Postgrad Med J: first published as 10.1136/pgmj.22.254.405 on 1 December 1946. Downloaded from THE INVESTIGATION OF PROLONGED PYREXIA By T. W. PRESTON, M.D.(LOND.), M.R.C.P.(LOND.) Physician, Croydon General Hospital; Hon. Lieut.-Col. R.A.M.C., lately Officer i/c of a Medical Divisiont India Command Preliminary Considerations Br. abortus of Bang. A single reading against the enteric group will frequently be inconclusive By prolonged pyrexia will be understood pyrexia (especially if the patient has been innoculated), but of over ten days' duration. For the purposes of a series of three tests at two-day intervals may show this article itiwill be assumed that a careful clinical a rising titre of diagnostic significance. examination has failed to reveal physical signs (4) A bloodfilm should be examined for malarial of a definite character. parasites if the patient has lived in a tropical or Confronted with such a case it will rarely be sub-tropical country; if necessary this should be possible to make an immediate diagnosis and repeated several times, if possible during a rigor. investigation resolves itself into carrying out the result of Pending these investigations, theProtected by copyright. certain routine tests which will reduce a large case will be carefully reviewed, a study made of number of "possibles" into a lesser number of the type of fever as shown by a four-hourly chart, "probables" from which the final diagnosis can and inquiry made into the patient's recent and finally be determined by some specific test. The remote movements. This is particularly important late Sir Raymond Crawford was fond of saying to at the present time when so many men and women his students, "Rare things are rare and common have recently returned from military service over- things are common," and this is an adage which seas. In considering residence overseas it is may profitably be borne in mind in this type of case. desirable to ascertain with some accuracy the At this stage, the following investigations should particular location and in obscure cases to consult be carried out as routine. the relevant authorities as to the diseases endemic (i) Leucocyte and differential leucocyte count.- and epidemic. A general statement that the A high polymorphoneucleocytosis will make it patient has been "in Africa" or "in India" may extremely probable that the patient is suffering lead those unfamiliar with these countries to waste from some pyogenic infection-very probably a time looking for diseases which in fact never occur hidden collection of pus, and further investiga- in the areas concerned. tions should be concentrated in this direction. A http://pmj.bmj.com/ leucopenia, especially with a relative lymphocytosis, An ex-soldier was suffering from an obscure pyrexia. will indicate an entirely different field for further Information that he had served in India led the doctor in inquiry, whilst large numbers of monocytes or charge to institute investigations for Kala-azar. More detailed inquiry showed that in India he had been stationed eosinophiles will definitely narrow the field. exclusively in Hyderabad state and Bombay Presidency- Where the picture is indefinite, repeated counts at areas in which Kala-azar is as little prevalent as in the three-day intervals should be made. It must be Isle of Wight. remembered that the picture may vary from day to day and, moreover, the picture may be mis- After these preliminary considerations, the various on October 1, 2021 by guest. leading if the patient has been having a course of diseases likely to be the cause of prolonged pyrexia sulphonamide. may be enumerated and briefly reviewed. They (2) Blood culture.-One sample of blood should may conveniently be subdivided into the following be cultured on glucose broth, a second on a medium, groups: suitable for the isolation of the Enteric Group (e.g. McConkey's medium). A positive culture will (a) Diseases of World-Wide Incidence. usually be conclusive but a negative result excludes i. Likely to be associated with a polymor- nothing. phonucleo-leucocytosis. ii. Likely to be associated with a leucopenia. (3) Agglutination reactions against B. typhosus iii. Likely to be associated with an indefinite blood and B. paratyphosis A. and B.; M. melitensis and picture. .406 POST-GRADUATE MEDICAL JOURNAL December, I946Postgrad Med J: first published as 10.1136/pgmj.22.254.405 on 1 December 1946. Downloaded from (b) Diseases peculiar to certain areas. person. If the patient has been previously inno- culated however (even twenty years previously) (a) (i) Diseases of World-Wide Incidence H-agglutination is valueless. Associated with Polymorphonucleo- "O" agglutination is not specific for separate leucocytosis. members of the "E" group but is not produced by i. Septicaemia (including Bacterial Endocar- innoculation. Hence, a rising titre in serial tests ditis). is of diagnostic significance of enteric infection, ii. Pyaemia. but is not specific. iii. Hidden collection of pus.-It is neither "VV" agglutinins are highly specific. practicable nor desirable to discuss the numerous It is suggested that the terms "+ Widal" and conditions included under this heading, but special "- Widal" should be abandoned as valueless mention may be made of perinephric abscess and and misleading; the only report of clinical value is "carbuncle of the kidney." There are probably a rising titre in at least two and preferably three few clinicians of experience who have not at some tests done at two-day intervals. time had under their care cases of obscure pyrexia 2. Undulant Fever (Abortus type) is seen occa- which have long eluded diagnosis and which have sionally in all parts of the world. Clinically it is ultimately turned out to have had a perinephric milder than Melitensis infections (see under (B)); it abscess. In view of the obscure signs, special has few characteristic features of diagnostic signi- attention should always be concentrated on the ficance and it is rarely diagnosed until it has run exclusion of this most difficult condition. A for many weeks and numerous investigations previous history of boils will lead to a suspicion of made with negative result; if the pyrexia assumes the closely allied condition of "carbuncle of the the characteristic undulant type the case may be Kidney." (En passant, a warning may be uttered suspected clinically; but frequently the fever is at the too facile dismissal of a staphylococcus continuous or irregular. Diagnosis is established grown from blood or urine culture as a contamina- by agglutination of I-IOO or more to Br. AbortusProtected by copyright. tion. Mention may be made of a case ultimately of Bang. Infection is due to ingestion of infected diagnosed as carbuncle of the kidney which had milk or contiguity to infected animals, but often it remained undiagnosed for many weeks. Perusal is impossible to trace any connection and the -of the case papers revealed that early after ad- clinical history may be most misleading. mission a urine culture had grown a staphylococcus A soldier was admitted to a Military Hospital in Scotland -and disregarded.) with the following history: Six weeks previously whilst stationed in the English Midlands he had been admitted to hospital with acute tonsillitis: contrary to established (a) (ii) Diseases of World-Wide Incidence practice his tonsils had been enucleated during the stage Associated with Leucopenia. of acute infection. After a stormy convalescence he was sent on leave to his home in Scotland where he spent most I. Enteric Group of Fevers.-It is essential to of the time in bed feeling unwell and running irregular exclude this group in any case of prolonged pyrexia. fever. At the expiration of his leave he consulted a local Characteristically.the temperature chart will show doctor who sent him to the nearest Military Hospital as a a step-like rise and a relatively slow pulse, but all "P.U.O." Physical examination was negative and although blood culture was sterile a provisional diagnosis types of fever may occur. Although commonest of streptococcal septicaemia seemed, under the circum-http://pmj.bmj.com/ in tropical countries, especially when associated stances, not unreasonable. This diagnosis seemed streng- with faulty hygiene, it occurs sporadically and in thened when the temperature subsided coincidentally with -minor epidemics in this country. the exhibition of sulphonamide. After a few days, however, the temperature rose again, and the diagnosis The surest method of diagnosis is by blood was only established several weeks later when agglutina- -culture. This is most likely to be positive in the tion to Br. Abortus was obtained in high dilution. early stages but is well worth carrying out at any stage. 3. Agranulocytosis.-This condition is to be Failing a positive blood culture, isolation of the borne in mind especially in view of the prevalent, on October 1, 2021 by guest. -bacilli from the stools is successfully undertaken and sometimes injudicious, use of the suphonamide in many cases when an efficient technique is group of drugs. Differential diagnosis may be employed; although most likely to give positive difficult from aplastic anaemia, acute aleukaemic results after the third week, an increasing number leukaemia and acute mononucleosis. Examination of bacteriologists are now successful in the early of sternal marrow by a skilled haematologist may stages. help. Agglutination Reactions: (A) (iii) Diseases of World-Wide Incidence "H" agglutination is indicative of infection with with Indefinite-Blood Picture. -the homologous organism in an uninnoculated i. Atypical Pneumonia. Usually the fever sub- December, 1946 INVESTIGATION OF PROLONGED PYREXIA 407Postgrad Med J: first published as 10.1136/pgmj.22.254.405 on 1 December 1946. Downloaded from sides within io days, but in more prolonged cases 30,000 per c.mm. is unusual and raises suspicion of the absence of physical signs will make diagnosis a leukaemia.