DOCSLIB.ORG

Fever of Unknown Origin: a Challenging Case Sarah Vella,1 Bernard Coleiro,2 Charles Mallia Azzopardi3

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Fever of Unknown Origin: a Challenging Case Sarah Vella,1 Bernard Coleiro,2 Charles Mallia Azzopardi3 Rare disease BMJ Case Reports: first published as 10.1136/bcr-2017-224031 on 4 June 2018. Downloaded from CASE REPORT Fever of unknown origin: a challenging case Sarah Vella,1 Bernard Coleiro,2 Charles Mallia Azzopardi3 1Medicine, Mater Dei Hospital, SUMMARY She had already been hospitalised 3 weeks prior Msida, Malta We report a case of Cogan’s syndrome presenting as to this admission, at which time she was treated 2 Rheumatology, Mater Dei fever of unknown origin in a 31-year-old woman who with empirical antibiotics for a presumed commu- Hospital, Msida, Malta was admitted to the hospital with a 7-week history of nity-acquired pneumonia as CT scan of the thorax/ 3Infectious Diseases, Mater Dei abdomen/pelvis had revealed subsegmental patchy Hospital, Msida, Malta fever, night sweats and other constitutional symptoms. The diagnosis remained elusive despite numerous consolidation of the left lower lobe of the lung. Correspondence to investigations, and the patient subsequently developed The patient was readmitted as she continued to Dr Sarah Vella, rash, episcleritis, dizziness and sensorineural hearing have fever despite completing the course of antibi- smv2610@ gmail. com loss. While initially thought to be a postinflammatory otics prescribed. The history was reviewed in detail response to a previous infection, confirmation of the with special attention being given to social, sexual Accepted 15 May 2018 rash as a vasculitis together with the audiovestibular and and travel history. She had been working in a glass ocular involvement led to a clinical diagnosis of Cogan’s factory for a number of years and had not left the syndrome. This was further corroborated by resolution country in recent months. There was no family or of her symptoms once immunosuppressive therapy sexual history of note and she had no contact with animals apart from her healthy pet dog. The fever was instituted. Early recognition of Cogan’s syndrome had been going on for a total of 7 weeks, and she is crucial to reducing the risk of serious complications had also been experiencing drenching night sweats, through the timely initiation of treatment. joint pains and myalgias, with recent development of dizziness and hearing impairment. She denied any gastrointestinal symptoms. On examination she BACKGROUND was noted to have conjunctival injection secondary Fever of unknown origin (FUO) is defined as a body to episcleritis and a non-pruritic maculopapular rash temperature of ≥38.3°C on at least two occasions and over the upper limbs (figure 1), as well as nodular, a duration of illness of ≥3 weeks or having multiple tender lesions over her lower limbs. There were no febrile episodes over this time period. There must be orogenital ulcerations or joint swellings and she was no obvious diagnosis despite complete history taking neurologically intact. http://casereports.bmj.com/ and examination, as well as appropriate investigation that should include routine blood tests, inflamma- INVESTIGATIONS tory markers, autoimmune screen, cultures, chest Routine blood investigations were unremarkable radiography and abdominal imaging.1 Investigation apart from a normocytic normochromic anaemia includes identifying any potential diagnostic clues with a high reticulocyte count, a neutrophilic (PDCs) that can help reveal the underlying cause leucocytosis and raised inflammatory markers of the fever; however, up to 50% of cases of FUO (figure 2). Blood and urine cultures, as well as an remain undiagnosed.2 extensive viral screen which included serology for The case described here is of a rare condition Epstein-Barr virus, Cytomegalovirus and HIV, were presenting with FUO that proved to be a diagnostic negative. on 24 September 2021 by guest. Protected copyright. challenge. Despite its rarity, accurate documentation Systemic vasculitis such as granulomatosis with of cases of Cogan’s syndrome remains crucial to polyangiitis was excluded as repeat autoimmune screens, which included ANA (antinuclear anti- improving our awareness and understanding of this body), ANCA (anti-neutrophil cytoplasmic anti- condition. This could in turn bring about the devel- body), ASMA (anti-smooth muscle antibody), opment of more effective treatment as well as reduce rheumatoid factor, anti-CCP (anti-cyclic citrulli- patient morbidity by leading to earlier diagnosis. Our nated peptide) and complement levels, were nega- case also stresses how laboratory and radiological tive. Repeat imaging of the chest showed complete investigations should not serve as an alternative to resolution of the previous pulmonary consolidation thorough clinical assessments since early recognition following antibiotic treatment. This, together with of PDCs and symptom complexes is more likely to the absence of lymphadenopathy, a normal serum help clinch a diagnosis than investigations which can calcium and negative serum ACE, excluded a diag- at times return non-specific results. nosis of sarcoidosis, and no further pulmonary investigations were considered. To cite: Vella S, Coleiro B, CASE PRESENTATION Serological tests for Mycoplasma, Bartonella, Mallia Azzopardi C. BMJ Case A 31-year-old Caucasian female smoker was Rep Published Online First: Coxiella, Brucella, Borrelia burgdorferi and Chla- [please include Day Month admitted to the hospital with a 7-week history mydia, as well as for other infective conditions Year]. doi:10.1136/bcr-2017- of fever associated with night sweats, joint pains, including syphilis and leishmania, were negative. 224031 myalgia and nasal congestion. Tests for antistreptolysin O titre, cryoglobulins and Vella S, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-224031 1 Rare disease BMJ Case Reports: first published as 10.1136/bcr-2017-224031 on 4 June 2018. Downloaded from was excluded on the basis of the patient not having gastroin- testinal symptoms and a negative faecal calprotectin. A provisional diagnosis of postinflammatory reaction to a previous infection complicated by low-grade haemolysis with possible myringitis was made, with both of these being recognised complications of Mycoplasma pneumoniae infection. The patient was prescribed doxycycline together with a non-steroidal anti-in- flammatory agent for fever control and prochlorperazine to help relieve the dizziness. A week after being discharged on the above treatment, her symptoms had not improved. In view of her worsening hearing impairment, audiometry was performed and this confirmed bilat- eral sensorineural hearing loss. Biopsies from the lower limb rash showed a perivascular lymphocytic infiltrate typical of small-sized and medium-sized vessel vasculitis. On considering all of the patient’s symptoms and their evolu- tion, a tentative diagnosis of Cogan’s syndrome was entertained. She had gone on to develop all the classical features of the condi- Figure 1 Upper limb maculopapular rash. tion, that is, audiovestibular and ocular involvement together with vasculitis. cold agglutinins were also performed in order to rule out an TREATMENT underlying infectious cause. After being diagnosed with Cogan’s syndrome, the patient was An MRI of the patient’s brain was performed in view of her started on oral prednisolone therapy with subsequent addition audiovestibular symptoms; however, this only revealed long- of methotrexate and folic acid. standing mastoid effusions. OUTCOME AND FOLLOW-UP DIFFERENTIAL DIAGNOSIS Within a week of starting systemic steroids, our patient became The causes of FUO can be grouped as infectious, non-infec- afebrile with significant improvements in both her skin rash and tious inflammatory disorders, malignancy, and miscellaneous hearing. She was advised to gradually tail off her steroids but which includes conditions such as thyrotoxicosis. All of the returned soon after in view of flare-up of all her prior symptoms, possible causes in these categories which could potentially including low-grade fever, skin lesions, hearing impairment and explain the clinical picture in this case, including rare ones, conjunctival suffusion. It was also noted that her inflammatory were considered and excluded following intensive investiga- markers had started to increase again (figure 2). tion. One such example was syphilis, which can present with The patient was reviewed by a rheumatologist who agreed http://casereports.bmj.com/ similar ocular manifestations. The absence of orogenital ulcer- with the diagnosis and started her on methotrexate and folic ation made Behçet’s unlikely, and inflammatory bowel disease acid with more gradual tailing down of steroids. The patient has on 24 September 2021 by guest. Protected copyright. Figure 2 Graph showing trend in the patient’s white cell count (WCC) and C reactive protein (CRP). High CRP level improved once steroid therapy was initiated; however, a second rise was noted on tailing down of the dose. The persistently elevated WCC can be attributed to that same steroid therapy. 2 Vella S, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-224031 Rare disease BMJ Case Reports: first published as 10.1136/bcr-2017-224031 on 4 June 2018. Downloaded from since remained stable on methotrexate, folic acid and low-dose case Migliori et al10 advised monthly vestibuloauditory steroid therapy. assessment for the first 3 months, then 3 monthly for the first 2 years, every 6 months in the third year and yearly DISCUSSION thereafter. Cogan’s syndrome is a rare immune-mediated vasculitis that Early treatment is important in order to limit progres- mostly affects young adults with no known gender predomi-
Load more

Recommended publications
  • Overview of Fever of Unknown Origin in Adult and Paediatric Patients L
    Overview of fever of unknown origin in adult and paediatric patients L. Attard1, M. Tadolini1, D.U. De Rose2, M. Cattalini2 1Infectious Diseases Unit, Department ABSTRACT been proposed, including removing the of Medical and Surgical Sciences, Alma Fever of unknown origin (FUO) can requirement for in-hospital evaluation Mater Studiorum University of Bologna; be caused by a wide group of dis- due to an increased sophistication of 2Paediatric Clinic, University of Brescia eases, and can include both benign outpatient evaluation. Expansion of the and ASST Spedali Civili di Brescia, Italy. and serious conditions. Since the first definition has also been suggested to Luciano Attard, MD definition of FUO in the early 1960s, include sub-categories of FUO. In par- Marina Tadolini, MD Domenico Umberto De Rose, MD several updates to the definition, di- ticular, in 1991 Durak and Street re-de- Marco Cattalini, MD agnostic and therapeutic approaches fined FUO into four categories: classic Please address correspondence to: have been proposed. This review out- FUO; nosocomial FUO; neutropenic Marina Tadolini, MD, lines a case report of an elderly Ital- FUO; and human immunodeficiency Via Massarenti 11, ian male patient with high fever and virus (HIV)-associated FUO, and pro- 40138 Bologna, Italy. migrating arthralgia who underwent posed three outpatient visits and re- E-mail: [email protected] many procedures and treatments before lated investigations as an alternative to Received on November 27, 2017, accepted a final diagnosis of Adult-onset Still’s “1 week of hospitalisation” (5). on December, 7, 2017. disease was achieved. This case report In 1997, Arnow and Flaherty updated Clin Exp Rheumatol 2018; 36 (Suppl.
    [Show full text]
  • The Diagnostic Approach to Fever of Unknown Origin in Cats*
    3 CE CREDITS CE Article 2 The Diagnostic Approach to Fever of Unknown Origin in Cats* ❯❯ Julie Flood, DVM, DACVIM Abstract: Identifying the cause of fever of unknown origin (FUO) in cats is a diagnostic challenge, Antech Diagnostics just as it is in dogs. Infection is the most common cause of FUO in cats. As in dogs, the diagnostic Irvine, California workup can be frustrating, but most FUO causes can eventually be determined. This article address- es the potential diagnostic tests for, and the differential diagnosis and treatment of, FUO in cats. rue fever (pyrexia) is defined as an during the initial workup or responds to increase in body temperature due to antibiotic treatment; therefore, most cats T an elevation of the thermal set point do not have a true FUO.4 in the anterior hypothalamus secondary to the release of pyrogens.1 With hyperther- Differential Diagnosis mic conditions other than true fever, the Information regarding FUO in cats is hypothalamic set point is not adjusted.1 extremely limited, and there are no retro- At a Glance Nonfebrile hyperthermia occurs when heat spective studies. Fevers are common in cats, gain exceeds heat loss, such as with inade- and most diseases associated with FUO Differential Diagnosis quate heat dissipation, exercise, and patho- in cats are infectious.5 Neoplasia is a less Page 26 logic or pharmacologic causes.1 common cause of FUO in cats, and FUO Clinical Approach Cats with true fever typically have body due to immune-mediated disease is rare in Page 26 temperatures between 103°F and 106°F cats.6 FUO causes are often separated into Potential Causes of Fever (39.5°C to 41.1°C).2 Cats are less likely than groups based on the underlying disease of Unknown Origin in Cats dogs to succumb to the dangerous effects mechanism.2,3,7 Most FUOs are caused by a Page 27 of body temperatures greater than 106°F, common disease presenting in an obscure 8 Staged Diagnostic which are usually seen with nonfebrile fashion.
    [Show full text]
  • Fever of Unknown Origin in Childhood: Difficulties in Diagnosis
    Annals of the Rheumatic Diseases 1994; 53: 429-433 429 MASTERCLASS Ann Rheum Dis: first published as 10.1136/ard.53.7.429 on 1 July 1994. Downloaded from Fever of unknown origin in childhood: difficulties in diagnosis Katherine Martin, E Graham Davies, John S Axford Case report (CRP) 208 mg/I. Liver function tests were A twelve year old white boy presented to abnormal: alanine transaminase 91 IUAL another hospital with a two month history of (normal range 1-40), gamma glutamyl intermittent fever with night sweats, general transferase 134 IUAL (normal range 0-60), malaise, arthralgia and myalgia. He had bilirubin 18 micromolVL (0-17), alkaline marked cervical lymphadenopathy. Latex phosphatase 217 IU/L (30-100) and albumin agglutination for toxoplasma antibodies was 18 g/l (35-45). Renal impairment was apparent positive at a dilution of 1/128. A diagnosis of with a raised serum creatinine (224 micromol/ acquired toxoplasmosis was made and sulpha- L (60-110)). Chest radiograph showed right diazine 1 g four times a day, trimethoprim 300 middle lobe consolidation. Abdominal mg twice a day and folinic acid 15 mg ultrasound scan (USS) confirmed hepato- alternative days, were started. Over the next splenomegaly and ascites. Echocardiogram week he developed a generalised urticarial rash, showed a small pericardial effusion. peripheral oedema and profuse bloody A diagnosis of Stevens-Johnson syndrome diarrhoea and was referred to our unit. with acute renal failure and disseminated On examination he was delirious with a intravascular coagulation (DIC) was made. persistent fever of up to 42°C and he was Supportive therapy, broad spectrum anti- bleeding from his nose and mouth.
    [Show full text]
  • A Case of Cat Scratch Disease Confirmed by Polymerase Chain Reaction for Bartonella Henselae DNA
    Korean Journal of Pediatrics Vol. 48, No. 7, 2005 □ Case Report □ 1) A Case of Cat Scratch Disease Confirmed by Polymerase Chain Reaction for Bartonella henselae DNA Ju-Young Chung, M.D., Ja Wook Koo, M.D., Sang Woo Kim, M.D. Young Sam Yoo, M.D.*, Tae Hee Han, M.D.† and Seong Jig Lim☨ Departments of Pediatrics, Otolaryngology*, Diagnostic Laboratory Medicine†, and Pathology‡ Sanggyepaik Hospital, Inje University College of Medicine, Seoul, Korea We report a case of cat scratch disease (CSD) caused by Bartonella henselae in a 14-year-old boy who developed lymphadenopathy in the right cervical area, after a raising canine pet for 10 months. The cervical lymphadenopathy persisted for 14 days. Immunofluorescent antibody testing for B. henselae with the patient's serum was 1:64 positive. Polymerase chain reaction (PCR) analysis using the patient's lymph node aspirates for B. henselae DNA was also positive. This is the first case of cat scratch disease confirmed by PCR for B. henselae DNA in children. (Korean J Pediatr 2005;48: 789-792) Key Words : Bartonella henselae,Catscratchdisease,PCR,Children due to the difficulty of isolating the organism from pa- Introduction tients. Recently, the detection of B. henselae DNA by using PCR with specimen of lymph nodes from patients 4-6) Cat scratch disease (CSD) is usually characterized as a and blood is available for genetic diagnosis of CSD .In self-limiting regional lymphadenopathy associated with a Korea, few cases of lymphadenitis showing positive results cat scratch or bite, caused by B. henselae or possibly B. by immunofluorescent assay for B.
    [Show full text]
  • Systemic Cat Scratch Disease Hui-Min Liao,1 Fu-Yuan Huang,1 Hsin Chi,1,4* Nieu-Lu Wang,2 Be-Fong Chen3
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector CASE REPORT Systemic Cat Scratch Disease Hui-Min Liao,1 Fu-Yuan Huang,1 Hsin Chi,1,4* Nieu-Lu Wang,2 Be-Fong Chen3 Systemic cat scratch disease (CSD) is often associated with prolonged fever and microabscesses in the liver and/or spleen. We report a case of systemic CSD with hepatic, splenic and renal involvement in an abori- ginal child in Taiwan. A previously healthy 9-year-old girl had an intermittent fever for about 17 days, and complained of abdominal pain, headache and weight loss. Abdominal computed tomography showed multiple tiny hypodense nodular lesions in the spleen and both kidneys. Laparotomy revealed multiple soft, whitish-tan lesions on the surface of the liver and spleen. Histopathologic examination of a biopsy specimen of the spleen showed necrotizing granulomatous inflammation with central necrosis sur- rounded by epithelioid cells and occasional Langhans’ giant cells, strongly suggestive of Bartonella henselae infection. History revealed close contact with a cat. B. henselae DNA was detected by polymerase chain reaction in the tissue specimen, and the single antibody titer against B. henselae was greater than 1:2048. These results confirmed the diagnosis of visceral CSD caused by B. henselae. The patient’s symptoms resolved after treatment with rifampin and tetracycline. This case illustrates the need for inclusion of systemic CSD in patients with fever of unknown origin and abdominal pain. [J Formos
    [Show full text]
  • Fever of Unknown Origin
    CME: CLINICAL PRACTICE AND ITS BASIS uted to infection, neoplasm, collagen vascular disease and miscellaneous Infectious diseases causes. Arnow and Flaherty have sug- gested a minimum set of investigations to be performed prior to so defining a Edited by Andrew Freedman MD FRCP, patient (Table 1).5 Adoption of these Senior Lecturer in Infectious Diseases and Honorary Consultant Physician, criteria is recommended to attempt to Cardiff University School of Medicine establish greater comparability between future publications on FUO. It has been suggested that FUO can be subclassified into four different types: Fever of unknown origin • classic FUO • nosocomial FUO • immune-deficient FUO John Williams MRCP DTMH, Infectious ness of at least three weeks’ duration, with HIV-related FUO. Diseases Specialist Registrar repeated temperature measurements of • Richard Bellamy MRCP DPhil MSc MMedEd, 38.3°C or higher, that defies diagnosis Only the definition of classic FUO Infectious Diseases Consultant after one week of hospital inpatient evalu- specifies that the patient must have had 4 6 Department of Infection and Travel Medicine, ation. This has subsequently been modi- fevers for at least three weeks. This may James Cook University Hospital, fied to remove the requirement that potentially cause confusion; it is prob- Middlesbrough investigations are performed in the inpa- ably preferable to restrict the term FUO tient setting because most patients can be to those cases where FUO has been pre- Clin Med 2008;8:526–30 evaluated as outpatients. sent for at least three weeks and to One problem with the definition of exclude HIV and immune deficiency. FUO is that it does not specify which Unfortunately, many clinicians use the Definitions investigations should have been per- term loosely to include any fever for formed prior to stating that a patient ful- which a cause has not been found.
    [Show full text]
  • Fever of Unknown Origin in Cats
    BRIARPOINTE VETERINARY CLINIC 47330 Ten Mile Road Novi, MI 48374 (248) 449-7447 Ronald A. Studer, D.V.M., L.P.C. John S. Parker, D.V.M. FEVER OF UNKNOWN ORIGIN IN CATS What is a fever of unknown origin? Fever is a term that refers to an elevated body temperature. The normal body temperature range for cats is between 100.0°F and 102.5°F (37.9°C to 39.2°C). To be classified as a fever of unknown origin (FUO), the body temperature must be above 103.5°F (39.7°C) on at least four occasions over a fourteen-day period , accompanied by an illness of fourteen days’ duration without an obvious cause. What causes a fever? A fever is initiated by the presence of the body’s own (endogenous) or an outside (exogenous) source of a pyrogen (a fever-producing substance). This then causes the release of substances from the body such as interleukin-1 and prostaglandins that reset the body’s temperature regulation mechanism (which is located in the hypothalamus). This resetting to a higher temperature activates physiologic responses within the body to elevate the temperature. If this is a natural process, why is it a problem? Generally speaking, a fever is beneficial to the body because it hampers the ability of bacteria to reproduce and improves the immune system response. However, if the fever remains above 105°F (40.5°C) for more than a day or two, dehydration, anorexia and depression often result. If the fever persists above 106°F (41.1°C), cerebral edema (swelling around the brain), bone marrow suppression and clotting disorders may develop.
    [Show full text]
  • Fever of Unknown Origin (FUO)
    Fever of Unknown Origin (FUO) The syndrome is defined as the following: (1) a temperature greater than 38.3°C on several occasions, (2) more than 3 weeks' duration of illness, and (3) failure to reach a diagnosis despite one week of inpatient investigation . FUO is currently classified into 4 distinct categories: • Classic FUO: Fever for > 3 wk with no identified cause after 3 days of hospital evaluation or ≥ 3 outpatient visits • Health care–associated FUO: Fever in hospitalized patients receiving acute care and with no infection present or incubating at admission if the diagnosis remains uncertain after 3 days of appropriate evaluation • Immune-deficient FUO: Fever in patients with immunodeficiencies if the diagnosis remains uncertain after 3 days of appropriate evaluation, including negative cultures after 48 h • HIV-related FUO: Fever for > 3 wk in outpatients with confirmed HIV infection or > 3 days in inpatients with confirmed HIV infection if the diagnosis remains uncertain after appropriate evaluation Etiology • Infections (25 to 50%) • Connective tissue disorders (10 to 20%) • Neoplasms (5 to 35%) • Miscellaneous (15 to 25%) Infections are the most common cause of FUO. In patients with HIV infection, opportunistic infections (eg, TB; infection by atypical mycobacteria, disseminated fungi, or cytomegalovirus) should be sought. Common connective tissue disorders include SLE, RA, giant cell arteritis, vasculitis, and juvenile RA of adults (adult Still disease). The most common neoplastic causes are lymphoma, leukemia, renal cell carcinoma, hepatocellular carcinoma, and metastatic carcinomas. However, the incidence of neoplastic causes of FUO has been decreasing, probably because they are being detected by ultrasonography and CT, which are now widely used during initial evaluation.
    [Show full text]
  • Cat Scratch Disease
    Infectious Disease Epidemiology Section Office of Public Health, Louisiana Dept of Health & Hospitals 800-256-2748 (24 hr number) – (504) 568-8313 www.infectiousdisease.dhh.louisiana.gov CAT SCRATCH DISEASE Revised 07/21/2004 Cat-scratch disease (CSD) is a subacute, usually self-limited bacterial disease most often caused by Bartonella henselae. Bartonella henselae is closely related to Bartonella quintana, the agent of trench fever and also a cause of bacillary angiomatosis. Epidemiology CSD is probably relatively common, but the true incidence is unknown. Approximately 80% of cases occur in people under 20 years of age. Over 90% of patients report a history of recent contact with cats or kittens, which usually appear healthy. Transmission seems to be a result of a scratch, bite, lick, or other exposure to a healthy, usually young cat. Other animals, such as dogs, monkeys, rabbits, chickens, and horses, may be possible sources, but this is not confirmed. Cat fleas are another possible, but unproven, source of infection. Transmission from person to person does not occur. The incubation period from the time of the scratch to the appearance of the primary cutaneous lesion, is 7 to 12 days and 5 to 50 days (median 12 days) from appearance of the primary lesion to appearance of lymphadenopathy. Clinical Description The main sign of cat-scratch disease (CSD) is regional lymphadenopathy in an immunocompetent person. It involves nodes that drain the site of inoculation and may include cervical, axillary, epitrochlear, or inguinal nodes. The area around affected lymph nodes typically is tender, warm, erythematous, and indurated. The affected nodes may suppurate spontaneously.
    [Show full text]
  • Pyrexia of Unknown Origin - Physician’S Challenge
    CHAPTER Pyrexia of Unknown Origin - Physician’s Challenge 3 Asha N Shah PUO(FUO) should be reserved for prolonged febrile cause of fever is often found before three weeks of illness illnesses without an established etiology despite intensive and therefore only more difficult to diagnose cases meet evaluation and diagnostic testing. FUO remains a the definition of FUO as given in Table 1. challenging diagnostic problem with all the physicians. The etiologies of the PUO have changed over time With the development of better diagnostic techniques, the because of shifting disease patterns and new diagnostic techniques. In general, infection accounts for about Table 1: Definition of PUO 20–25% of cases of PUO in Western countries; next in 0 frequency are neoplasms and noninfectious inflammatory Original (1961, • Temperature >101 F(38.3 C) on diseases (NIIDs). In tropical and subtropical areas(INDIA), petersdorf and several separate occasions infections are a much more common cause of PUO), while Beteson) • Fever lasting for more than 3 the proportions of cases due to NIIDs and neoplasms weeks are similar. Up to 50% of cases caused by infections in • Evaluation of at least one week in patients with PUO outside Western nations are due to hospital tuberculosis, which is a less common cause in the United Revised (1991) • Temperature of >1010F on several States and Western Europe. separate occasions CAUSES • Fever lasting more than 3 weeks More than 200 causes of PUO have been described in • Evaluation of at least 3 outpatient literature. The causes for PUO are extensive, but it is visits or 3 days in inpatient care important to remember that PUO is far more often caused New • Temperature >1010F documented by an atypical presentation of a rather common disease clinically on several separate than by a very rare disease.
    [Show full text]
  • Fever of Unknown Origin in Patients with Cat Scratch Disease
    Fever of unknown origin in patients with cat scratch disease Landes M1, Maor Y2, Bilavsky E3, Chazan B4, Cohen R5, Glikman D6, Strahilevitz J7, Katzir M8, Litachevsky V9, Melamed R10, Habot-Wilner Z1, Paul M11, Zimhony O12, Srugo I13, Rahav G9, Bishara J14, Rasis M1, Ben-Ami R1, Ephros M15, Giladi M1. 1 Tel Aviv Sourasky Medical Center, 2 Wolfson Medical Center, 3 Schneider Children’s Medical Center of Israel, 4 Ha'Emek Medical Center, 5 Laniado Medical Center, 6 Galilee Medical Center, 7 Hadassah-Hebrew University Medical Centers, 8 Meir Medical Center,9 Sheba Medical Center, 10 Soroka Medical Center,11 Rambam Health Care Campus, 12 Kaplan Medical Center,13 Bnai Zion Medical Center,14 Rabin Medical Center,15 Carmel Medical Center, Israel. BACKGROUND RESULTS A B Fever of unknown origin (FUO) is a rare Table: Data on 32 CSD-FUO patients was identified in 2012-16. manifestation of cat scratch disease (CSD). Patients characteristics n/N* (%)/ Median (range) Familiarity with this syndrome is important, Male 19/32 (59%) however, data are limited. We aimed to Age 41 (5-78) identify patients with CSD-FUO and Immunocompetent 32/32 (100%) characterize disease manifestations and Cat contact 28/32 (88%) long-term clinical outcome. Clinical manifestations Hospitalization 31/32 (97%) A. CT: multiple hypoechoic splenic lesions. Fever pattern: B. PET FDG: left axillary lymphadenopathy not palpable METHODS Relapsing 15/30 (50%) on physical examination Continuous 15/30 (50%) Duration of fever (weeks) 3 (2-9) § This is a part of an ongoing CSD surveillance study Night sweats 15/29 (52%) in Israel, where all CSD diagnostic assays are Weight loss 13/29 (45%) performed in a central national laboratory.
    [Show full text]
  • Approach to Fever of Unknown Origin Authors: Patrick Tierney MD and Trushar Dungarani DO
    Approach to Fever of Unknown Origin Authors: Patrick Tierney MD and Trushar Dungarani DO The approach to a patient presenting with fever of unknown origin (FUO) should include a comprehensive history, physical examination, and appropriate diagnostic testing Definitions: Common Etiologies: A. Classic FUO: Infection (especially TB, endocarditis, osteomyelitis, intra-abdominal abscess), (1) Daily or intermittent fever > 101°F malignancy (especially lymphoma, renal cell (2) Duration of at least 3 consecutive weeks carcinoma, hepatocellular), collagen vascular disease (3) No source identified by clinical evaluation despite: a.) 3 days of hospital evaluation OR b.) 7 days of outpatient evaluation OR c.) Three outpatient visits B. Nosocomial FUO: Clostridium difficile colitis, drug-induced fever, alcohol/drug withdrawal, pulmonary (1) Daily or intermittent fever > 101°F embolism, septic thrombophlebitis, sinusitis, (2) Hospitalized ≥ 24 hours with no fever on admission acalculus cholecystitis, pancreatitis (3) Fever evaluation of at least 3 days C. Immune-deficient FUO: Opportunistic bacterial infections, aspergillosis, candidiasis, herpes virus (1) Daily or intermittent fever > 101°F (2) ANC < 500/mm3 (3) Fever evaluation of at least 3 days D. HIV-associated FUO: Cytomegalovirus, Mycobacterium avium- intracellulare complex, Pneumocystis (1) Daily or intermittent fever > 101°F jiroveckii pneumonia, drug-induced, Kaposi's (2) Inpatient fever > 3 days OR sarcoma, lymphoma (3) Outpatient fever > 4 weeks History: A comprehensive history should include questions about: A. The fever itself (e.g. route of measurement, peak temperature, patterns, time of day, etc.) B. Systemic symptoms (e.g. weight loss, decreased appetite, rash, myalgias, arthralgias, etc.) C. Localized symptoms (e.g. cough, urinary symptoms, headache, abdominal pain, bone pain, etc.) D.
    [Show full text]