Postgrad Med J: first published as 10.1136/pgmj.24.268.81 on 1 February 1948. Downloaded from THE DIAGNOSIS OF OBSCURE PYREXIA By M. H. PAPPWORTH, M.D., M.R.C.P. Lately Medical Tutor, Liverpool University The task of diagnosis in a patient with pyrexia Clinical Examination of uncertain origin demands a close alliance be- Complete and careful clinical examination is tween clinician and pathologist-an alliance based essential before any special investigations are on a full understanding of each other's powers and undertaken. The whole body must be searched limitations. On the one hand the clinician must for a rash. The typhoid rash is ephemeral, often have a sound knowledge of the tests which he asks sparse; occasional rose spots may indeed be the pathologist to carry out; on the other, the atypical so that their significance is overlooked. pathologist must not be used merely as a sort A purpuric eruption in a patient with pyrexia of penny in the slot machine to deliver an answer should particularly bring to mind septicaemias (in- of yes or no to such questions as, ' Has this patient cluding infective endocarditis) haemorrhagic exan- typhoid fever ? ' themata and the primary blood diseases. Ephemeral fevers, so common, yet to which so frequently no diagnostic label can be assigned, are Enlargement of lymphatic glands should ob- outside the scope of this paper, as are also the viously lead to careful examination of the area of Protected by copyright. common exanthemata. lymphatic drainage and also to a search for other The importance of an accurate history. A care- enlarged glands and splenomegaly it also calls ful history of the illness, especially of its onset, is for a blood count to exclude the leukaemias and of the first importance. For example, in typhoid glandular fever. If in a- patient with glandular fever the onset is usually gradual, but frequently enlargement these further examinations yield no the classical ingravescent fever with gastro- further information, biopsy of one of the glands intestinal symptoms does not occur and the should be undertaken, for this is the only way- of presenting symptoms may be bronchial. Again, diagnosing for certainty glandular tuberculosis, previous illnesses may afford a clue to the present lymphadenoma and lymphosarcoma. Malignant condition, which may be a relapse, a complication, metastases or sarcoidosis may also be revealed by or a sequel of either a recent or a long-standing glandular biopsy. Occasionally the differentiation illness. Has the patient been abroad, particularly between hyperplastic tuberculosis and lympha- in the period directly preceding the illness ? If denoma is very difficult, even microscopically. so, the type of fever common to the foreign parts According to Gordon, intracerebral inoculation http://pmj.bmj.com/ visited must be kept in mind. Are other members into a rabbit of a glandular emulsion may be of the family, or fellow workers similarly affected ? decisive, lymphadenomatous tissue producing a If the latter, Weil's disease should be considered typical encephalitis. as an. industrial hazard; in this country minor In protozoal infections, other than Weil's disease epidemics have been reported among sewer the tongue is reasonably clean even though the: labourers, coal miners, bargemen, fish workers, pyrexia has been prolonged. On abdominal and tripe makers and it is important to realize that examination regard must be paid to any localized on September 28, 2021 by guest. more than half the cases are not jaundiced. tenderness or rigidity. Tenderness and slight Usually the disease has an abrupt febrile onset bulging in the loin, often without any urinary followed by marked prostration, muscular pains, symptoms, suggest a perinephric abscess, a fre- evidence of nephritis without oedema, frequently quent cause of obscure pyrexia. The tenderness meningismus and marked injection ofthe episcleral is very marked when the twelfth rib is pressed vessels of the conjunctivae' and haemorrhages upon and questioning of the patient may reveal from various sites, most commonly the nose. that within recent weeks he has suffered from a Particular attention must be paid to symptoms boil or carbuncle, an episode which often appears which cannot be attributed to the pyrexia per se, to the patient to be so trivial as to have passed out e.g., cough, dyspnoea, dysuria, or diarrhoea, which of his mind. Perinephric abscess is frequently may give a direct clue to the particular organ which bilateral. is diseased. Enlargement of the spleen rarely helps in the 82 THE POST GRADUATE MEDICAL JOURNAL Fvebruary 1948Postgrad Med J: first published as 10.1136/pgmj.24.268.81 on 1 February 1948. Downloaded from diagnosis of a case of fever as it may be enlarged mittent, intermittent, continued, undulant-are in almost any fever, but when extreme, points to incorrectly used. A remittent pyrexia is one in the likelihood of a blood dyscrasia or a protozoal which the difference between the maximum and infection. minimum temperature (usually thQ evening and Rectal examination should never be forgotten. the morning temperature respectively) is more It may reveal an unsuspected pelvic abscess or a than two degrees, the temperature being raised malignant growth. throughout the whole or almost the whole of the Examination of the chest must be meticulous; day. Most fevers, and especially those of coccal to be on the look-out here for possible causes of origin, are of this type. An intermittent pyrexia pyrexia is often to get more than half-way to a is one in which there are paroxysms of fever, diagnosis. Conditions such as rapidly advancing usually high and often accompanied by a rigor, pulmonary tuberculosis, pulmonary abscess, inter- lasting for a comparatively short period of the day lobar empyema and chronic empyema (sometimes only. The temperature chart therefore shows secondary to a bronchial neoplasm) and the atypical high peaks, with. subsidence to the normal line pneumonias, at times cause so few unequivocal or below. The paroxysms occur daily or every signs that they are easily overlooked. third or fourth day-quotidian, tertian and The presence of a valvular or congenital lesion quartian fevers. Malaria, pyaemias, acute pyelitis of the heart in any febrile patient must arouse and septicaemias commonly give rise to this type suspicion of an infective endocarditis and search of fever. A continued pyrexia is one inx which the should be made for evidence of emboli, especially temperature remains high throughout the day in the skin (petechiae) and kidneys (red blood with a difference between the maximum and corpuscles in the urine, sometimes so scanty as to minimum temperature of less than two degrees. be recognized only by careful investigation of the In this country there are only three common centrifugalized deposit). In any suspected case causes of a prolonged continued pyrexia-the en- repeated blood cultures should be carried out. teric group of infections, miliary tuberculosis, andProtected by copyright. The nervous system must not escape attention. infective endocarditis. An atypical pneumonia Nuchal rigidity is rarely well developed except in may give rise to such a continued pyrexia but its cases of meningitis. The Kernig and Brudzinski duration is rarely prolonged beyond a week. signs are, by themselves, never of great value. Miliary tuberculosis is often very difficult to Cerebro-spinal fluid examination is necessary in diagnose clinically for there is usually an absence any patient with obscure fever if positive neuro- of physical signs in the lungs. A slight cyanosis logical signs or nuchal rigidity are present. Very is often present in these cases and should arouse rarely in tuberculous meningitis choroidal tubercles suspicion. are seen. Chameleon eye movements are possibly An undulant pyrexia is one in which periods of pathognomonic of tuberculous meningitis. continued fever alternate with afebrile periods. The diagnosis of acute encephalitis lethargica is The Brucellosis group of infections, lympha- fraught with great difficulties. Its possibility denoma (Pel-Epstein type of fever) and certain should be borne in mind in a patient with obscure spirochaetal diseases, notably the relapsing fevershttp://pmj.bmj.com/ pyrexia if any of the following signs and symptoms and rat-bite fever, are of this type. Malta or un- be present. (i) Sudden mental change in a dulant fever may be due to Brucella melitensis patient previously mentally normal. (2) Ocular (caprine), Brucella abortus (bovine), or Brucella paresis or diplopia. (3) Any suggestion of Par- suis (porcine). These types cannot be differ- kinsonism. (4) Central pain. (5) Sleep changes. entiated clinically. The symptoms are conmnonly (6) Involuntary movements of a myoclonic, mild and, except in the rare typhoid type, not as choreiform, or athetoid type. severe as would be expected from the temperature Focal sepsis is of little importance when con- chart. Apart from the frequency of severe pains on September 28, 2021 by guest. sidering the problein of uncertain pyrexia. Un- in the loins, limbs and joints, the symptoms are complicated infection of tonsils, teeth or nasal usually those common to any fever. If in a patient sinuses is very rarely if ever, the cause of pro- with pyrexia, arthritic pains with or without longed fever. effusion into the joints do not respond to the The presence of transverse white bands on the administration of salicylates, the possibility of a nails should lead to a careful scrutiny of the Brucellosis infection must be considered. Some- temperature chart, because these are often seen in times gastro-intestinal symptoms including haema- association with undulant fevers, each white line temesis or melaena, occasionally orchitis, and corresponding to a period of pyrexia. rarely jaundice dominate the clinical picture. The The type of fever may be a great help in duration of the illness is very variable with an diagnosis. Often, however, the classical terms average of about three months, but it may be given to the different categories of fever-re- protracted for very much longer, even years.