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Myalgia, fever, abnormal muscle enzymes and blue urine in a farmworker from Thailand.

A 37 year old farmworker from Thailand was admitted to the department of medicine with a 2 week history of fever, myalgia and leg edema. In Thailand, a year before his admission and later in Israel, he supplemented his diet with wild animals. On physical examination the patient was febrile with hepatomegaly and significant peripheral edema. Blood analysis revealed elevated levels of liver and muscle enzymes (aspartate aminotransferase 267 U/ml, alanine aminotransferase 548 U/ml, lactate dehydrogenase 3,356 U/ml; creatine phosphokinase 5,692 U/ml and aldolase 134 U/ml). Unexpectedly, his urine color was navy blue on repeated tests. He later admitted to having taken a home-made antiseptic remedy based on methylene blue. A skeletal muscle biopsy demonstrated an infiltration composed of plasma cells, lymphocytes, granulocytes and eosinophils. There were also many larvae inside the muscle cells, with structures typical for Tricinella spiralis [Figure]. Treatment with albendazole resulted in amelioration of the myalgia, edema and fever, and normalization of liver and muscle enzymes.