A fever of unknown origin as a presenting symptom in toxoplasmosis: Back to earth

Introduction: Fever of unknown origin (FUO) and weakness in the upper legs are among the presenting symptoms in acute toxoplasmosis, which can occur in immune-competent individuals. Case Report: A 76-year-old Caucasian male presented at the hospital with relapsing fever and weakness in both upper legs. A neurological examination confirmed weakness in the quadriceps muscles, which appeared to be atypical for any neurological substrate. An extensive work-up did not lead to a diagnosis. After two weeks of clinical investigations and persistent fever, we re-examined our patient to look for anamnestic signs. We again asked about (recent) vacations, hobbies and potential exposures. Ultimately, the patient told us he performed charity work at a care farm for more than ten years. He had contact with sheep and soil, which occurred while working in the garden without wearing gloves. A diagnosis of a primo toxoplasmosis infecton was made and the patient was treated with daraprim and clindamycin. Within two days his temperature normalized and the strength in his legs improved gradually. He achieved a complete recovery within three months. Afterwards his wife mentioned that her husband was afraid of losing his volunteer job, when telling his doctors about his work with disabled people. Conclusion: In patients presenting with FUO, clinicians in search of a diagnosis must struggle through a long list of possible diagnosis. Diagnostic delay can be shortened by considering the potential clues in the patient's history.