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Myalgia beyond tolerance

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Susan, a 39-year-old year old fashion designer, presented because of very severe pain in her lower back and legs. The problem followed a febrile illness of sudden onset following a recent business trip to Singapore and Thailand. She had attributed the pain to a recurrence of an old problem of lumbago and sciatica and was concerned that she may have been infected with swine flu. Two days ago she had visited an emergency department for pain relief and was prescribed oxycodone because Codral Forte was ineffective. She said that now the pains in her legs were unbearable and not responding well to opioids. Further detailed history revealed that she had associated fever, malaise, nausea, headache and generalised muscular aching. She also admitted to feeling very depressed—even suicidal. On physical examination there were no specific musculoskeletal or neurological signs (despite the severe pain), just a temperature of 38.2 °C.

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As tears streamed from her eyes describing the unbearable pain in her thighs and lower back the term ‘breakbone fever’ went though my mind. Blood tests confirmed dengue fever which is caused by a Flavivirus transmitted by the Aedes mosquito.

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DISCUSSION AND LESSONS LEARNED

  • Dengue fever is widespread in the south-east Pacific and endemic in Queensland. A returned traveller with myalgia and fever < 39 °C is more likely to have dengue than malaria.

  • A similar tropical infectious disease is Chikungunya, which should be considered.

  • We should use caution with opioids in diseases causing temporary myalgia.

  • Depression with suicide has been reported in troops with dengue fever fighting in the tropics.

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A Yankee bug in Oz

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Mr T is a 33-year-old asthmatic patient, who initially presented in May 1988 with pain and tenderness of his right knee that restricted his daily bicycle ride of 20 km to and from work. On examination he was very tender over the medial aspect of his knee and the condition was provisionally diagnosed as medial ligament strain. He was treated with naproxen, a bandage was applied and he was told to rest.

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He returned one month later complaining of pain in his right calf, which prevented his riding the bicycle. Examination confirmed tenderness in the gastrocnemius muscle, but the knee movement was normal. His general practitioner was so concerned about the unusual non-trauma-related problem that he organised a battery of blood tests including FBE, ESR, urea and electrolytes, calcium and magnesium. All were normal, and so he was referred to an orthopaedic surgeon. He was concerned with a radicular type of pain in Mr T’s leg and diagnosed a spinal cause, probably a L3-L4 disc prolapse. A CT scan of his lumbar spine was normal, but an arthrogram of his right knee showed some irregularity of the medial meniscus.

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He was referred to a neurologist who could find no neurological abnormality but who organised a magnetic resonance imaging (MRI) scan. During the months awaiting this scan, ...

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