Fever of Unknown Origin in Older Adults

Serum Soluble IL-2 Receptors Are Elevated in Febrile Illnesses and Useful for Differentiating Clinically Similar Malignant Lymphomas from Kikuchi Disease: A Cross-Sectional Study

Background: The use of serum soluble interleukin 2 receptor (sIL-2R) for the diagnosis of febrile illnesses has not been examined. In this study, febrile patients were classified according to etiology and disease, and serum sIL-2R levels were evaluated. We determined whether serum sIL-2R is a useful marker for differentiating between malignant lymphoma (ML) and non-ML patients and between patients with ML and Kikuchi disease, which present similar clinical manifestations. Methods: This study was a cross-sectional study and included 344 patients with uncomplicated hemophagocytic syndrome, who had a fever of 38 °C or higher within 1 week of admission to our institution. Patient serum sIL-2R was measured, and the serum sIL-2R values are shown as median and IQR. Results: Serum sIL-2R increased above the upper reference limit in all disease groups with fever. The serum sIL-2R level in ML patients (n = 13) was 4760 (2120-6730) U/mL and significantly higher (p < 0.001) than the level of 998 (640-1625) U/mL in non-ML patients (n = 331). The serum sIL-2R level in ML patients (n = 13) was also significantly higher (p < 0.001) compared with that in patients with Kikuchi disease (n = 20; 705 (538-1091) U/mL). Conclusions: Serum sIL-2R tends to exceed the upper reference limit in patients with febrile illnesses. We conclude that the measurement of serum sIL-2R is useful for differentiating ML from non-ML and ML from Kikuchi disease.

Pseudogout as a Cause of Fever of Unknown Origin Following Staphylococcal Bacteremia in an Older Patient

The causes of fevers in older adults are numerous and diverse, resulting in fevers of unknown origin that complicate the diagnosis process. Compared to young adults, older adults are characterized by comorbidities, aging-induced physiological changes, decreased homeostasis, reduced activities of daily living, and a diminished quality of life due to disease and aging. Thus, diverse perspectives are required to facilitate the accurate diagnosis of fever in older adults. In this study, we experienced a case of epidermal staphylococcal bacteremia of unknown cause with a persistent fever that eventually led to the diagnosis of cervical pseudogout. A 94-year-old bedridden woman visited our hospital with a chief complaint of persistent fever. She was diagnosed with cervical pseudogout after closely examining the prolonged fever following Staphylococcus epidermidis bacteremia. Noninfectious diseases are frequent causes of unexplained fever in older adults, and systemic inflammatory diseases, such as cervical pseudogout, should be considered during examination.

Retrospective study of elderly onset sarcoidosis in Tunisian patients

BACKGROUND

Sarcoidosis is a systemic granulomatous disease of unknown etiology. It affects mostly young adults. In the elderly, the presentation of this disease is different, often posing positive diagnosis problems.

OBJECTIVES

We intend to describe the various clinical features and the management of sarcoidosis in elderly patients (age ≥65 years) compared to the younger ones.

METHODS

We performed a retrospective, descriptive and comparative study in the Department of Internal Medicine in the University Hospital Hedi Chaker, Sfax, Tunisia, between 1996 and 2016.

RESULTS

From a series of 80 patients, we found sixteen patients (20%) with sarcoidosis diagnosed after the age of 65 years. A female preponderance (81,25%) was noted. Intrathoracic involvement concerned 13 patients (81,3%). Extrapulmonary signs were also frequent (93,8%). The main extrathoracic manifestations were ganglionar involvement (75%), an alteration of the general health (31,3%), hepatic involvement (31,3%), cutaneous involvement (25%) and ocular involvement (25%). Biological manifestations were hypercalcemia, hypercalciuria, lymphopenia and hypergammaglobulinemia noted in respectively 12,5%, 12,5%, 31,3% and 50% of the cases. Angiotensin-converting enzyme(ACE) level was elevated in 100% of the patients. Lymphadenopathy and cutaneous biopsies were important contributing factors to diagnosis (respectively: 100% and 75% were positive). Oral corticosteroid therapy was required in 50% of cases. Evolution was marked by pulmonary fibrosis in two cases. Satisfactory course of the disease was observed in the other patients.

CONCLUSION

Young and elderly subjects had common characteristics of sarcoidosis, except for more coexisting chronic morbidities, no erythema nodosum and more frequent high levels of ACE in the elderly group.

Imaging a Fever-Redefining the Role of 2-deoxy-2-[18F]Fluoro-D-Glucose-Positron Emission Tomography/Computed Tomography in Fever of Unknown Origin Investigations

Growing evidence suggests that 2-deoxy-2-[18F]fluoro-D-glucose (18FDG)-positron emission tomography/computed tomography (PET/CT) is a useful imaging technique for the evaluation of fever of unknown origin (FUO). This imaging technique allows for accurate localization of foci of hypermetabolism based on 18FDG uptake in glycolytically active cells that may represent inflammation, infection, or neoplasia. The presence of abnormal uptake can help direct further investigation that may yield a final diagnosis. A lack of abnormal uptake can be reasonably reassuring that these conditions are not present, thereby avoiding unnecessary additional testing. Insurers have not routinely covered outpatient 18FDG-PET/CT for the indication of FUO in the United States. However, data published since 2007 suggest early use in FUO diagnostic evaluations improves diagnostic efficiency and reduces costs. Clinicians and insurers should consider 18FDG-PET/CT as a useful tool when preliminary studies are unrevealing.

Key diagnostic characteristics of fever of unknown origin in Japanese patients: a prospective multicentre study

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.

Infections in the Elderly Critically-Ill Patients

Infections are leading causes of morbidity and mortality in the advanced aged. Various factors including immunosenescens, comorbid chronic diseases, and alterations in normal physiological organ functions may modify the frequency and severity of infections in elderly patients. Normal body reactions to ensuing infection, such as increased body temperature, may be blunted in those patients causing difficulties in differential diagnosis between infection and other diseases. In severe infections the respiratory and urinary tracts are the most frequently involved systems which may be accompanied by severe sepsis. Bacteremia and sepsis are also associated with indwelling vascular catheters in the elderly who are admitted to the intensive care unit (ICU). Older patients are more vulnerable to the Clostridioides difficile infection, as well. Although the general management of infections in severely ill elderly patients is not different than in younger patients, meticulous care in fluid management and careful individualized optimization in antibiotic therapy, along with the other principals of antimicrobial stewardship are warranted in order to prevent increased mortality caused by infection. Organized team management when treating critically ill elderly patients in the ICU is essential and will reduce the morbidity and mortality due to infection in such patients.

Contribution of 18F-FDG PET/CT in a case-mix of fever of unknown origin and inflammation of unknown origin: a meta-analysis

BACKGROUND

Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are challenging medical problems. Previous studies have shown that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) plays an important role in the diagnosis of FUO, but few studies have explored this diagnostic technique in relation to IUO.

PURPOSE

To systematically review and perform a meta-analysis of published data on the diagnostic performance of PET/CT in the diagnosis of FUO and IUO.

MATERIAL AND METHODS

A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines published in March 2018. Meta-analysis of diagnostic performance was performed using STATA 12.0 software. Subgroup analysis was performed by stratification based on study design, number of patients, geographic area, and final diagnosis based on 18F-FDG PET/CT. Meta-regression analyses were performed to recognize heterogeneity.

RESULTS

Our meta-analysis included 23 studies, comprising a total sample size of 1927 patients. The pooled diagnosis performance was calculated with a per-patient-based analysis: sensitivity = 0.84 (95% confidence interval [CI] = 0.79-0.89), specificity = 0.63 (95% CI = 0.49-0.75), positive likelihood ratio = 2.3 (95% CI = 1.5-3.4), negative likelihood ratio = 0.25 (95% CI = 0.16-0.38), diagnostic odds ratio = 9 (95% CI = 4.0-20), and AUC = 0.84 (95% CI = 0.81-0.87).

CONCLUSION

In patients with non-specific symptoms and signs, 18F-FDG PET/CT is very helpful for recognizing and excluding diseases, directing further diagnostic decisions, and avoiding unnecessary invasive examinations. We recommend that 18F-FDG PET/CT should be considered among the first-line diagnostic tools for patients with FUO and IUO.

Pyrexia of unknown origin

The syndrome of pyrexia of unknown origin (PUO) was first defined in 1961 but remains a clinical challenge for many physicians. Different subgroups with PUO have been suggested, each requiring different investigative strategies: classical, nosocomial, neutropenic and HIV-related. This could be expanded to include the elderly as a fifth group. The causes are broadly divided into four groups: infective, inflammatory, neoplastic and miscellaneous. Increasing early use of positron emission tomography-computed tomography (PET-CT) and the development of new molecular and serological tests for infection have improved diagnostic capability, but up to 50% of patients still have no cause found despite adequate investigations. Reassuringly, the cohort of undiagnosed patients has a good prognosis. In this article we review the possible aetiologies of PUO and present a systematic clinical approach to investigation and management of patients, recommending potential second-line investigations when the aetiology is unclear.

The management and the diagnosis of fever of unknown origin

Prolonged fever presents a challenge for the patient and the physician. Fever with a temperature higher than 38.3°C on several occasions that lasts for at least 3 weeks and lacks a clear diagnosis after 1 week of study in the hospital is called a fever of unknown origin (FUO). More than 200 diseases can cause FUO, and the information gathered from history taking, physical examination, laboratory and imaging studies should be evaluated with care. History taking and physical examination may provide some localizing signs and symptoms pointing toward a diagnosis. Infection, cancers, noninfectious inflammatory diseases and some miscellaneous diseases are the main etiologies, and some patients remain undiagnosed despite investigations. Tuberculosis, lymphoma and adult-onset Still's disease are the main diseases. Fluorodeoxyglucose PET is a promising imaging modality in FUO. Establishing a uniform algorithm for FUO management is difficult. Every patient should be carefully evaluated individually considering the previous FUO management experience.

5 Koorts bij volwassenen

Koorts wordt bij niet-immuungecompromitteerde volwassenen in de eerste lijn zonder recent verblijf in het buitenland meestal veroorzaakt door een luchtweginfectie. Bij ouderen vormen urineweginfecties een relatief frequente oorzaak van koorts. Bij ontbreken van richtinggevende voorgeschiedenis, klachten of verschijnselen volstaat men in eerste instantie met lichamelijk onderzoek van KNO-gebied en longen. Bij negatieve bevindingen volgt urineonderzoek. Wanneer geen afwijkingen gevonden worden, gaat men uit van een onschuldige virale oorzaak.

Bij een ernstig zieke indruk of verminderd bewustzijn is het lichamelijk onderzoek allereerst gericht op eventuele stoornissen in de vitale functies, omdat deze onmiddellijke therapeutische implicaties hebben. Als de koorts een week aanhoudt of eerder bij verandering van het beeld, dient een uitgebreide anamnese en algemeen lichamelijk onderzoek plaats te vinden om diagnostische aanknopingspunten op te sporen. Ook kan de arts dan aanvullend onderzoek laten verrichten: in eerste instantie bloed-, urine- en fecesonderzoek en een X-thorax, eventueel gevolgd door X-sinussen en een mantouxreactie. Medicatie wordt zoveel mogelijk gestaakt om een allergie aan te tonen of uit te sluiten. Na enkele dagen herhaalt men anamnese en lichamelijk onderzoek. Twee weken onbegrepen koorts is reden voor verdere (poli)klinische evaluatie.

Concrete aanwijzingen op grond van steeds herhaalde anamnese en lichamelijk onderzoek zijn richtinggevend voor de inzet van complex aanvullend onderzoek. Dit bestaat onder meer uit bloedkweken, uitgebreider bloedonderzoek, leverbiopsie, beenmergpunctie en CT-scan buik en thorax. Bij patiënten ouder dan 55 jaar met koorts en een verhoogde bezinking is een biopsie van de arteria temporalis zinvol.

The ageing immune system and its clinical implications

Ageing is associated with multiple changes in many different components of the immune system. A healthy immune system exists in a state of balance between efficient effector responses against pathogens and tolerance to self antigens. This balance is changed with age; functions such as antigen recognition, phagocytosis, antigen presentation, chemotaxis, cytokine secretion and killing ability are all compromised. Aberrant cellular responses lead to an altered cytokine network with increases in inflammatory cytokines and decreases in anti-inflammatory cytokines leading to a pro-inflammatory state. Consequently older patients require extra care in diagnosis of infections as symptoms may be perturbed, resulting in unusual presentations of common conditions. The defects in immunity due to immunosenescence also mean that older patients require more care and screening than other patients in the same disease cohort. Though it is generally understood by clinicians that older patients are more at risk from multiple infections, the wider clinical effects of immunosenescence are less understood. The immune system is involved in several neurodegenerative conditions and the inflammatory conditions of immunosenescence may be a key factor in pathogenesis. Similarly, there is reason to believe that immunosenescence might be a key factor explaining the increased incidence of cancer in older age. With increasing understanding of the immune system's involvement in many of these pathological processes, and the contribution that immunosenescence makes to these, more efficient vaccines and novel therapies may be developed to prevent/treat these conditions.

[Febrile syndrome in an elderly patient]

Fever in the elderly as compared with young adults has a clinical expression, prevalence, and diagnosis that require a specific type of evaluation. The significance of fever in the elderly gains importance with the increase of the population's age and it must be considered an alarm signal in these patients. Etiologically, the primary cause of prolonged fever with unspecific origin in this population, is arteritis of giant cells, followed by (according to epidemiological environment) tuberculosis and hematological neoplasias. There is no consensus on diagnostic approaches, but it is essential to take great care in the process due to risk associated with invasive tests and low tolerance to them.