Question
Case Report: - A 5 years old boy presented with remittent fever for 2½ months. There is no cough, urine or bowel complaints or contact with TB. He was treated with various antibiotics – Piperacillin plus Tazobactum, Ampicillin, Ciprofloxacin but had no response. On examination, he was febrile, had multiple insignificant cervical, axillary and inguinal lymphadenopathy with splenomegaly. Other examination findings were normal. Investigations showed:

• Hemoglobin: 8.2gm, dl, WBC: 6700 {54 percent polymorphs, 45 percent lymphocytes}, platelets = 3,77,000, cumm and ESR of 70 mm at end of 1 hour
• SGPT = 22 IU, L
• S. Creatinine = 0.7 mg percent
• Total proteins = IgM percent, Albumin = 3.2 gm percent
• OptiMAL test for malaria = Negative
• LDH = 902 IU, L, Uric Acid = 2.7 mg percent
• Weil Felix test = OX–19 = 1:160, OX–2 = 1: 640
• Brucella IgG, IgM – Negative
• USG Abdomen = Splenic microabscesses with multiple , Subcentimetric lymphnodes
• CT Abdomen = Splenomegaly
• Stool and Urine examination = Normal
• Blood culture = Negative
• HIV ELISA = Negative
• RA factor, ANA, dsDNA = Negative
• Bone marrow = Normal
• Lymph node biopsy = Reactive hyperplasia
• EBV nuclear antigen IgG = Weakly positive

The child was treated with Inj Ceftriaxone and Cloxacillin for splenic microabscesses which were stopped after CT abdomen did not show any abscesses. He also received chloramphenicol for 7 days in view of Weil Felix test but fever did not subside. On Day 8 of admission, he developed bilateral knee and ankle joint swelling which responded to Valacyclovir {10 days} given in view of positive EBV nuclear antigen test. However fever persists.