Hello,
I would appreciate your advice regarding a 52-year-old female patient who has been experiencing some concerning symptoms. A month ago, she began to suffer from weakness, sweating, and intermittent fever with temperatures reaching up to 104°F (40°C), but no other symptoms or pain were reported. Some of her blood test results showed elevated levels: White Blood Cells (WBC) - 78.9, Erythrocyte Sedimentation Rate (ESR) - 120, C-reactive protein (CRP) - 150, Alkaline phosphatase (ALP) - 659, Aspartate aminotransferase (AST) - 42.8, and Alanine aminotransferase (ALT) - 122.4.
She was hospitalized for two weeks, during which she underwent several examinations: a chest CT scan without any abnormalities, an abdominal CT scan that revealed a hyperdense formation (13x12x10 mm) with a round and smooth shape and clear, even contours (calcified lymph node) but was otherwise reported as "no abnormalities", a transabdominal ultrasound of the uterus and adnexa which showed signs of uterine fibroids (a long-standing issue for her), and tests for hepatitis and coronavirus, which were negative. During her hospital stay, she was treated with antibiotics. Upon discharge, her blood and urine tests were within normal limits, and her fever subsided.
However, 12 days after being discharged, she started feeling unwell again, with a fever intermittently reaching 103.1°F (39.5°C) and occasionally subsiding without antipyretics. New tests were conducted:
Blood test:
CRP - 190 mg/L; Bilirubin - 14.5 µmol/L; AST - 31.2 U/L; ALT - 40 U/L; ESR - 50; WBC - 12.3, Red Cell Distribution Width (RDW) - 15.4%.
Urine test (previous urine tests were normal):
Color - Amber; pH - 5.0; Protein - 1.11 g/L; Ketone bodies - 1.5 mmol/L; Erythrocytes - 181 cells/µL; Leukocytes - 220 cells/µL; Bacteria - significantly present in the field of view. Other parameters of the general urine test were within normal limits.
Given her history and test results, what should be the primary focus of our investigation?
What examinations should be prioritized to determine the cause of her recurring symptoms?
Thank you for your assistance.