1. Case presentaion
May, 5, 2005.

2. A male patient, 35 years old, worker in a farm dealing with milking of caws, married and has two children and he is a smoker since 20 years (30 cigarettes per day).
Complaint:
High fever and arthralgia since about 50 days of acute onset and progressive course .

3. Present history:
The condition started , 50 days ago with sudden onset of high fever, mostly at night, accompanied with rigors but no sweating. At the same time the patient suffered pain in all joints specially in both knees and ankles which was swollen The pain was so severe that interfered with walking and usual activity After two days , a generalized , reddish , itchy rash developed and disappeared after few days.
The patient was suffering from anorexia, vomiting , sore throat, mouth ulceration but there was no diarrhea or constipation.

4. There was cough & expectoration of odorless greenish sputum, small in amount and not related to posture There was some feeling of shortness of breath and no hemoptysis.
The symptoms of other system affection are irrelevant .
3 days after the onset of the disease, the patient asked medical advise and referred by one physician to a fever hospital where he received medications but the symptoms became more worst and after 6 days of admission , an attack of hematemesis and melina developed The patient was referred to Kasr El Einy Faculty hospital but not accepted, then he went to Ain Shams Faculty hospital and fortunately was admitted

5. A lot of investigations were done including upper GIT endoscopy , 3 bottles of blood was given and also drugs , hematemesis and melina stopped but the fever was not controlled and the patient referred to us because of fever The patient was admitted in our hospital after about 3 weeks of onset of the disease.
Past history:
No history of similar attack, TB, bilharziasis , brucellosis , rheumatic fever , operations, blood transfusions or traveling abroad.

6. Family history:
No history of similar condition, TB, malignancy or autoimmune diseases.
Drug history:
Irrelevant.
Social history:
He is living with his small family( wife and 2 children) in a small house in rural area in Qaliub area ,his income is low and no social problems.

7. Examination:
General exam.:
The patient was conscious, pale , distressed with miserable look and dyspnea There was tinge of jaundice but no cyanosis No congested neck veins, nail clupping, edema of lower limbs or enlarged lymph nodes No malar nor skin rash but there was oral ulceration and congested throat Neck was lax Temp. was 39, Pulse: 110/min.& B.P : 120/70

8. Local exam.:
Heart : free far from tachycardia.
Chest: scattered rhonchi.
Abdomen: lax, not tender with just palpable liver and
spleen no palpable masses or hernias,
testicles was free.
Joints: both knee and ankle joints was swollen ,
hot and tender. All joints were tender.

9. Investigations: Urine analysis: Albumen: +. Pus cells: 2-4, RBCs: 0-2.
At Ain Shams Hospital:
Urine analysis: Albumen: Pus cells: 2-4, RBCs: 0-2.
CBC: /4/2005.
WBC: /cmm No blast cells RBCs: ,480,000 /cmm Hb: 6,8 g
Platelets: /cmm.
-Prothrombin time PT: 14.6 sec. control: 13 sec.
- PTT: 34 sec. Normal: sec.
- Blood glucose: 180 mg/ dl Normal up to 200 mg.
S. creatinine: 1.2.
- Serum Na.: – Serum K: – Uric a.: 5.6 mg/dl
-ALT: /40. – AST: 45/ ALP:
- Total plasma proteins: gm/dl. – Albumen: 2.3 gm/dl.

10. - Negative blood culture for bacteria& fungi.
- Triglycerides: / 160 mg/dl.
- Negative blood culture for bacteria& fungi.
Negative serology for HerpesV, EBV, CMV&
Hepatitis A,B&C.
- CBC: /4/2005.
WBC: / cmm No blast cells.
Marked hypochromic normocytic anemia.
- Upper GIT endoscopy revealed multiple
oesophageal, gastric & duodenal ulcers.

11. In our hospital: 11/4/2005.
- CBC:
WBC: /cmm.
Neutrophil: 79% Lymphocytes: 17.8%
RBCs: ,100,000 /cmm Hb: 5.4 g/dl.
Platelets: /cmm
- ESR: mm 1st hour.
- ASOT: Negative CRP: Positive
- RF( Rheumatoid Factor): Negative
- ANA: Negative.
- Widal test: Negative. – Brucella aggl. Titre : Negative.
- HIV antibodies by ELISA: Negative.
- Chest X-Ray: Free.
- Abdominal U/S revealed hepato-splenomegaly.

12. Positive Data: after exclusion High fever – Sore throat – Skin rash – Arthritis – Leucocytosis – Anemia - High ESR – Elevated liver enzymes - Negative RF.
These data suggests a picture of Adult presentation of Still's Disease.(AOSD)
The patient was given 8 mg Dexamethasone IV/ 12 hours with I Zantac amp. / 12 hours with dramatic response The temp. returned to normal with improvement of general condition, Mouth ulcers disappeared and the patient started eating and walking. After about Tow weeks he was discharged in a good condition and referred to the Rheumatology clinic.