What is the diagnosis for a 61-year-old male presenting with myalgia (muscle aches) and fever, with leukocytosis (elevated White Blood Cell (WBC) count) of 16, neutrophilia (elevated neutrophils), mild hyperbilirubinemia (elevated bilirubin) of 1.7, normal aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and an elevated Prostate-Specific Antigen (PSA) of 6?

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Differential Diagnosis for 61-year-old Male with Body Aches, Fever, and Laboratory Abnormalities

Single Most Likely Diagnosis

  • Prostatitis: Given the elevated PSA (6) and symptoms of body aches and fever, prostatitis is a strong consideration. The elevated WBC count with neutrophilia further supports an infectious or inflammatory process, which is consistent with prostatitis.

Other Likely Diagnoses

  • Urinary Tract Infection (UTI): The presence of fever, body aches, and elevated WBC count could also suggest a UTI, especially in an older male. The elevated PSA might be secondary to the infection.
  • Pneumonia: Although not directly indicated by the provided lab results, pneumonia could cause fever, body aches, and an elevated WBC count. It's a common condition that needs to be considered, especially in older adults.
  • Chronic Prostate Cancer: An elevated PSA of 6 could indicate prostate cancer. However, the acute presentation with fever and body aches is less typical for cancer, making it less likely but still a consideration given the PSA level.

Do Not Miss Diagnoses

  • Sepsis: Although the patient's presentation does not fully align with sepsis (e.g., no clear source of infection, relatively mild bilirubin elevation), any condition that could potentially lead to sepsis should be considered, especially in older adults with fever and elevated WBC counts.
  • Endocarditis: This condition, although less likely given the information, can present with fever, body aches, and elevated inflammatory markers. It's a diagnosis that could be deadly if missed.
  • Diverticulitis or Other Abdominal Infections: These conditions can cause fever, body aches, and elevated WBC counts. While the normal AST and ALT might suggest against some abdominal pathologies, diverticulitis or other infections could still be present.

Rare Diagnoses

  • Lymphoma: Certain types of lymphoma can present with systemic symptoms like fever and body aches, along with abnormal lab results. However, this would be a less common diagnosis and might require further investigation.
  • Myeloproliferative Neoplasms: Conditions like chronic myeloid leukemia (CML) or other myeloproliferative neoplasms could potentially explain an elevated WBC count but would be less likely given the acute presentation and other symptoms.
  • Familial Mediterranean Fever: This is a rare genetic disorder that causes recurrent episodes of fever and body aches, but it would be an unusual diagnosis in a 61-year-old without a known family history.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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