Folate deficiency is an uncommon cause of pyrexia. We describe the case of a 29-year-old male who presented with a pyrexial illness subsequently attributed to megaloblastic anaemia secondary to severe folate deficiency, after exclusion of other infective or inflammatory causes. A temperature chart documenting the course of the patient's pyrexia is presented and potential pathophysiological mechanisms are proposed. Folate deficiency is a reversible cause of pyrexia that should be considered in any patient who presents with a pyrexial illness of unknown cause. Case presentationA 29-year-old caucasian male presented to our medical admissions unit complaining of a 6 week history of dyspnoea on exertion, recurrent fevers and sweats. He had a 7 year history of alcohol excess, drinking 3-4 litres of cider per day. He was a smoker of 10 cigarettes per day, but was otherwise fit and well with no significant past medical or family history. The patient reported no other symptoms and did not take any regular medication.Examination revealed a pulse rate of 124 beats/minute and a blood pressure of 120 mmHg/48 mmHg. He was noted to be febrile with a temperature of 38.8°C. Oxygen saturations were 100% on room air with no signs of respiratory distress. He had visibly pale conjunctiva and a lemon yellow tint to the skin (but no evidence of icteric sclerae). There were no signs of chronic liver disease and no peripheral stigmata of bacterial endocarditis. Cardiovascular examination revealed a collapsing pulse and a soft systolic murmur audible at the left sternal edge. Auscultation of the chest revealed vesicular breath sounds with no added sounds. On abdominal examination there was palpable splenomegaly but not other organomegaly or ascites. Neurological examination was normal with was no evidence of neck stiffness or skin rashes.Admission blood tests revealed a severe pancytopenia with a raised mean cell volume (see table 1). Also notable was a mild hyperbilirubinaemia but otherwise normal liver function with no evidence of impaired hepatic synthetic function (normal serum albumin and normal prothrombin time).Subsequently, serum folate levels were found to be low at 1.2 ug/L (normal range 4-24 ug/L) and vitamin B 12 levels were low-normal at 202 ng/L (normal range 180-900 ng/ L). Iron studies were normal. Initial blood film and subsequent bone marrow examination confirmed a severe megaloblastic picture, consistent with folate deficiency.Urine dip test and subsequent urine cultures were negative. Three sets of blood cultures were taken from different sites (before commencement of antibiotics) but were all negative after 5 days culture. Chest radiograph was nor-
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