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Chief complaint
fever with chillness for 1 day

Present illness
A 55 year old female presents with fever, sore throat, skin rash (Figure 1) and arthritis. She reports that she has been having fever with chillness for 1 day. She has difficult with squat. Sore throat and skin rash over trunk and limbs were also noted. She denied symptoms including headache, cough with/without sputum, nausea, vomiting, abdomen pain or diarrhea.

Figure 1. Skin rash


Past history
1.Hypertension under Amtrel for 10 years, in fair-controlled condition.
2.Type 2 diabetes mellitus for 5 months, treated with oral hypoglycemic agents in fair-controlled condition, recent HbA1C:6.9%.

Personal History
Smoking: Nil
Alcohol: Nil
Betel nut: Nil
Drug history
Amtrel 1 tab QD, Forxiga 10mg QD, Glimepride 1mg QD, Metformin 500mg QD, Rosuvastatin 5mg QD

Travel history
No

Allergy history
Drug : Nil
Food : Nil
Blood transfusion : Nil

Family history
Significant disease history in the family: Nil

Contact History
No

Physical Examination                          
On exam, macule rashes was found at anterior chest. Patellar tap test was positive at left knee and arthrocentesis was done.

Laboratory Data
Basic labs are high ferritinemia, abnormal serum aminotransferase, lactate dehydrogenase level and inflammatory arthritis. Autoantibody testing is notable for a positive ANA (Figure 2) at a titer of 1:160 with nuclear homogenous (AC1) and nuclear fine speckled (AC4) pattern, followed absence of double stranded DNA antibodies, myositis antibodies or SSA antibodies. Joint fluid revealed inflammatory arthritis.

Figure 2. Positive ANA