Fever of unknown origin in a 71-year-old woman

Fever in neurologic diseases

In the sense that the brain houses the central mechanism for the regulation of body temperature, almost all illnesses that cause fever must interact with the central nervous system. There are far fewer diseases, however, in which the nervous system symptomatology is of prime diagnostic importance. A helpful way to view fever in association with neurologic disease is to roughly divide these disease entities into four broad categories: (1) neurologic impairment resulting from fever itself, (2) fever as the sole manifestation of a central nervous system infection, (3) systemic febrile disorders with central nervous system signs and symptoms, and (4) primary neurologic diseases, either central or peripheral in origin, with fever as a presenting sign. This article discusses the clinical presentation of disorders in each of these categories as an aid to the clinician in diagnosing and differentiating between these syndromes.

Disseminated visceral giant cell arteritis

Autopsy findings of disseminated visceral giant cell arteritis in a 78-year-old man who was in chronic renal failure for two years were presented. Arteritis had not been suspected clinically and definite diagnosis was made after the autopsy. Only small arteries and arterioles were involved. The arteritis was characterized by granulomatous lesion with exclusively multinucleated giant cells. Fibrinoid necrosis with polymorphonuclear leukocyte infiltration was found only in one arteriole of the stomach. The arteritis was distributed in the heart, lungs, kidneys, gastrointestinal tract, liver, gallbladder, pancreas, prostate, and lymph nodes, but not in the aorta and brain. This peculiar type of arteritis was reported only by LIE and the entity was designated as disseminated visceral giant cell arteritis.

Clinical usefulness of temporal artery biopsy

To assess the diagnostic usefulness of temporal artery biopsy in temporal arteritis (TA) and establish clinical features capable of predicting its positivity we have retrospectively studied the biopsy specimens and the clinical features of 103 patients who had undergone temporal artery biopsy. Temporal artery biopsy reached a positive predictive value of 90.2% with respect to the final diagnosis based on the criteria proposed by Ellis and Ralston and the clinical course. The simultaneous presence of recent onset headache, jaw claudication, and abnormalities of the temporal arteries on physical examination had a specificity of 94.8% with respect to the histological diagnosis and of 100% with respect to final diagnosis. The presence of any of these clinical features, though of little specificity (34.4%), had a sensitivity of 100% with respect to histological diagnosis, selecting a group of patients in whom temporal artery biopsy has more discriminative value.