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Case records of the Massachusetts General Hospital. Case 31-2013. A 29-year-old man with abdominal pain, fever, and weight loss.

Dr. Nosheen Reza (Medicine): A 29-year-old man was seen in an outpatient clinic affiliated with this hospital because of abdominal pain, fever, and weight loss. The patient was reportedly well until unintentional weight loss occurred approximately 6 weeks before presentation. Three weeks before presentation, upper abdominal pain developed that the patient rated at 8 on a scale of 0 to 10, with 10 indicating the most severe pain. The pain radiated to his throat, increased after eating and drinking, and did not diminish with ibuprofen. At the outpatient clinic, the patient reported nausea, occasional vomiting, decreased food intake, and a loss of 10 kg from his usual weight of 64.4 kg. He reported no headaches, visual changes, neck stiffness, dyspnea, substernal chest pain, lower abdominal pain, diarrhea, back pain, dysuria, rashes, or joint pain. He had had a respiratory illness approximately 2 years before this evaluation. He had no known allergies. He was born in Central America and had been living in the United States for 4 years. He worked in agriculture and did not speak English. He smoked cigars occasionally, drank alcohol infrequently, and did not use illicit drugs. On examination, the patient appeared cachectic. The temperature was 37.3°C, the blood pressure 101/68 mm Hg, the pulse 114 beats per minute, the respiratory rate 20 breaths per minute, and the oxygen saturation 100% while he was breathing ambient air. The abdomen was soft, with normal bowel sounds and without tenderness or distention. There was macular hyperpigmentation of the feet and legs that reportedly had not changed for 10 years. The remainder of the examination was normal. Urinalysis revealed 1+ protein and was otherwise normal. Ranitidine was prescribed, and the patient returned home with instructions to follow up the next day when test results were available. Blood levels of glucose, calcium, phosphorus, lipase, and amylase were normal, as were the results of tests of liver and renal function. Testing for antibodies to hepatitis C virus was negative; other test results are shown in Table 1. Dr. Carol C. Wu: A frontal chest radiograph showed subtle, tiny nodules throughout both lungs, without focal consolidation (Fig. 1A). There was no evidence of mediastinal or hilar lymphadenopathy. Dr. Reza: Two days later, the patient returned to the outpatient clinic. He reported