missing neoplasia.

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Elimairi, I., A. Sami, D. A. Baur, A. Elimairi, and A. Minisandram. "Effect of novalgin, ibuprofen and therapeutic jaw exercises on patients with facial arthromyalgia." International Journal of Oral and Maxillofacial Surgery 46 (March 2017): 343. http://dx.doi.org/10.1016/j.ijom.2017.02.1156.

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Dragomir, Raluca A., Cristian Ilie Drochioi, Alexandra Carp, Bogdan Dragomir, Otilia Boisteanu, and Victor-Vlad Costan. "The use of botulinum toxin in the management of bruxism and facial arthromyalgia syndrome." Romanian Journal of Medical Practice 15, no. 1 (March 31, 2020): 77–81. http://dx.doi.org/10.37897/rjmp.2020.1.15.

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Tomaselli, Carmen. "Use of nilotinib in the diabetic patient." Clinical Management Issues 4, no. 5S (October 13, 2015): 19–22. http://dx.doi.org/10.7175/cmi.v4i5s.1094.

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A 42-year-old man, diabetic patient, after CML Ph+ diagnosis started a treatment with imatinib reaching both CHR and CCyR within 6 months. Because of two episodes of vitreous haemorrhage the treatment was discontinued for four months with the lost of the CCyR and the maintenance of the CHR. The patient begun second line therapy with nilotinib, another TK inhibitor, recovering CCyR after 3 months and MMolR after 12 months, and keeping them up after 18 months of treatment. Nilotinib related side effects were transient rash and first degree arthromyalgia that occurred during the first month of therapy. In this case nilotinib therapy has shown to be safe and effective also for diabetic patients with intolerance to imatinib.

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Lewis, R., and M. Fardy. "The management of facial arthromyalgia at the University Hospital of Wales. How does it improve the patients quality of life?" International Journal of Oral and Maxillofacial Surgery 46 (March 2017): 230–31. http://dx.doi.org/10.1016/j.ijom.2017.02.779.

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Agus, Marcello, Maria Elena Ferrara, Paola Bianco, Cristina Manieli, Paolo Mura, Raffaele Sechi, Matteo Runfola, Fabrizio Polo, and Nicola Cillara. "Atraumatic Splenic Rupture in a SARS-CoV-2 Patient: Case Report and Review of Literature." Case Reports in Surgery 2021 (June 4, 2021): 1–5. http://dx.doi.org/10.1155/2021/5553619.

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Splenic rupture in the absence of trauma or previously diagnosed disease is rare. Due to the delay of diagnosis and treatment, this is a potentially life-threatening condition. We report a case of atraumatic splenic rupture in a SARS-CoV-2 patient. This report is of particular interest as it first identifies SARS-CoV-2 infection as a possible cause of spontaneous rupture of the spleen. A 46-year-old Caucasian woman presented at the emergency department pale and sweaty, complaining of syncopal episodes, tachycardia, hypotension, diarrhea, intense abdominal pain, diffuse arthromyalgia, and fever from the day before. RT-PCR was positive for SARS-CoV-2 infection. CT scan demonstrated extensive hemoperitoneum due to rupture of the splenic capsule. The patient required an emergency open splenectomy because of an unresponsive hemorrhagic shock. At the end of the surgery, the patient was relocated to a COVID-19 dedicated facility. COVID-19 is a new disease of which all manifestations are not yet known. Inpatients affected by SARS-CoV-2 infection with abdominal pain and spontaneous splenic rupture should be considered to avoid a delayed diagnosis.

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Iruarrizaga, Eluska, Eider Azkona, Unai Aresti, Itziar Rubio, Mikel Arruti, Sergio Carrera, Natalia Fuente, et al. "Bevacizumab (BV) plus irinotecan (I) in recurrent glioblastoma multiforme (GBM): A single center experience." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): e13000-e13000. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e13000.

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e13000 Background: Glioblastoma multiforme constitutes the most common and malignant form of primary brain tumor. Median survival for recurrent disease is 3-9 months. Combining bevacizumab with irinotecan represents an option of treatment in recurrent GBM. Methods: We performed a retrospective review of patients with recurrent GBM treated with bevacizumab (10 mg/kg) and irinotecan (340 mg/m2 for patients receiving enzyme-inducing antiepileptic drugs –EIAEDs- and 125 mg/m2 for patients not receiving EIAEDs) every 14 days on a 4-week cycle. Inclusion criteria: age ≥ 18, histology of GBM, progression after radiotherapy and temozolomide and signed informed consent for bevacizumab compassionate use. MRI-FLAIR sequence was used every 8 weeks to assess response. Results: From October 2009 to December 2012, a total of 26 patients were included; 15 (57.7%) male/11 (42.3%) female. Median age of the patients was 52 years (32-69); ECOG 0/1/2/3: 7.7/46.2/38.5/7.7% respectively; 19.23 % of patients received EIAEDs. Median number of cycles was 2.5 (1-14). Response rate was 30.8% (23.1% PR; 7.7 % CR); SD 23.1 %. Median PFS was 23 weeks; median OS was 30 weeks. Most common grade 3 toxicities were: asthenia 26.9%, arthromyalgia 3.8%, diarrhea 3.8% and hepatotoxicity 15.4%; grade 2 thromboembolic complications: 3.8 %. Conclusions: Combination of bevacizumab and irinotecan is effective against recurrent GBM and prolongs PFS and OS compared with historical controls, with mild toxicity.

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Molina, I., F. Salvador, A. Sánchez-Montalvá, B. Treviño, N. Serre, A. Sao Avilés, and B. Almirante. "Toxic Profile of Benznidazole in Patients with Chronic Chagas Disease: Risk Factors and Comparison of the Product from Two Different Manufacturers." Antimicrobial Agents and Chemotherapy 59, no. 10 (July 20, 2015): 6125–31. http://dx.doi.org/10.1128/aac.04660-14.

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ABSTRACTBenznidazole is considered the first-line treatment option against Chagas disease. The major drawback of benznidazole is its toxicity profile. The main objectives of this study were to describe the adverse events (AEs) in patients with chronic Chagas disease treated with benznidazole, determine the risk factors involved and compare the toxic profiles of two different preparations of the drug from ELEA and Roche. A total of 746 patients were diagnosed with Chagas disease in a 5-year period, and of these 472 were treated with benznidazole. A high proportion of patients (n= 360 [76%]) suffered AEs, the most frequent being those related to hypersensitivity (52.9% of patients), headache (12.5%), and epigastric pain (10.4%). In 72 (12.7%) cases, treatment was discontinued. Overall, women had a higher incidence of AEs compared to men (81.3% versus 66%,P= 0.001) and were subject to higher levels of hypersensitivity-related events. Dermatological events, digestive tract manifestations, and general symptoms had a greater likelihood to appear around day 10 and neurological AEs around day 40 after starting treatment. With respect to liver function and hematological tests, the majority of patients did not suffer significant perturbation of liver enzymes or altered blood cell counts. However, 14 patients suffered from neutropenia, and 14 patients had aminotransferase levels that were more than four times the upper limit of the normal range. Patients treated with the ELEA benznidazole product experienced more arthromyalgia, neutropenia, and neurological disorders (mainly paresthesias) than those treated with the Roche product. Both drug products resulted in approximately the same percentage of permanent withdrawals.

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Rubio-Rivas, Manuel, Xavier Corbella, José María Mora-Luján, Jose Loureiro-Amigo, Almudena López Sampalo, Carmen Yera Bergua, Pedro Jesús Esteve Atiénzar, et al. "Predicting Clinical Outcome with Phenotypic Clusters in COVID-19 Pneumonia: An Analysis of 12,066 Hospitalized Patients from the Spanish Registry SEMI-COVID-19." Journal of Clinical Medicine 9, no. 11 (October 29, 2020): 3488. http://dx.doi.org/10.3390/jcm9113488.

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(1) Background: Different clinical presentations in COVID-19 are described to date, from mild to severe cases. This study aims to identify different clinical phenotypes in COVID-19 pneumonia using cluster analysis and to assess the prognostic impact among identified clusters in such patients. (2) Methods: Cluster analysis including 11 phenotypic variables was performed in a large cohort of 12,066 COVID-19 patients, collected and followed-up from 1 March to 31 July 2020, from the nationwide Spanish Society of Internal Medicine (SEMI)-COVID-19 Registry. (3) Results: Of the total of 12,066 patients included in the study, most were males (7052, 58.5%) and Caucasian (10,635, 89.5%), with a mean age at diagnosis of 67 years (standard deviation (SD) 16). The main pre-admission comorbidities were arterial hypertension (6030, 50%), hyperlipidemia (4741, 39.4%) and diabetes mellitus (2309, 19.2%). The average number of days from COVID-19 symptom onset to hospital admission was 6.7 (SD 7). The triad of fever, cough, and dyspnea was present almost uniformly in all 4 clinical phenotypes identified by clustering. Cluster C1 (8737 patients, 72.4%) was the largest, and comprised patients with the triad alone. Cluster C2 (1196 patients, 9.9%) also presented with ageusia and anosmia; cluster C3 (880 patients, 7.3%) also had arthromyalgia, headache, and sore throat; and cluster C4 (1253 patients, 10.4%) also manifested with diarrhea, vomiting, and abdominal pain. Compared to each other, cluster C1 presented the highest in-hospital mortality (24.1% vs. 4.3% vs. 14.7% vs. 18.6%; p < 0.001). The multivariate study identified age, gender (male), body mass index (BMI), arterial hypertension, chronic obstructive pulmonary disease (COPD), ischemic cardiopathy, chronic heart failure, chronic hepatopathy, Charlson’s index, heart rate and respiratory rate upon admission >20 bpm, lower PaO2/FiO2 at admission, higher levels of C-reactive protein (CRP) and lactate dehydrogenase (LDH), and the phenotypic cluster as independent factors for in-hospital death. (4) Conclusions: The present study identified 4 phenotypic clusters in patients with COVID-19 pneumonia, which predicted the in-hospital prognosis of clinical outcomes.

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Sevillano Fernandez, Elena, Javier Puente, Natalia Vidal, Alvaro Pinto, Lourdes Garcia Sanchez, Aldo Fiorini, Luis Enrique Chara Velarde, et al. "Retrospective study to assess the efficacy and safety of checkpoint inhibitors in advanced urothelial carcinoma in real-world setting." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e17043-e17043. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e17043.

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e17043 Background: Checkpoint Inhibitors (CPI) have become a new standard of treatment in advanced urothelial carcinoma. However, little is known regarding the outcome of patients in daily practice.We aimed to assess tumor response and toxicity of CPIs in a cohort of patients treated in “real world” conditions. In parallel, a comprehensive molecular study in tumor samples from these patients, is ongoing. Methods: We designed an observational retrospective study within the “Grupo Centro” collaborative group. Adult patients diagnosed of metastasic urothelial carcinoma (mUC) and treated with CPIs between 2011-2019 in any of the 20 centers of the group, were eligible. Results: Up to date 100 patients have been included (82% males) with a median age of 74 years (48 -96). In 82% patients primary was bladder cancer. Most common metastasic sites were bone (26%) and liver (16%).With a median follow up of 10,6 months(mo) median progression free survival (mPFS) was 6,6mo (1,4-95,4 range) and median Overall Survival (mOS) was 21.3mo (3,8-121,8). 38% of patients received CPIs in first line(L): atezolizumab:27, pembrolizumab: 10, nivolumab:1. The median number of cycles was 8,2. Up to 51% received platinum-based combinations in first line. 69% (69/100) pts received 2L treatment: 68% with CPIs, 27,5% with chemotherapy and 4% with FGFR inhibitors (as part of a clinical trial). 2L mPFS was 3,5 mo (1,9-25.9). 23% (23/100) patients received 3L, of them 26% (6/23) were treated with CPIs. 3L mPFS:8,3mo(0,4-43,8). As a whole, patients treated with CPI accross different lines, achieved complete response in 8% of the cases, partial response in 18% and stable disease in 15%. Up to 44% of cases presented progressive disease as best response and evaluation was not available in 15%. Most common G1-2 AEs related to immunotherapy were: asthenia:31%,pruritus:16% and anorexia: 9%.10% pts experienced G3-4 toxicity: asthenia G3: 4, diarrhea G3: 1, erythrodysesthesia G3:1, arthromyalgia G3: 1, cardiac arrest G4:1,pneumonitis G4:1,anemia G3:1. Conclusions: This study confirms the efficacy and security of CPIs in real world. Response rates and toxicity profile were comparable to those reported in clinical trials.

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Abelleira, Romina, Alberto Ruano-Ravina, Adriana Lama, Gema Barbeito, María E. Toubes, Cristina Domínguez-Antelo, Francisco J. González-Barcala, et al. "Influenza A H1N1 Community-Acquired Pneumonia: Characteristics and Risk Factors—A Case-Control Study." Canadian Respiratory Journal 2019 (March 17, 2019): 1–8. http://dx.doi.org/10.1155/2019/4301039.

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Introduction. Influenza A H1N1 community-acquired pneumonia (CAP) is a quite frequent respiratory disease. Despite being considered more serious than other CAPs, there are very few studies comparing its characteristics with noninfluenza CAP. We aim to establish the differences between pneumonia due to H1N1 virus and pneumonia not caused by H1N1 influenza virus and to determine the probability that a pneumonia is due to an H1N1 virus infection based on the most relevant variables. Methods. We used a case-control study where cases were H1N1 CAP patients with confirmed microbiological diagnosis and controls were patients with CAP admitted to hospital. H1N1 and other influenza types were discarded among controls. We calculated the probability of being a case or control using multivariate logistic regression. Results. We included 99 cases and 270 controls. Cases were younger than controls (53 vs 71 years, respectively). Mortality was much higher for H1N1 patients (13% vs 0.3%), and admission to intensive care unit was more frequent for H1N1 cases. The variables most associated with presenting H1N1 CAP were bilateral affectation on chest X-rays (OR: 5.70; 95% CI 2.69–10.40), followed by presence of arthromyalgias, with cases presenting close to three times more arthromyalgias compared to controls. Low leukocytes count and high AST values were also significantly associated with H1N1 CAP. H1N1 CAPs are characterized by bilateral affectation, low leukocyte count, presence of arthromyalgias, and high AST. Conclusions. A few and easy to obtain clinical parameters might be extremely useful to distinguish H1N1 CAP from CAPs of other origin.

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Mariette, X. "Virus de l’hépatite C, arthrites et arthromyalgies." Revue du Rhumatisme 70, no. 7 (July 2003): 555–56. http://dx.doi.org/10.1016/s1169-8330(03)00155-8.

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Hidalgo, C., C. Román, M. E. Acosta, L. Gómez-Lechón, M. D. Sánchez, L. Pantoja, O. Compán, S. Pastor, C. A. Montilla-Morales, and L. López Corral. "FRI0244 EOSINOPHILIC FASCIITIS-LIKE SECONDARY TO CHRONIC GRAFT-VERSUS-HOST DISEASE: CLINICAL DESCRIPTION OF 28 PATIENTS." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 706.1–706. http://dx.doi.org/10.1136/annrheumdis-2020-eular.3389.

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Background:Eosinophilic fasciitis (EF) is an uncommon chronic inflammatory disease characterized by myalgia, soft tissue hardening, peripheral eosinophilia and increased acute phase reactants, often triggered after strenuous physical exercise. Its appearance has been described as a rare complication after allogeneic transplantation of hematopoietic progenitors in the context of chronic graft-versus-host disease (cGVHD). Its etiopathogenesis is not well known and usually the treatment with systemic corticosteroids is effectiveObjectives:Describe the clinical and transplant-related characteristics of a cohort of patients with eosinophilic fasciitis-like in the context of cGVHDMethods:Observational, retrospective and descriptive study of the clinical characteristics of 28 patients affected by EF-like followed in a multidisciplinary consultation of cGVHD, started in March, 2014. Regular demographic variables, clinical characteristics related to the transplant and with the cGVHD, laboratory parameters, rescue therapies and their response were collected. The statistical analysis was done with Microsoft Excel 2007.Results:Seventeen (60.7%) patients were male and 11 (39.35%) were women with a mean age of 48.75 years (range from 10 to 74). Acute myeloid leukemia was the most frequent cause of the transplant in 11 patients (39.3%). Transplant related characteristics are reflected in Table 1 and the clinical manifestations, therapies received and their response in Table 2. Four (14.2%) patients died during their follow-up, being the cause of death in 2 cases due to sepsis, and in 1 case attributable to GVHD.Table 1.Baseline and transplant related characteristics (N = 28)..VariablesN (%)Donor Type (related / not related)13(46.4%)/15(53.6%)Type of conditioning (reduced intensity / myeloablative)18(64.25%)/10(35.7%)Source of cells (Peripheral blood / bone marrow)27(96.4%/1(3.6%)cGVHD type quiescent / de novo / progressive11(39.3%)/13(46.4%)/4(14.3%)Other affected organs (cGVHD score)-Mouth6(21.4%)-Eyes10(35.7%)-Lung2(7.1%)-Liver3(10.7%)-Gastrointestinal tract0(0%)-Genital2(7.1%)-Cutaneous16(57.14%)Global ScoreNIH1(mild / moderate / severe)4(14.2%)/14(50%)/10(35.7%)1NIH: National Institute of Health.Table 2.Clinical manifestations and therapies (N = 28)..VariablesN (%)/Median (range)Prodromic symptoms: yes / no20(71%)/8(29%)- Stiffness2(7.1%)- Artromyalgia17(60.7%)- Edema3(10.7%)Time until first visit31.3 months (range 9-73)Contracture Yes / No18(64.3%)/10(35.7%)Mobility limitation (mild / moderate)13(46.4%)/9(32.1%)ECOG1affected11(39.2%)Eosinophilia17(60.7%)Positive autoantibodies8(28.5%)First line therapies (corticosteroids)28(100%)Extracorporeal photoapheresis19(67.9%)Therapies of 2nd line/ 3rd or more6(21.4%)/12 (42.8%)Physiotherapy14 (50%)Response: complete / sequels10(35.7%)/18(64.2%)1ECOG: Eastern Cooperative Oncology Group scale to assess the quality of lifeConclusion:Nonspecific joint symptoms such as stiffness, edema or arthromyalgia in patients undergoing allogeneic transplantation of hematopoietic progenitors may be factors that predict the development of sclerotic GVHD type eosinophilic fasciitis-like and should be closely monitored in order to be able to perform early stage diagnoses of the disease. It is necessary to deepen the pathogenesis of this entity and the multidisciplinary approach to improve the prognosis of patients with GVHDReferences:[1]Inamoto Y. Arthritis Rheumatol. 2014;66(4):1044–52.Disclosure of Interests:None declared

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Espejo, Elena, Marta Andrés, Maria-Consol Garcia, Anna Fajardo, Josefa Pérez, and Feliu Bella. "Prospective Cohort Study of Single-Day Doxycycline Therapy for Mediterranean Spotted Fever." Antimicrobial Agents and Chemotherapy 62, no. 11 (August 27, 2018). http://dx.doi.org/10.1128/aac.00978-18.

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ABSTRACTThe objective of this study is to evaluate the results of single-day doxycycline therapy for Mediterranean spotted fever (MSF). This is a prospective cohort study of cases with confirmed MSF treated with the single-day doxycycline regimen in a teaching hospital from 1990 to 2015. Patients received two oral doses of 200 mg of doxycycline for 1 day. The outcomes evaluated were the time interval between the start of treatment and apyrexia, the time interval between the start of treatment and disappearance of other symptoms, and the adverse reactions to treatment and death. The study included 158 subjects, 18 of whom (11.4%) had a severe form of MSF and 31 (19.6%) were >65 years. The interval between onset of symptoms and start of treatment was 4.31 ± 1.54 days. All patients recovered uneventfully. Fever disappeared 2.55 ± 1.14 days after the start of treatment. The remaining symptoms (headache, arthromyalgia) disappeared 3.63 ± 1.35 days after the start of treatment. Only one patient had a delay in reaching apyrexia (8 days). The fever disappeared somewhat later in severe cases (median, 3 days; interquartile range [IQR], 2 to 4 days) than in nonsevere cases (median, 2 days; IQR, 2 to 3 days). Likewise, the remaining symptoms disappeared later in severe cases (median, 5 days; IQR, 4 to 6 days) than in nonsevere cases (median, 3 days; IQR, 3 to 4 days). The outcome was similar in both elderly and nonelderly patients. Eight patients had mild adverse effects possibly related to treatment. The results of the study confirm that single-day doxycycline therapy is an effective and well-tolerated treatment for MSF, including elderly patients and severe cases.

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Guccione, Cristoforo, Claudia Colomba, Raffaella Rubino, Celestino Bonura, Antonio Anastasia, Stefano Agrenzano, Valentina Caputo, Giovanni Maurizio Giammanco, and Antonio Cascio. "A severe case of Israeli spotted fever with pleural effusion in Italy." Infection, September 9, 2021. http://dx.doi.org/10.1007/s15010-021-01693-8.

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Abstract Background The most common Italian rickettsiosis is Mediterranean Spotted Fever (MSF). MSF is commonly associated with a symptom triad consisting of fever, cutaneous rash, and inoculation eschar. The rash is usually maculopapular but, especially in severe presentations, may be petechial. Other typical findings are arthromyalgia and headache. Herein, we describe for the first time an unusual case of Israeli spotted fever (ISF) associated with interstitial pneumonia and pleural effusion in which R. conorii subsp. israelensis was identified by molecular methods in the blood, as well as in the pleural fluid. Case presentation A 72-year-old male presented with a 10-day history of remittent fever. On admission, the patient’s general condition appeared poor with confusion and drowsiness; the first assessment revealed a temperature of 38.7°, blood pressure of 110/70 mmHg, a blood oxygen saturation level of 80% with rapid, frequent, and superficial breathing using accessory muscles (28 breaths per minute), and an arrhythmia with a heart rate of 90 beats per minute. qSOFA score was 3/3. Chest CT revealed ground-glass pneumonia with massive pleural effusion. Petechial exanthema was present diffusely, including on the palms and soles, and a very little eschar surrounded by a violaceous halo was noted on the dorsum of the right foot. Awaiting the results of blood cultures, broad-spectrum antibiotic therapy with meropenem 1 g q8h, ciprofloxacin 400 mg q12h, and doxycycline 100 mg q12h was initiated. Doxycycline was included in the therapy because of the presence of petechial rash and fever, making us consider a diagnosis of rickettsiosis. This suspicion was confirmed by the positivity of polymerase chain reaction on whole blood for R. conorii subsp. israelensis. Thoracentesis was performed to improve alveolar ventilation. R. conorii subsp. israelensis was again identified in the pleural fluid by PCR technique. On day 4 the clinical condition worsened. Blood exams showed values suggestive of secondary hemophagocytic lymphohistiocytosis; 4 out of 8 diagnostic criteria were present and empirical treatment with prednisone was started resulting in a gradual improvement in general condition. Conclusions Israeli spotted fever may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis.

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Journal articles on the topic 'Arthromyalgia'

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