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Ratti N, Ly KH, Dumonteil S, François M, Sailler L, Lambert M, Hot A, Gondran G, Palat S, Bezanahary H, Desvaux E, Aslanbekova N, Parreau S, Fauchais AL, Sève P, Liozon E. Recurrent (or episodic) fever of unknown origin (FUO) as a variant subgroup of classical FUO: A French multicentre retrospective study of 170 patients. Clin Med (Lond) 2024; 24:100202. [PMID: 38642612 PMCID: PMC11107460 DOI: 10.1016/j.clinme.2024.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/23/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Recurrent FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking. METHODS We performed a retrospective multicentre study of patients with recurrent FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical and prognostic variables independently associated with final diagnosis and mortality. RESULTS Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR = 5.2; p < 0.001), contributory history (OR = 10.4; p < 0.001), and abnormal clinical examination (OR = 4.0; p = 0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p = 0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death. CONCLUSION This study extends the known yield of recurrent FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow-up. Moreover, their overall prognosis is excellent.
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Affiliation(s)
- N Ratti
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France.
| | - K H Ly
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - S Dumonteil
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - M François
- Departments of Internal Medicine, University Hospitals of Lyon Sud, Pierre-Bénite, France
| | - L Sailler
- Departments of Internal Medicine, University Hospitals of Toulouse, Purpan, France
| | - M Lambert
- Departments of Internal Medicine, University Hospitals of Lille, Claude Huriez, France
| | - A Hot
- Departments of Internal Medicine, University Hospitals of Lyon, Édouard Herriot, France
| | - G Gondran
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - S Palat
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - H Bezanahary
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - E Desvaux
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - N Aslanbekova
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - S Parreau
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - A L Fauchais
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
| | - P Sève
- Departments of Internal Medicine, University Hospitals of Lyon, La Croix-Rousse, France
| | - E Liozon
- Departments of Internal Medicine, University Hospitals of Limoges, Dupuytren, France
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Jiang L, Wu H, Zhao S, Zhang Y, Song N. Structured diagnostic scheme clinical experience sharing: a prospective study of 320 cases of fever of unknown origin in a tertiary hospital in North China. BMC Infect Dis 2023; 23:452. [PMID: 37420165 DOI: 10.1186/s12879-023-08436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND There has been little research on the long-term clinical outcomes of patients discharged due to undiagnosed fevers of unknown origin (FUO). The purpose of this study was to determine how fever of unknown origin (FUO) evolves over time and to determine the prognosis of patients in order to guide clinical diagnosis and treatment decisions. METHODS Based on FUO structured diagnosis scheme, prospectively included 320 patients who hospitalized at the Department of Infectious Diseases of the Second Hospital of Hebei Medical University from March 15, 2016 to December 31,2019 with FUO, to analysis the cause of FUO, pathogenetic distribution and prognosis, and to compare the etiological distribution of FUO between different years, genders, ages, and duration of fever. RESULTS Among the 320 patients, 279 were finally diagnosed through various types of examination or diagnostic methods, and the diagnosis rate was 87.2%. Among all the causes of FUO, 69.3% were infectious diseases, of which Urinary tract infection 12.8% and lung infection 9.7% were the most common. The majority of pathogens are bacteria. Among contagious diseases, brucellosis is the most common. Non-infectious inflammatory diseases were responsible for 6.3% of cases, of which systemic lupus erythematosus(SLE) 1.9% was the most common; 5% were neoplastic diseases; 5.3% were other diseases; and in 12.8% of cases, the cause was unclear. In 2018-2019, the proportion of infectious diseases in FUO was higher than 2016-2017 (P < 0.05). The proportion of infectious diseases was higher in men and older FUO than in women and young and middle-aged (P < 0.05). According to follow-up, the mortality rate of FUO patients during hospitalization was low at 1.9%. CONCLUSIONS Infectious diseases are the principal cause of FUO. There are temporal differences in the etiological distribution of FUO, and the etiology of FUO is closely related to the prognosis. It is important to identify the etiology of patients with worsening or unrelieved disease.
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Affiliation(s)
- Lin Jiang
- Department of Infectious Diseases, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Critical Care Medicine, Shiyan Renmin Hospital, Shiyan, China
| | - Han Wu
- Department of Infectious Diseases, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Sen Zhao
- Department of Infectious Diseases, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu Zhang
- Department of Infectious Diseases, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ning Song
- Department of Infectious Diseases, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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Hadano Y, Inoue T. Unraveling the Mystery of Fever Source: The Vital Role of Physical Examination in Hospitalized Patients With Emphasis on Peripheral Line-Associated Bloodstream Infections. Cureus 2023; 15:e42301. [PMID: 37609087 PMCID: PMC10441823 DOI: 10.7759/cureus.42301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 08/24/2023] Open
Abstract
Fever in hospitalized patients requires timely identification of the underlying cause for appropriate treatment. While laboratory tests and imaging studies are valuable, the significance of physical examination should not be overlooked. We present a case of peripheral line-associated bloodstream infection that was readily diagnosed through physical examination during an infectious disease consultation for fever of unknown origin. It is important for busy physicians to prioritize physical examinations to prevent diagnostic errors. Prompt and focused physical examinations contribute to improved patient outcomes and the prevention of healthcare-associated infections.
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Affiliation(s)
- Yoshiro Hadano
- Division of Infection Control and Prevention, Shimane University Hospital, Izumo, JPN
| | - Tomohiro Inoue
- Department of Emergency Medicine, St. Mary's Hospital, Kurume, JPN
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Naito T, Tanei M, Ikeda N, Ishii T, Suzuki T, Morita H, Yamasaki S, Tamura J, Akazawa K, Yamamoto K, Otani H, Suzuki S, Kikuchi M, Ono S, Kobayashi H, Akita H, Tazuma S, Hayashi J. Key diagnostic characteristics of fever of unknown origin in Japanese patients: a prospective multicentre study. BMJ Open 2019; 9:e032059. [PMID: 31748308 PMCID: PMC6886908 DOI: 10.1136/bmjopen-2019-032059] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To identify the key diagnostic features and causes of fever of unknown origin (FUO) in Japanese patients. DESIGN Multicentre prospective study. SETTING Sixteen hospitals affiliated with the Japanese Society of Hospital General Medicine, covering the East and West regions of Japan. PARTICIPANTS Patient aged ≥20 years diagnosed with classic FUO (axillary temperature≥38.0°C at least twice within a 3-week period, cause unknown after three outpatient visits or 3 days of hospitalisation). A total of 141 cases met the criteria and were recruited from January 2016 to December 2017. INTERVENTION Japanese standard diagnostic examinations. OUTCOME MEASURES Data collected include usual biochemical blood tests, inflammatory markers (erythrocyte sedimentation rate (ESR), C reactive (CRP) protein level, procalcitonin level), imaging results, autopsy findings (if performed) and final diagnosis. RESULTS The most frequent age group was 65-79 years old (mean: 58.6±9.1 years). The most frequent cause of FUO was non-infectious inflammatory disease. After a 6-month follow-up period, 21.3% of cases remained undiagnosed. The types of diseases causing FUO were significantly correlated with age and prognosis. Between patients with and without a final diagnosis, there was no difference in CRP level between patients with and without a final diagnosis (p=0.121). A significant difference in diagnosis of a causative disease was found between patients who did or did not receive an ESR test (p=0.041). Of the 35 patients with an abnormal ESR value, 28 (80%) had causative disease identified. CONCLUSIONS Age may be a key factor in the differential diagnosis of FUO; the ESR test may be of value in the FUO evaluation process. These results may provide clinicians with insight into the management of FUO to allow adequate treatment according to the cause of the disease.
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Affiliation(s)
- Toshio Naito
- Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Mika Tanei
- Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobuhiro Ikeda
- Department of General Medicine, Eiju General Hospital, Tokyo, Japan
| | - Toshihiro Ishii
- Department of General Medicine, Oita University Faculty of Medicine, Oita, Japan
| | - Tomio Suzuki
- Department of General Medicine, Osaka Medical College Hospital, Osaka, Japan
| | - Hiroyuki Morita
- General Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Sho Yamasaki
- General Internal Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Jun'ichi Tamura
- General Medicine, Gunma University Graduate School of Medicine School of Medicine, Maebashi, Japan
| | - Kenichiro Akazawa
- Internal Medicine, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Japan
| | | | - Hiroshi Otani
- General Medicine, Tachikawa Sogo Hospital, Tachikawa, Tokyo, Japan
| | - Satoshi Suzuki
- Division of General Medicine, Tone Chuo Hospital, Gunma, Japan
| | - Motoo Kikuchi
- Department of General Medicine, Nagoya City West Medical Center, Nagoya, Japan
| | - Shiro Ono
- General Medicine, Nara Medical University, Nara, Japan
| | | | - Hozuka Akita
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Jun Hayashi
- Kyushu General Internal Medicine Center, Haradoi Hospital, Fukuoka, Japan
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A Stab in the Dark: A Case Report of an Atypical Presentation of Giant Cell Arteritis (GCA). Geriatrics (Basel) 2018; 3:geriatrics3030036. [PMID: 31011074 PMCID: PMC6319224 DOI: 10.3390/geriatrics3030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Giant cell arteritis/temporal arteritis (GCA) is an inflammatory condition that affects large to medium vessels such as the aorta and its primary branches. Patients classically present with fatigue, fever, headache, jaw claudication and in severe cases, may suffer either transient (amaurosis fugax) or permanent visual loss. The reference standard for diagnosis is the temporal artery biopsy (TAB) and the mainstay of treatment is with immunosuppression. Our patient JG, presented with a range of non-specific symptoms that mimicked generalised sepsis, but was ultimately diagnosed with GCA through effective, methodical multi-disciplinary team (MDT) work. Clinical case: JG, an 81 year old gentleman, presented acutely with a 3-4 weeks history of fatigue, lethargy, pyrexia and a marked inflammatory response suggestive of a sepsis but without a clear primary source or clinical features of vasculitis. His inflammatory markers were markedly raised although his erythrocyte sedimentation rate (ESR) was not elevated. He was initially treated for sepsis of unknown origin however, body imaging after admission suggested a possible infection around a previous aortic graft site. This was refuted in subsequent 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) scanning. Microbiological, parasitic, as well as autoimmune assays were unremarkable. He underwent a TAB which was diagnostic for GCA and as a result, was started on oral corticosteroids with immediate symptom relief. He was discharged and followed up on an outpatient basis. Conclusions: This case highlights how a vasculitis can present with a range of non-specific symptoms that may resemble a fever of unknown origin (FUO)/sepsis that can lead to a delay in making the correct diagnosis. It also highlights the importance of considering a diagnosis of vasculitis in patients who present with a FUO where there is no clear focus of infection. Delays in diagnosis and management of these conditions can potentially lead to significant irreversible morbidity.
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Takeda R, Mizooka M, Kobayashi T, Kishikawa N, Yokobayashi K, Kanno K, Tazuma S. Key diagnostic features of fever of unknown origin: Medical history and physical findings. J Gen Fam Med 2017; 18:131-134. [PMID: 29264008 PMCID: PMC5689409 DOI: 10.1002/jgf2.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 08/26/2016] [Indexed: 12/31/2022] Open
Abstract
Background Fever of unknown origin (FUO) has many possible causes, so detailed history taking and physical examination are required. We identified key diagnostic features of medical history and physical findings for an efficient diagnosis of FUO. Methods A total of 42 consecutive patients (mean age: 50.6±20.3 years) with classic FUO were retrospectively recruited from January 2010 to March 2012. Key diagnostic features were identified from among diagnostic criteria for underlying diseases, indicators for diagnostic tests, and more useful factors for differential diagnosis. Results The mean number of abnormal findings per patient was 5.8 from taking the history and 2.0 from performing physical examination. In addition, the mean number of key diagnostic features identified was 0.7 (14.0%) from history taking and 0.6 (35.0%) from physical examination. The most relevant key diagnostic feature was arthritis, followed by cervical lymphadenopathy, dyspnea (with hypoxia), and ocular symptoms. Conclusion The usefulness of certain features of medical history and physical findings for diagnosing FUO was determined. Focusing on arthritis, cervical lymphadenopathy, dyspnea with hypoxia, and ocular symptoms might improve diagnostic efficiency in patients with FUO.
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Affiliation(s)
- Rinne Takeda
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Masafumi Mizooka
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Tomoki Kobayashi
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Nobusuke Kishikawa
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Kenichi Yokobayashi
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Keishi Kanno
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
| | - Susumu Tazuma
- Department of General Internal Medicine Hiroshima University Hospital Hiroshima Japan
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