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Wright WF, Wang J, Auwaerter PG. Fever of Unknown Origin (FUO) Criteria Influences Diagnostic Outcomes: A Systematic Review and Meta-Analysis. Am J Med 2024:S0002-9343(24)00476-5. [PMID: 39069200 DOI: 10.1016/j.amjmed.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Criteria classifying fever of unknown origin (FUO) patients remains subject to discrepancies. A minimal standardized set of investigative tests serves as the foundation for the qualitative criteria, whereas quantitative incorporates the length of evaluation (7 or 3 days). A systematic review of studies would help physicians anticipate the frequency of illness types that could influence management. METHODS Prospective studies published in Medline (PubMed), Embase, Scopus, and Web of Science databases from January 1, 1997, to July 31, 2022, were included. A meta-analysis estimated associated pooled proportions between these criteria and diagnostic outcomes adjusted to the International Classification of Diseases, 10th edition (ICD-10) definitions. RESULTS Five qualitative studies corresponded to an increase of 15.3% (95% CI: 2.3-28.3%, p=0.021) in undiagnosed FUO proportions compared to eleven quantitative studies. Quantitative studies had 19.7% (95% CI: 6.0-33.4%, p=0.005) more in adjusted infectious disease proportions than qualitative studies. No significant differences in proportions between FUO defining criteria were noted for adjusted noninfectious inflammatory disorders (p=0.318), oncology (p=0.901), non-inflammatory miscellaneous disorders (p=0.321), diagnostic evaluation process, gross national income (GNI), or World Health Organization (WHO) geographic region. CONCLUSIONS Use of either qualitative or quantitative FUO criteria was associated with a statistically significant risk of over- or under-estimating infectious diseases and undiagnosed illnesses when using an ICD-10 adjusted FUO five-category system. Clinicians should anticipate differences depending on which criteria are used. While further research is warranted, qualitative criteria provide the best framework for study comparisons.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, Maryland, USA.
| | - Jiangxia Wang
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, Maryland, USA.
| | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, Maryland, USA; The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, 725 North Wolfe Street, Baltimore, Maryland, USA.
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Erdem H, Al-Tawfiq JA, Abid M, Yahia WB, Akafity G, Ramadan ME, Amer F, El-Kholy A, Hakamifard A, Rahimi BA, Dayyab F, Caskurlu H, Khedr R, Tahir M, Zambrano L, Khan MA, Raza A, El-Sayed NM, Baymakova M, Yalci A, Cag Y, Elbahr U, Ikram A. Infectious causes of fever of unknown origin in developing countries: An international ID-IRI study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:94-100. [PMID: 38263972 PMCID: PMC10800762 DOI: 10.1016/j.jointm.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 01/25/2024]
Abstract
Background Fever of unknown origin (FUO) in developing countries is an important dilemma and further research is needed to elucidate the infectious causes of FUO. Methods A multi-center study for infectious causes of FUO in lower middle-income countries (LMIC) and low-income countries (LIC) was conducted between January 1, 2018 and January 1, 2023. In total, 15 participating centers from seven different countries provided the data, which were collected through the Infectious Diseases-International Research Initiative platform. Only adult patients with confirmed infection as the cause of FUO were included in the study. The severity parameters were quick Sequential Organ Failure Assessment (qSOFA) ≥2, intensive care unit (ICU) admission, vasopressor use, and invasive mechanical ventilation (IMV). Results A total of 160 patients with infectious FUO were included in the study. Overall, 148 (92.5%) patients had community-acquired infections and 12 (7.5%) had hospital-acquired infections. The most common infectious syndromes were tuberculosis (TB) (n=27, 16.9%), infective endocarditis (n=25, 15.6%), malaria (n=21, 13.1%), brucellosis (n=15, 9.4%), and typhoid fever (n=9, 5.6%). Plasmodium falciparum, Mycobacterium tuberculosis, Brucellae, Staphylococcus aureus, Salmonella typhi, and Rickettsiae were the leading infectious agents in this study. A total of 56 (35.0%) cases had invasive procedures for diagnosis. The mean qSOFA score was 0.76±0.94 {median (interquartile range [IQR]): 0 (0-1)}. ICU admission (n=26, 16.2%), vasopressor use (n=14, 8.8%), and IMV (n=10, 6.3%) were not rare. Overall, 38 (23.8%) patients had at least one of the severity parameters. The mortality rate was 15 (9.4%), and the mortality was attributable to the infection causing FUO in 12 (7.5%) patients. Conclusions In LMIC and LIC, tuberculosis and cardiac infections were the most severe and the leading infections causing FUO.
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Affiliation(s)
- Hakan Erdem
- Department of Infectious Diseases & Clinical Microbiology, Gulhane School of Medicine, Turkish Health Sciences University, Ankara, Turkey
| | - Jaffar A. Al-Tawfiq
- Specialty Internal Medicine and Quality and Patient Safety Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maha Abid
- Department of Infectious Diseases, Farhat Hached University Hospital, Ibn El Jazzar Medical School, University of Sousse, Sousse, Tunisia
| | - Wissal Ben Yahia
- Internal Medicine Department, Farhat Hached University Hospital, Ibn El Jazzar Medical School, University of Sousse, Sousse, Tunisia
| | | | | | - Fatma Amer
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Amani El-Kholy
- Department of Clinical Pathology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Atousa Hakamifard
- Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bilal Ahmad Rahimi
- Department of Infectious Diseases, Kandahar University Medical Faculty, Teaching Hospital, Kandahar, Afghanistan
| | - Farouq Dayyab
- Department of Infectious Diseases, Mohammed Bn Khalifa Bn Salman Alkhalifa Specialist Cardiac Center, Awali, Bahrain
| | - Hulya Caskurlu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Reham Khedr
- Department of Pediatric Oncology, National Cancer Institute – Cairo University, Children Cancer Hospital Egypt, Cairo, Egypt
| | - Muhammad Tahir
- Department of Medicine, Federal General Hospital, Islamabad, Pakistan
| | - Lysien Zambrano
- Institute for Research in Medical Sciences and Right to Health (ICIMEDES), Scientific Research Unit (UIC), Faculty of Medical Sciences (FCM), National Autonomous University of Honduras (UNAH), Tegucigalpa, Honduras
| | | | - Aun Raza
- Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | | | - Magdalena Baymakova
- Department of Infectious Diseases, Military Medical Academy, Sofia, Bulgaria
| | - Aysun Yalci
- Department of Infectious Diseases & Clinical Microbiology, Gulhane School of Medicine, Turkish Health Sciences University, Ankara, Turkey
| | - Yasemin Cag
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Umran Elbahr
- Department of Infectious Diseases, Bahrain Oncology Center, King Hamad University Hospital, Al Muharraq, Bahrain
| | - Aamer Ikram
- National Institute of Health, Islamabad, Pakistan
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Wright WF, Yenokyan G, Auwaerter PG. Geographic Upon Noninfectious Diseases Accounting for Fever of Unknown Origin (FUO): A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac396. [PMID: 36004312 PMCID: PMC9394765 DOI: 10.1093/ofid/ofac396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Diagnostic outcomes for fever of unknown origin (FUO) remain with notable numbers of undiagnosed cases. A recent systemic review and meta-analysis of studies reported geographic variation in FUO-related infectious diseases. Whether geography influences types of FUO noninfectious diagnoses deserves examination.
Methods
Medline (PubMed), Embase, Scopus, and Web of Science databases were searched systematically using medical subject headings published from January 1, 1997, to March 31, 2021. Prospective clinical studies investigating participants meeting adult FUO defining criteria were selected if they assessed final diagnoses. Meta-analyses were based on the random-effects model according to World Health Organization (WHO) geographical regions.
Results
Nineteen studies with significant heterogeneity were analyzed, totaling 2,667 participants. Noninfectious inflammatory disorders had a pooled estimate at 20.0% (95%CI: 17.0-23.0%). Undiagnosed illness had a pooled estimate of 20.0% (95%CI: 14.0-26.0%). The pooled estimate for cancer was 15.0% (95%CI: 12.0-18.0%). Miscellaneous conditions had a pooled estimate of 6.0% (95%CI: 4.0-8.0%). Noninfectious inflammatory disorders and miscellaneous conditions were most prevalent in the Western Pacific region with a 27.0% pooled estimate (95%CI: 20.0-34.0%) and 9.0% (95%CI: 7.0-11.0%), respectively. The highest pooled estimated for cancer was in the Eastern Mediterranean region at 25.0% (95%CI: 18.0-32.0%). Adult-onset Still’s disease (114 [58.5%]), systemic lupus (52 [26.7%]), and giant-cell arteritis (40 [68.9%]) predominated among the noninfectious inflammatory group. Lymphoma (164 [70.1%]) was the most common diagnosis in the cancer group.
Conclusions
In this systematic review and meta-analysis, noninfectious disease diagnostic outcomes varied among WHO-defined geographies. Evaluation of FUO should consider local variations in disease prevalence.
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Affiliation(s)
- William F Wright
- Correspondence: William F. Wright, DO, MPH, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205 ()
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Betrains A, Moreel L, De Langhe E, Blockmans D, Vanderschueren S. Rheumatic disorders among patients with fever of unknown origin: A systematic review and meta-analysis. Semin Arthritis Rheum 2022; 56:152066. [PMID: 35868032 DOI: 10.1016/j.semarthrit.2022.152066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To conduct a systematic literature review and meta-analysis to estimate the proportion of fever of unknown origin (FUO) and inflammation of unknown origin (IUO) cases that are due to rheumatic disorders and the relative frequency of specific entities associated with FUO/IUO. METHODS We searched PubMed and EMBASE between January 1, 2002, and December 31, 2021, for studies with ≥50 patients reporting on causes of FUO/IUO. The primary outcome was the proportion of FUO/IUO patients with rheumatic disease. Secondary outcomes include the association between study and patient characteristics and the proportion of rheumatic disease in addition to the relative frequency of rheumatic disorders within this group. Proportion estimates were calculated using random-effects models. RESULTS The included studies represented 16884 patients with FUO/IUO. Rheumatic disease explained 22.2% (95%CI 19.6 - 25.0%) of cases. Adult-onset Still's disease (22.8% [95%CI 18.4-27.9%]), giant cell arteritis (11.4% [95%CI 8.0-16.3%]), and systemic lupus erythematosus (11.1% [95%CI 9.0-13.8%]) were the most frequent disorders. The proportion of rheumatic disorders was significantly higher in high-income countries (25.9% [95%CI 21.5 - 30.8%]) versus middle-income countries (19.5% [95%CI 16.7 - 22.7%]) and in prospective studies (27.0% [95%CI 21.9-32.8%]) versus retrospective studies (20.6% [95%CI 18.1-24.0%]). Multivariable meta-regression analysis demonstrated that rheumatic disease was associated with the fever duration (0.011 [95%CI 0.003-0.021]; P=0.01) and with the fraction of patients with IUO (1.05 [95%CI 0.41-1.68]; P=0.002). CONCLUSION Rheumatic disorders are a common cause of FUO/IUO. The care of patients with FUO/IUO should involve physicians who are familiar with the diagnostic workup of rheumatic disease.
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Affiliation(s)
- A Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - L Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - E De Langhe
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - D Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - S Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
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Wright WF, Betz JF, Auwaerter PG. Prospective Studies Comparing Structured vs Nonstructured Diagnostic Protocol Evaluations Among Patients With Fever of Unknown Origin: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2215000. [PMID: 35653154 PMCID: PMC9164007 DOI: 10.1001/jamanetworkopen.2022.15000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/14/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Patients meeting the criteria for fever of unknown origin (FUO) can be evaluated with structured or nonstructured approaches, but the optimal diagnostic method is unresolved. Objective To analyze differences in diagnostic outcomes among patients undergoing structured or nonstructured diagnostic methods applied to prospective clinical studies. Data Sources PubMed, Embase, Scopus, and Web of Science databases with librarian-generated query strings for FUO, PUO, fever or pyrexia of unknown origin, clinical trial, and prospective studies identified from January 1, 1997, to March 31, 2021. Study Selection Prospective studies meeting any adult FUO definition were included. Articles were excluded if patients did not precisely fit any existing adult FUO definition or studies were not classified as prospective. Data Extraction and Synthesis Abstracted data included years of publication and study period, country, setting (eg, university vs community hospital), defining criteria and category outcome, structured or nonstructured diagnostic protocol evaluation, sex, temperature threshold and measurement, duration of fever and hospitalization before final diagnoses, and contribution of potential diagnostic clues, biochemical and immunological serologic studies, microbiology cultures, histologic analysis, and imaging studies. Structured protocols compared with nonstructured diagnostic methods were analyzed using regression models. Main Outcomes and Measures Overall diagnostic yield was the primary outcome. Results Among the 19 prospective trials with 2627 unique patients included in the analysis (range of patient ages, 10-94 years; 21.0%-55.3% female), diagnoses among FUO series varied across and within World Health Organization (WHO) geographic regions. Use of a structured diagnostic protocol was not significantly associated with higher odds of yielding a diagnosis compared with nonstructured protocols in aggregate (odds ratio [OR], 0.98; 95% CI, 0.65-1.49) or between Western Europe (Belgium, France, the Netherlands, and Spain) (OR, 0.95; 95% CI, 0.49-1.86) and Eastern Europe (Turkey and Romania) (OR, 0.83; 95% CI, 0.41-1.69). Despite the limited number of studies in some regions, analyses based on the 6 WHO geographic areas found differences in the diagnostic yield. Western European studies had the lowest percentage of achieving a diagnosis. Southeast Asia led with infections at 49.0%. Noninfectious inflammatory conditions were most prevalent in the Western Pacific region (34.0%), whereas the Eastern Mediterranean region had the highest proportion of oncologic explanations (24.0%). Conclusions and Relevance In this systematic review and meta-analysis, diagnostic yield varied among WHO regions. Available evidence from prospective studies did not support that structured diagnostic protocols had a significantly better rate of achieving a diagnosis than nonstructured protocols. Clinicians worldwide should incorporate geographical disease prevalence in their evaluation of patients with FUO.
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Affiliation(s)
- William F. Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua F. Betz
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul G. Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wright WF, Yenokyan G, Simner PJ, Carroll KC, Auwaerter PG. Geographic Variation of Infectious Disease Diagnoses Among Patients with Fever of Unknown Origin (FUO) – A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac151. [PMID: 35450085 PMCID: PMC9017373 DOI: 10.1093/ofid/ofac151] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Fever of unknown origin (FUO) investigations yield a substantial number of patients with infectious diseases. This systematic review and meta-analysis aimed to quantify more common FUO infectious diseases etiologies and to underscore geographic variation. Methods Four databases (PubMed, Embase, Scopus, and Web of Science) were searched for prospective studies reporting FUO rates among adult patients from 1 January 1997 to 31 March 2021. The pooled proportion for infectious diseases etiology was estimated using the random-effects meta-analysis model. Results Nineteen prospective studies were included with 2667 total cases. No studies were available for Africa or the Americas. Overall, 37.0% (95.0% confidence interval [CI], 30.0%–44.0%) of FUO patients had an infectious disease etiology. Infections were more likely from Southeastern Asia (pooled proportion, 0.49 [95% CI, .43–.55]) than from Europe (pooled proportion, 0.31 [95% CI, .22–.41]). Among specifically reported infectious diseases (n = 832), Mycobacterium tuberculosis complex predominated across all geographic regions (n = 285 [34.3%]), followed by brucellosis (n = 81 [9.7%]), endocarditis (n = 62 [7.5%]), abscesses (n = 61 [7.3%]), herpesvirus (eg, cytomegalovirus and Epstein-Barr virus) infections (n = 60 [7.2%]), pneumonia (n = 54 [6.5%]), urinary tract infections (n = 54 [6.5%]), and enteric fever (n = 40 [4.8%]). Conclusions FUO patients from Southeastern Asia were more likely to have an infectious diseases etiology when compared to other regions. The predominant factor for this finding appears to be differences in disease prevalence among various geographical locations or other factors such as access to timely care and diagnosis. Noting epidemiological disease factors in FUO investigations could improve diagnostic yields and clinical outcomes.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patricia J Simner
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Diagnostic value of F-18 FDG PET/CT in fever or inflammation of unknown origin in a large single-center retrospective study. Sci Rep 2022; 12:1883. [PMID: 35115619 PMCID: PMC8813902 DOI: 10.1038/s41598-022-05911-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Cause determination is challenging in fever or inflammation of unknown origin (FUO/IUO) despite today’s diagnostic modalities. We evaluated the value of F-18 FDG PET/CT in an unselected patient collective. This retrospective nonrandomized single-center study enrolled 300 male and female patients with FUO/IUO. PET/CT findings were compared with final clinical outcomes to determine the sensitivity, specificity, clinical significance, etiological distribution of final diagnoses, impact on treatment, role of white-blood cell count (WBC), and C-reactive protein (CRP). In 54.0% (162/300) PET/CT was the decisive exanimation for establishing the final diagnosis, in 13.3% (40/300) the findings were equivocal and indecisive, in 3.3% (10/300) PET/CT findings were false positive, while in 29.3% (88/300) a normal F-18 FDG pattern was present. Statistical analysis showed a sensitivity of 80.2% and a specificity of 89.8% for the contribution of PET/CT to the final diagnosis. CRP levels and WBC were not associated with PET/CT outcome. PET/CT let to new treatment in 24.0% (72/300), treatment change in 18.0% (54/300), no treatment change in 49.6% (149/300), and in 8.3% (25/300) no data was available. Our study demonstrates the utility of F-18 FDG PET/CT for source finding in FUO/IUO if other diagnostic tools fail.
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Søgaard KK, Farkas DK, Leisner MZ, Schmidt SAJ, Lash TL, Sørensen HT. Fever of unknown origin and incidence of cancer. Clin Infect Dis 2022; 75:968-974. [PMID: 35079799 DOI: 10.1093/cid/ciac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diagnostic tools for determining causes of fever of unknown origin (FUO) have improved over time. We examined if cancer incidence among these patients changed over a 20-year period. METHODS Population-based cohort study using nationwide Danish registries. We identified individuals diagnosed with FUO (1998-2017) to quantify the excess risk of cancer among these patients compared with the general population. Follow-up for cancer started 1 month after FUO. We computed absolute risks and standardized incidence ratios (SIRs) of cancer, and mortality rate ratios adjusted for age, sex, and cancer stage. RESULTS Among 6620 patients with FUO (46.9% male, median age: 39 years), 343 were diagnosed with cancer (median follow-up: 6.5 years). The 1 to <12-month risk was 1.2%, and the SIR was 2.3 (95% confidence interval, 1.8-2.9). The increased 1 to <12-months SIR was mainly due to an excess of Hodgkin lymphoma (SIR=41.7) non-Hodgkin lymphoma (SIR=16.1), myelodysplastic syndrome/chronic myeloproliferative diseases (SIR=6.0), lower gastrointestinal cancer (SIR=3.3), and urinary tract cancer (SIR=2.9). Beyond 1 year of follow-up, malignant melanoma, hepatobiliary tract/pancreatic cancer, and brain/CNS/eye cancer were diagnosed more often than expected. The 1 to <12-month cancer SIR attenuated over time, and for the 2013-2017 period we found no excess risk. Patients diagnosed with cancer within 1 year after FUO had similar mortality to cancer patients without this diagnosis. CONCLUSIONS Patients with FUO have a higher 1 to <12-month cancer SIR; thereafter, the incidence for most cancers equals that of the general population. Decreasing SIRs over time suggests improvements in the initial diagnostic work-up for FUO.
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Affiliation(s)
- Kirstine K Søgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Michelle Z Leisner
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Sigrun Alba Johannesdottir Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Fu ZF, Zhang HC, Zhang Y, Cui P, Zhou Y, Wang HY, Lin K, Zhou X, Wu J, Wu HL, Zhang WH, Ai JW. Evaluations of Clinical Utilization of Metagenomic Next-Generation Sequencing in Adults With Fever of Unknown Origin. Front Cell Infect Microbiol 2022; 11:745156. [PMID: 35127548 PMCID: PMC8813867 DOI: 10.3389/fcimb.2021.745156] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction The diagnosis of infection-caused fever of unknown origin (FUO) is still challenging, making it difficult for physicians to provide an early effective therapy. Therefore, a novel pathogen detection platform is needed. Metagenomic next-generation sequencing (mNGS) provides an unbiased, comprehensive technique for the sequence-based identification of pathogenic microbes, but the study of the diagnostic values of mNGS in FUO is still limited. Methods In a single-center retrospective cohort study, 175 FUO patients were enrolled, and clinical data were recorded and analyzed to compare mNGS with culture or traditional methods including as smears, serological tests, and nucleic acid amplification testing (NAAT) (traditional PCR, Xpert MTB/RIF, and Xpert MTB/RIF Ultra). Results The blood mNGS could increase the overall rate of new organisms detected in infection-caused FUO by roughly 22.9% and 19.79% in comparison to culture (22/96 vs. 0/96; OR, ∞; p = 0.000) and conventional methods (19/96 vs. 3/96; OR, 6.333; p = 0.001), respectively. Bloodstream infection was among the largest group of those identified, and the blood mNGS could have a 38% improvement in the diagnosis rate compared to culture (19/50 vs. 0/50; OR, ∞; p = 0.000) and 32.0% compared to conventional methods (16/50 vs. 3/50; OR, 5.333; p = 0.004). Among the non-blood samples in infection-caused FUO, we observed that the overall diagnostic performance of mNGS in infectious disease was better than that of conventional methods by 20% (9/45 vs. 2/45; OR, 4.5; p = 0.065), and expectedly, the use of non-blood mNGS in non-bloodstream infection increased the diagnostic rate by 26.2% (8/32 vs. 0/32; OR, ∞; p = 0.008). According to 175 patients’ clinical decision-making, we found that the use of blood mNGS as the first-line investigation could effectively increase 10.9% of diagnosis rate of FUO compared to culture, and the strategy that the mNGS of suspected parts as the second-line test could further benefit infectious patients, improving the diagnosis rate of concurrent infection by 66.7% and 12.5% in non-bloodstream infection, respectively. Conclusion The application of mNGS in the FUO had significantly higher diagnostic efficacy than culture or other conventional methods. In infection-caused FUO patients, application of blood mNGS as the first-line investigation and identification of samples from suspected infection sites as the second-line test could enhance the overall FUO diagnosis rate and serve as a promising optimized diagnostic protocol in the future.
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Affiliation(s)
- Zhang-fan Fu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hao-cheng Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Peng Cui
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- BGI PathoGenesis Pharmaceutical Technology Co., Ltd., BGI-Shenzhen, Shenzhen, China
| | - Hong-yu Wang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ke Lin
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xian Zhou
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Wu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong-long Wu
- BGI PathoGenesis Pharmaceutical Technology Co., Ltd., BGI-Shenzhen, Shenzhen, China
- BGI Wuhan Biotechnology, BGI-Shenzhen, Wuhan, China
| | - Wen-hong Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing-wen Ai
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Jingwen Ai,
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Das S, Sathyendra S, Hephzibah J, Karuppusami R, Gunasekaran K, Shanthly N, Miraclin A, Iyadurai R. Utility of positron emission tomography-computed tomography in the evaluation of fever of unknown origin in a resource-limited tropical nation. World J Nucl Med 2021; 20:237-246. [PMID: 34703391 PMCID: PMC8488897 DOI: 10.4103/wjnm.wjnm_99_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 01/08/2023] Open
Abstract
Positron emission tomography–computed tomography (PET-CT) has been used as an imaging modality in workup of fever of unknown origin (FUO). The aim of our study is to evaluate the diagnostic utility of PET-CT in FUO workup in a resource-limited setting. We also looked at laboratory parameters as predictors of contributory PET-CT scans and propose an algorithm for evaluation of FUO in resource-limited tropical regions. This retrospective observational study included patients admitted for FUO workup under general medicine in a teaching hospital in South India from June 2013 to May 2016. PET-CT was done when the patient remained undiagnosed after a detailed clinical assessment and first- and second-tier investigations. Among 43 patients included in our study, a definite diagnosis was established in 74% (32). Noninfectious inflammatory diseases, infections, malignancies, and miscellaneous diseases were diagnosed in 37.2% (16/43), 23.3% (10/43), 9.3% (4/43), and 4.7% (2/43), respectively. Tuberculosis was the single most common disease seen in 20.9% (9/43). PET-CT scans were contributory toward establishment of final diagnosis in 90.7% (39/43). High C-reactive protein (CRP) and aspartate aminotransferase (AST) levels were associated with contributory PET-CT scans (P = 0.006 and 0.011, respectively). PET-CT delineating organ/tissue for diagnostic biopsy was associated with final diagnosis of infectious disease (P = 0.001). Sensitivity, specificity, and positive and negative predictive value of PET-CT scans were 76.9% (20/26), 33.3% (2/6), 83% (20/24), and 25% (2/8), respectively. High CRP and AST were predictors of contributory PET-CT scans. PET-CT scans have high sensitivity and positive predictive value when used in evaluation of FUO. Although it is a useful tool in FUO workup, especially in the diagnosis of tropical infections, PET-CT should be done after a comprehensive clinical assessment and basic investigations.
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Affiliation(s)
- Sohini Das
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Julie Hephzibah
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Gunasekaran
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nylla Shanthly
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Angel Miraclin
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ramya Iyadurai
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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11
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Bilici Salman R, Gülbahar Ateş S, Satiş H, Tufan A, Akdemir ÜÖ, Yapar D, Ataş N, Güler AA, Karadeniz H, Babaoglu H, Aydos U, Göker B, Haznedaroğlu Ş, Atay LÖ, Öztürk MA. Diagnostic Role of 18F-Fluorodeoxyglucose Positron Emission Tomography for the Evaluation of Patients With Inflammation of Unknown Origin. J Clin Rheumatol 2021; 27:219-225. [PMID: 32195847 DOI: 10.1097/rhu.0000000000001297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sometimes, the underlying causes of inflammation cannot be established despite meticulous investigation, including medical history, physical examination, laboratory tests, and radiologic procedures. Rheumatologists are often faced with patients whose condition is known as inflammation of unknown origin (IUO). Differential diagnosis of IUO is diverse, and investigation of these cases is challenging and time-consuming. OBJECTIVE The study aimed to assess the diagnostic role of positron emission tomography/computed tomography (PET/CT) in the evaluation of patients with IUO. METHODS The study sample consisted of 97 adult patients with IUO who have not been previously diagnosed with an infectious, inflammatory, or malignant disease. The necessary data were collected from January 2015 to June 2018 with a 6-month follow-up period. The patients were screened using PET/CT after a specific diagnosis could not be established with detailed laboratory and radiologic evaluations. RESULTS A final diagnosis was established at follow-up, and 47 (54%) of the 97 patients had inflammatory diseases, 30 (34.4%) had malignancies, and 10 (11.4%) had infections. Despite meticulous investigation, 10 patients were left undiagnosed in the follow-up. PET/CT aided diagnosis in 59 patients (60.8%), but it was not helpful in 38 patients (39.2%). PET/CT was positive in 30 (63%) of the 47 patients with inflammatory diseases, whose final diagnosis was inflammatory rheumatic disease, as follows: large-vessel vasculitis in 19 patients, polymyalgia rheumatica in 7 patients, and seronegative arthritis or other rare miscellaneous diseases in 4 patients. The sensitivity of PET/CT was 67% with a specificity and diagnostic accuracy of 100% and 71%, respectively. CONCLUSIONS Investigation of the underlying etiology of IUO is time-consuming and challenging. PET/CT may help identify the final diagnosis more quickly by locating an obscure inflammatory site; thus, it may reduce the number of unnecessary biopsies, diagnostic time, anxiety, work loss, morbidity, and mortality.
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Affiliation(s)
| | | | - Hasan Satiş
- From the Division of Rheumatology, Department of Internal Medicine
| | | | | | - Dilek Yapar
- Department of Public Health, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nuh Ataş
- From the Division of Rheumatology, Department of Internal Medicine
| | | | - Hazan Karadeniz
- From the Division of Rheumatology, Department of Internal Medicine
| | - Hakan Babaoglu
- From the Division of Rheumatology, Department of Internal Medicine
| | | | - Berna Göker
- From the Division of Rheumatology, Department of Internal Medicine
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12
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Place of the 18F-FDG-PET/CT in the Diagnostic Workup in Patients with Classical Fever of Unknown Origin (FUO). J Clin Med 2021; 10:jcm10173831. [PMID: 34501277 PMCID: PMC8432230 DOI: 10.3390/jcm10173831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To explore the diagnostic contribution of the 18F-FDG-PET/CT in a population of patients with classical fever of unknown origin (FUO), to pinpoint its place in the diagnostic decision tree in a real-life setting, and to identify the factors associated with a diagnostic 18F-FDG-PET/CT. Method: All adult patients (aged ≥ 18 years) with a diagnosis of classical FUO who underwent an 18F-FDG-PET/CT in the University Hospital of Montpellier (France) between April 2012 and December 2017 were included. True positive 18F-FDG-PET/CT, which evidenced a specific disease causing FUO, were considered to be contributive. Results: Forty-four patients with FUO have been included (20 males, 24 females; mean age 57.5 ± 17.1 years). Diagnoses were obtained in 31 patients (70.5%), of whom 17 (38.6%) had non-infectious inflammatory diseases, 9 had infections (20.5%), and 3 had malignancies (6.8%). 18F-FDG-PET/CT was helpful for making a final diagnosis (true positive) in 43.6% of all patients. Sensitivity and specificity levels were 85% and 37%, respectively. A total of 135 investigations were performed before 18F-FDG-PET/CT, mostly CT scans (93.2%) and echocardiography (59.1%), and 108 after 18F-FDG-PET/CT, mostly biopsies (including the biopsy of a temporal artery) (25%) and MRIs (34%). In multivariate analysis, the hemoglobin level was significantly associated with a helpful 18F-FDG-PET/CT (p = 0.019, OR 0.41; 95% CI (0.20–0.87)), while the CRP level was not associated with a contributive 18F-FDG-PET/CT. Conclusion: 18F-FDG-PET/CT may be proposed as a routine initial non-invasive procedure in the diagnostic workup of FUO, especially in anemic patients who could be more likely to benefit from 18F-FDG-PET/CT.
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13
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Tsuzuki S, Watanabe A, Iwata M, Toyama H, Terasawa T. Predictors of Diagnostic Contributions and Spontaneous Remission of Symptoms Associated with Positron Emission Tomography with Fluorine-18-Fluorodeoxy Glucose Combined with Computed Tomography in Classic Fever or Inflammation of Unknown Origin: a Retrospective Study. J Korean Med Sci 2021; 36:e150. [PMID: 34100562 PMCID: PMC8185121 DOI: 10.3346/jkms.2021.36.e150] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In patients with fever or inflammation of unknown origin (fever of unknown origin [FUO] or inflammation of unknown origin [IUO], respectively), expert consensus recommends the use of positron emission tomography with fluorine-18-fluorodeoxy glucose combined with computed tomography (FDG-PET/CT) when standard work-up fails to identify diagnostic clues. However, the clinical variables associated with successful localization of the cause by FDG-PET/CT remain uncertain. Moreover, the long-term outcomes of patients with unexplained FUO or IUO after negative FDG-PET/CT results are unknown. Therefore, we assessed predictors of successful diagnosis of FUO or IUO caused by FDG-PET/CT and associations of spontaneous remission of symptoms with FDG-PET/CT results. METHODS All patients with FUO or IUO, who underwent FDG-PET/CT from 2013 to 2019 because diagnostic work-up failed to identify a cause, were retrospectively included. We calculated the diagnostic yield and performed multivariable logistic regression to assess characteristics previously proposed to be associated with successful localization of FUO or IUO causes. We also assessed whether the FDG-PET/CT results were associated with spontaneous remissions. RESULTS In total, 50 patients with diagnostically challenging FUO or IUO (35 with FUO and 15 with IUO) were assessed. Other than one case of infection, all the identified causes were either malignancy or non-infectious inflammatory diseases (each with 18 patients), and FDG-PET/CT correctly localized the cause in 29 patients (diagnostic yield = 58%). None of the proposed variables was associated with successful localization. All 13 patients with sustained unexplained cause remained alive (median follow-up, 190 days). Spontaneous remission was observed in 4 of 5 patients with a negative FDG-PET/CT, and 1 of 8 with a positive result (P = 0.018). CONCLUSION In the current cohort, the proposed variables were not predictive for successful localization by FDG-PET/CT. A negative FDG-PET/CT scan may be prognostic for spontaneous remission in patients with sustained FUO or IUO.
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Affiliation(s)
- Seiichiro Tsuzuki
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Ayumi Watanabe
- Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Toyama
- Department of Radiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan.
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14
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PET/Computed Tomography in the Evaluation of Fever of Unknown Origin and Infectious/Inflammatory Disease in Pediatric Patients. PET Clin 2021; 15:361-369. [PMID: 32498991 DOI: 10.1016/j.cpet.2020.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Fever in children is common. If it persists and its cause cannot be identified in a reasonable time, along with laboratory and conventional imaging investigations, it is defined as fever of unknown origin (FUO). 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) is well established in the evaluation of malignancy, which is a possible cause of FUO. FDG often locates inflammatory and infectious lesions considered nonspecific or false-positive for oncology; however, these findings are beneficial in FUO evaluation because infectious and inflammatory diseases are important FUO causes. FDG-PET/CT is being increasingly used for investigation of FUO as well as infectious/inflammatory disease.
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15
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Wright WF, Simner PJ, Carroll KC, Auwaerter PG. Progress Report: Next-Generation Sequencing (NGS), Multiplex Polymerase Chain Reaction (PCR), and Broad-Range Molecular Assays as Diagnostic Tools for Fever of Unknown Origin (FUO) Investigations in Adults. Clin Infect Dis 2021; 74:924-932. [PMID: 33606012 DOI: 10.1093/cid/ciab155] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Indexed: 11/12/2022] Open
Abstract
Even well into the 21st century, infectious diseases still account for most causes of fever of unknown origin (FUO). Advances in molecular technologies, including broad-range PCR of the 16S rRNA gene followed by Sanger sequencing, multiplex PCR assays, and more recently, next-generation sequencing (NGS) applications, have transitioned from research methods to more commonplace in some clinical microbiology laboratories. They have the potential to supplant traditional microbial identification methods and antimicrobial susceptibility testing. Despite the remaining challenges with these technologies, publications in the past decade justify excitement about the potential to transform FUO investigations. We discuss available evidence using these molecular methods for FUO evaluations, including potential cost-benefits and future directions.
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Affiliation(s)
- William F Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Patricia J Simner
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Karen C Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Paul G Auwaerter
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Torné Cachot J, Baucells Azcona JM, Blanch Falp J, Camell Ilari H. Classic fever of unknown origin: analysis of a cohort of 87 patients according to the definition with qualitative study criterion. Med Clin (Barc) 2020; 156:206-213. [PMID: 32593415 DOI: 10.1016/j.medcli.2020.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the characteristics of fever of unknown origin (FUO) according to the definition with qualitative study criterion and of patients without diagnosis. MATERIALS AND METHODS Prospective observational study performed from 2009 to 2017 of all patients who were diagnosed with FUO according to the extended definition with qualitative study criterion. Demographic, clinical, diagnostic and evolving variables were evaluated. RESULTS Of the 87 patients registered, 17.3% presented criteria of inflammation of unknown origin (IUO). The diagnoses were: non-infectious inflammatory diseases (NIID) in 19 patients (21.8%), infections in 15 (17.2%), miscellaneous in 14 (16.1%), malignant diseases in 13 (15%) and without diagnosis in 26 (29.9%). In 17.6% of the cases, a potentially diagnostic clue (PDC) was identified. The patients without diagnosis were characterized by a lower number of total PDC (5.9±3.3 vs. 8.7±3.4; P=.000), fewer clinical signs (.4±.6 vs. .9±.8; P=.001), a smaller number of tests in the previous study (2.7±2.1 vs. 4.6±2; P=.000), a shorter diagnostic interval (14.6±7.7 days vs. 21.4±9.5 days; P=.029) and less alteration of erythrocyte sedimentation rate (52.3±41.3mm/h vs. 89.8±42.7mm/h; P=.000), haemoglobin (12.9±1.7g/dl vs. 11.7±1.6g/dl; P=.003) and albumin (36.9±6.4g/l vs. 33.2±7.2g/l; P=.025). 18F-fluorodeoxyglucose positron-emission tomography combined with computed tomography (18F-FDG-PET/TC) proved to be helpful in 37% of the cases. Mortality was 6.8%. CONCLUSIONS The definition of FUO with qualitative study criterion incorporates a diagnostic protocol that provides clear benefits in terms of cost-effectiveness.
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Affiliation(s)
- Joaquim Torné Cachot
- Servicio de Medicina Interna, Hospital Sant Camil, Consorci Sanitari Alt Penedès-Garraf, San Pere de Ribes, Barcelona, España.
| | - José Manuel Baucells Azcona
- Servicio de Medicina Interna, Hospital Sant Camil, Consorci Sanitari Alt Penedès-Garraf, San Pere de Ribes, Barcelona, España
| | - Jesús Blanch Falp
- Servicio de Medicina Interna, Hospital Sant Camil, Consorci Sanitari Alt Penedès-Garraf, San Pere de Ribes, Barcelona, España
| | - Helena Camell Ilari
- Servicio de Medicina Interna, Hospital Sant Camil, Consorci Sanitari Alt Penedès-Garraf, San Pere de Ribes, Barcelona, España
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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: 26] [Impact Index Per Article: 5.2] [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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Fusco FM, Pisapia R, Nardiello S, Cicala SD, Gaeta GB, Brancaccio G. Fever of unknown origin (FUO): which are the factors influencing the final diagnosis? A 2005-2015 systematic review. BMC Infect Dis 2019; 19:653. [PMID: 31331269 PMCID: PMC6647059 DOI: 10.1186/s12879-019-4285-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/12/2019] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND The differential diagnosis of Fever of Unknown Origin (FUO) is very extensive, and includes infectious diseases (ID), neoplasms and noninfectious inflammatory diseases (NIID). Many FUO remain undiagnosed. Factors influencing the final diagnosis of FUO are unclear. METHODS To identify factors associated with FUO diagnostic categories, we performed a systematic review of classical FUO case-series published in 2005-2015 and including patients from 2000. Moreover, to explore changing over time, we compared these case-series with those published in 1995-2004. RESULTS Eighteen case-series, including 3164 patients, were included. ID were diagnosed in 37.8% of patients, NIID in 20.9%, and neoplasm in 11.6%, FUO were undiagnosed in 23.2%. NIIDs significantly increased over time. An association exists between study country income level and ID (increasing when the income decreases) and undiagnosed FUO (increasing when the income increases); even if not significant, the use of a pre-defined Minimal Diagnostic Work-up to qualify a fever as FUO seems to correlate with a lower prevalence of infections and a higher prevalence of undiagnosed FUO. The multivariate regression analysis shows significant association between geographic area, with ID being more frequent in Asia and Europe having the higher prevalence of undiagnosed FUO. Significant associations were found with model of study and FUO defining criteria, also. CONCLUSIONS Despite advances in diagnostics, FUO still remains a challenge, with ID still representing the first cause. The main factors influencing the diagnostic categories are the income and the geographic position of the study country.
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Affiliation(s)
- Francesco Maria Fusco
- Infectious Diseases Unit 1, S. Maria Annunziata Hospital, Central Tuscany Health Unit, Via dell'Antella 54, 50012, Bagno a Ripoli, FI, Italy.
| | - Raffaella Pisapia
- Epidemiology and Pre-clinical Research Department, National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - Salvatore Nardiello
- Infectious Diseases and Viral Hepatitis, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stefano Domenico Cicala
- Infectious Diseases, Azienda Ospedaliera, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Battista Gaeta
- Infectious Diseases, Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppina Brancaccio
- Department of Molecular Medicine, Infectious Diseases, University of Padua, Padua, Italy
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Clinical features and outcomes of patients with fever of unknown origin: a retrospective study. BMC Infect Dis 2019; 19:198. [PMID: 30813923 PMCID: PMC6391771 DOI: 10.1186/s12879-019-3834-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have reported the long-term clinical outcome of patients discharged with undiagnosed fever of unknown origin (FUO). In this study, the clinical features and outcomes of patients with unexplained fever were explored to improve our understanding of FUO. METHOD Patients diagnosed with FUO at admission and discharged without final diagnoses after systematic examination in the department of infectious diseases at Peking Union Medical College Hospital between 2004 and 2010 were followed up by telephone. Medical records were reviewed, and the clinical features and outcomes of patients for whom follow-up data were available were summarized. RESULTS Between 2004 and 2010, 58 patients with follow-up data, who were diagnosed with FUO at admission and did not have a final diagnosis at discharge, were enrolled in this study. The median duration of follow-up was 518 (0.4-830) weeks, and the fever duration was 24.6 (6.7-763.2) weeks. Final diagnoses were established in 11 cases (19%), and the diagnostic methods included clinical diagnosis, diagnostic therapy, genetic screening and biopsy pathology. The fever in 35 patients (60%) subsided during hospitalization or after discharge. Their condition was stable and self-limited after long-term follow-up, and they were ultimately thought to be cured. Two patients had periodic fever during prolonged observation: one patient needed intermittent use of nonsteroidal antiinflammatory drugs (NSAIDs), and the other needed intermittent use of NSAIDs and a steroid. Ten patients died during follow-up, with 9 deaths being caused by severe and worsening conditions related to the febrile illness. CONCLUSIONS Long-term follow-up should be performed for patients with undiagnosed FUO. Some patients can obtain a definitive diagnosis by repeated multiple invasive examinations and diagnostic treatment. Most patients have a self-limited illness, and their prognosis is good.
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Mulders-Manders CM, Engwerda C, Simon A, van der Meer JW, Bleeker-Rovers CP. Long-term prognosis, treatment, and outcome of patients with fever of unknown origin in whom no diagnosis was made despite extensive investigation: A questionnaire based study. Medicine (Baltimore) 2018; 97:e11241. [PMID: 29924054 PMCID: PMC6024966 DOI: 10.1097/md.0000000000011241] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In 30-50% of patients with fever of unknown origin (IUO) no explanation for the fever can be found. Prognosis and effects of empirical treatment of these patients are largely unknown.With this retrospective, questionnaire based corort study in all unexplained FUO patients in an expert center between 2003 and 2014 we studied mortality and outcome.In 131 of 274 FUO patients, FUO remained unexplained. Ninety-nine of them responded to the long-term follow up questionnaire. Adter a median duration of follow-up of 60 months, spontaneous remission of fever occured in 47.3%. Empirical treatment was effective in 66.7% of patients. Mortality was 6.9%. The cause of death was considered not to be related to the febrile disease in five out of six patients. Ten out of 99 responders reported to have received a final explanation for FUO after evaluation in the expertise center, but this diagnosis could not be confirmed in six cases and was considered to be an unlikely explanation for FUO in four out of six cases.We conclude that mortality in unexplained FUO is low en mostly unrelated to the febrile disease. Spontaneous resolution of fever is common. Empirical treatment prescribed by an expert physician is often effective, but should be avoided untill all diagnostic possibilities have been exhaused.
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Affiliation(s)
- Catharina M. Mulders-Manders
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Anna Simon
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jos W.M. van der Meer
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P. Bleeker-Rovers
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
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Kouijzer IJE, Mulders-Manders CM, Bleeker-Rovers CP, Oyen WJG. Fever of Unknown Origin: the Value of FDG-PET/CT. Semin Nucl Med 2017; 48:100-107. [PMID: 29452615 DOI: 10.1053/j.semnuclmed.2017.11.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fever of unknown origin (FUO) is commonly defined as fever higher than 38.3°C on several occasions during at least 3 weeks with uncertain diagnosis after a number of obligatory investigations. The differential diagnosis of FUO can be subdivided in four categories: infections, malignancies, noninfectious inflammatory diseases, and miscellaneous causes. In most cases of FUO, there is an uncommon presentation of a common disease. FDG-PET/CT is a sensitive diagnostic technique for the evaluation of FUO by facilitating anatomical localization of focally increased FDG uptake, thereby guiding further diagnostic tests to achieve a final diagnosis. FDG-PET/CT should become a routine procedure in the workup of FUO when diagnostic clues are absent. FDG-PET/CT appears to be a cost-effective routine imaging technique in FUO by avoiding unnecessary investigations and reducing the duration of hospitalization.
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Affiliation(s)
- Ilse J E Kouijzer
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Nuclear Medicine, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom.
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Mulders-Manders CM, Pietersz G, Simon A, Bleeker-Rovers CP. Referral of patients with fever of unknown origin to an expertise center has high diagnostic and therapeutic value. QJM 2017; 110:793-801. [PMID: 29036369 DOI: 10.1093/qjmed/hcx158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/15/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND up to 50% of patients with fever of unknown origin (FUO) remain undiagnosed despite extensive evaluation. In expertise centers, at least 25-63% of these patients are referred after evaluation in another hospital. The diagnostic and therapeutic yields of referral to an expertise center are currently unknown. AIM To determine the diagnostic and therapeutic yield of referral of patients with fever of unknown origin (FUO) that remain undiagnosed in non-expertise hospitals. DESIGN Data on workup, outcome, treatment and prognosis were extracted from medical records of all 236 patients referred to the Radboud university medical center's department of internal medicine because of FUO between January 2005 and June 2014. RESULTS A final diagnosis could be made in 110 of 192 tertiary referred FUO patients. The rate of diagnosis did not differ between patients referred for first opinion or after tertiary referral (68.2 vs. 57.3%, P = 0.234). Over half of undiagnosed tertiary referred patients were treated, and fever resolved in half of these patients. Of 96 undiagnosed patients, two died (2.1)% and in both death was considered unrelated to the febrile disease. CONCLUSION The diagnostic rate in patients with FUO does not differ between patients that are tertiary referred and patients that have not been previously evaluated in another hospital. With a total diagnostic value of 57.3% and an additional therapeutic yield of 10.9% in undiagnosed patients, tertiary referral should therefore be considered in patients that remain undiagnosed in a non-expertise center.
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Affiliation(s)
- C M Mulders-Manders
- From the Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Huispost 463, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - G Pietersz
- From the Department of Internal Medicine
| | - A Simon
- From the Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Huispost 463, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Gyawali N, Bradbury RS, Aaskov JG, Taylor-Robinson AW. Neglected Australian Arboviruses and Undifferentiated Febrile Illness: Addressing Public Health Challenges Arising From the 'Developing Northern Australia' Government Policy. Front Microbiol 2017; 8:2150. [PMID: 29163434 PMCID: PMC5681932 DOI: 10.3389/fmicb.2017.02150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/20/2017] [Indexed: 12/19/2022] Open
Abstract
The Australian Government is currently promoting the development of Northern Australia, with an associated increase in the local population. Consequent to this is the public health threat posed by heightened human exposure to many previously neglected arboviruses that are indigenous to the region. This initiative to support economic activity in the tropical north of the continent is leading to the accelerated expansion of an infection-naïve human population into hitherto un-encountered ecosystems inhabited by reservoir animals and vectors for these arboviruses. Combined with an apparent rise in the number and impact of dramatic climate events, such as tropical cyclones and floods caused by torrential monsoonal rainfall, this heightens the potential for viral transmission to humans. More than 75 arboviruses have been identified in Australia, some of which are associated with human disease but for which routine tests are not available to diagnose infection. Here, we describe briefly the neglected Australian arboviruses that are most likely to emerge as significant agents of human disease in the coming decades. We also advocate the establishment of a thorough surveillance and diagnostic protocol, including developing new pan-viral rapid tests for primary care use to assist in the early diagnosis and correct treatment of affected patients. We propose that the implementation of these activities will enhance our understanding of the geographical range, prevalence, identification and control of neglected Australian arboviruses. This would minimise and limit the possibility of large-scale outbreaks with these agents as population and economic growth expands further into Australia's tropical north.
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Affiliation(s)
- Narayan Gyawali
- Infectious Diseases Research Group, School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Richard S. Bradbury
- Infectious Diseases Research Group, School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD, Australia
| | - John G. Aaskov
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Andrew W. Taylor-Robinson
- Infectious Diseases Research Group, School of Health, Medical and Applied Sciences, Central Queensland University, Brisbane, QLD, Australia
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Gyawali N, Taylor-Robinson AW. Confronting the Emerging Threat to Public Health in Northern Australia of Neglected Indigenous Arboviruses. Trop Med Infect Dis 2017; 2:E55. [PMID: 30270912 PMCID: PMC6082055 DOI: 10.3390/tropicalmed2040055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 01/12/2023] Open
Abstract
In excess of 75 arboviruses have been identified in Australia, some of which are now well established as causative agents of debilitating diseases. These include Ross River virus, Barmah Forest virus, and Murray Valley encephalitis virus, each of which may be detected by both antibody-based recognition and molecular typing. However, for most of the remaining arboviruses that may be associated with pathology in humans, routine tests are not available to diagnose infection. A number of these so-called 'neglected' or 'orphan' arboviruses that are indigenous to Australia might have been infecting humans at a regular rate for decades. Some of them may be associated with undifferentiated febrile illness-fever, the cause of which is not obvious-for which around half of all cases each year remain undiagnosed. This is of particular relevance to Northern Australia, given the Commonwealth Government's transformative vision for the midterm future of massive infrastructure investment in this region. An expansion of the industrial and business development of this previously underpopulated region is predicted. This is set to bring into intimate proximity infection-naïve human hosts, native reservoir animals, and vector mosquitoes, thereby creating a perfect storm for increased prevalence of infection with neglected Australian arboviruses. Moreover, the escalating rate and effects of climate change that are increasingly observed in the tropical north of the country are likely to lead to elevated numbers of arbovirus-transmitting mosquitoes. As a commensurate response, continuing assiduous attention to vector monitoring and control is required. In this overall context, improved epidemiological surveillance and diagnostic screening, including establishing novel, rapid pan-viral tests to facilitate early diagnosis and appropriate treatment of febrile primary care patients, should be considered a public health priority. Investment in a rigorous identification program would reduce the possibility of significant outbreaks of these indigenous arboviruses at a time when population growth accelerates in Northern Australia.
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Affiliation(s)
- Narayan Gyawali
- School of Health, Medical & Applied Sciences, Central Queensland University, Rockhampton, QLD 4702, Australia.
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia.
| | - Andrew W Taylor-Robinson
- School of Health, Medical & Applied Sciences, Central Queensland University, Brisbane, QLD 4000, Australia.
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25
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Schönau V, Vogel K, Englbrecht M, Wacker J, Schmidt D, Manger B, Kuwert T, Schett G. The value of 18F-FDG-PET/CT in identifying the cause of fever of unknown origin (FUO) and inflammation of unknown origin (IUO): data from a prospective study. Ann Rheum Dis 2017; 77:70-77. [PMID: 28928271 DOI: 10.1136/annrheumdis-2017-211687] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 08/24/2017] [Accepted: 09/08/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are diagnostically challenging conditions. Diagnosis of underlying disease may be improved by 18F-fluorodesoxyglucose positron emission tomography (18F-FDG-PET). METHODS Prospective study to test diagnostic utility of 18F-FDG-PET/CT in a large cohort of patients with FUO or IUO and to define parameters that increase the likelihood of diagnostic 18F-FDG-PET/CT. Patients with FUO or IUO received 18F-FDG-PET/CT scanning in addition to standard diagnostic work-up. 18F-FDG-PET/CT results were classified as helpful or non-helpful in establishing final diagnosis. Binary logistic regression was used to identify clinical parameters associated with a diagnostic 18F-FDG-PET/CT. RESULTS 240 patients were enrolled, 72 with FUO, 142 with IUO and 26 had FUO or IUO previously (exFUO/IUO). Diagnosis was established in 190 patients (79.2%). The leading diagnoses were adult-onset Still's disease (15.3%) in the FUO group, large vessel vasculitis (21.1%) and polymyalgia rheumatica (18.3%) in the IUO group and IgG4-related disease (15.4%) in the exFUO/IUO group. In 136 patients (56.7% of all patients and 71.6% of patients with a diagnosis), 18F-FDG-PET/CT was positive and helpful in finding the diagnosis. Predictive markers for a diagnostic 18F-FDG-PET/CT were age over 50 years (p=0.019), C-reactive protein (CRP) level over 30 mg/L (p=0.002) and absence of fever (p=0.001). CONCLUSION 18F-FDG-PET/CT scanning is helpful in ascertaining the correct diagnosis in more than 50% of the cases presenting with FUO and IUO. Absence of intermittent fever, higher age and elevated CRP level increase the likelihood for a diagnostic 18F-FDG-PET/CT.
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Affiliation(s)
- Verena Schönau
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Kristin Vogel
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Jochen Wacker
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Daniela Schmidt
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
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Manger B, Schett G. Aortic dissection and fever: cause or consequence. Z Rheumatol 2017; 76:550-551. [PMID: 28523510 DOI: 10.1007/s00393-017-0316-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- B Manger
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
| | - G Schett
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
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Hofheinz K, Bertz S, Wacker J, Schett G, Manger B. Fever of unknown origin, giant cell arteritis, and aortic dissection. Z Rheumatol 2017; 76:83-86. [PMID: 28074266 DOI: 10.1007/s00393-016-0245-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Giant cell arteritis is one of the most frequent causes of pyrexia of unknown origin after infectious or malignant causes have been ruled out. In this case report we describe a 66-year old female patient, who after five weeks of remitting fever developed a life-threatening, painless severe aortic dissection. The timely use of modern imaging technologies such as magnetic resonance angiography or positron emission computed tomography could in the future be of help to recognize aortic involvement early and to avoid this devastating complication in patients with fever of unknown origin.
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Affiliation(s)
- K Hofheinz
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - S Bertz
- Institute for Pathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - J Wacker
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - G Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - B Manger
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
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Mulders-Manders C, Simon A, Bleeker-Rovers C. Rheumatologic diseases as the cause of fever of unknown origin. Best Pract Res Clin Rheumatol 2016; 30:789-801. [DOI: 10.1016/j.berh.2016.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/10/2016] [Accepted: 10/13/2016] [Indexed: 11/24/2022]
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Brown M. Pyrexia of unknown origin 90 years on: a paradigm of modern clinical medicine. Postgrad Med J 2015; 91:665-9. [PMID: 26489766 DOI: 10.1136/postgradmedj-2015-133554] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/28/2015] [Indexed: 11/04/2022]
Abstract
In 1925, Sir Thomas Horder, a leading physician of his day, gave a lecture, published in this journal, entitled 'Some cases of pyrexia without physical signs'. The paper highlighted what was already a familiar clinical presentation "which taxes our resources to the utmost". Fast-forward through 90 years of careful clinical description, technological innovation in diagnosis and treatment, emergent infections, novel diagnoses, demographic shifts, and radical changes in the health economy. Sir Thomas would find certain aspects familiar, and others revolutionary, in the differential diagnosis and management of the 21st century patient with pyrexia of unknown origin (PUO). Within high-income settings, the proportion of cases due to infection has declined, albeit unevenly. The era of untreated HIV, and the consequences of iatrogenic intervention and immunosuppression, led to Durack and Street's subclassification of the condition in the early 1990 s into classic, nosocomial, neutropenic and HIV-associated PUO. Shifts towards ambulatory care have driven a change in the definition of many diseases. An era of observant clinicians, who lent their names to eponymous syndromes, followed by meticulous serological, genetic and clinicopathological correlation, generated a battery of diagnoses that, along with malignancy, form a large proportion of diagnoses in more recent clinical care. In the current era, universal access to cross-sectional imaging and an infinite array of laboratory tests has undermined the attention paid to history and examination. In some areas of the clinical assessment, such as assessing the fever pattern, this shift is supported by research evidence. The issues that need to be addressed in the next 90 years of technological innovation, information sharing and health service transformation are likely to include: transcriptomic approaches to diagnosis; the place of positron emission tomography (PET) in the diagnostic pathway; the optimal management of high ferritin states; and the most cost-effective diagnostic environment, in the face of this era of specialisation and fragmentation of care. In the meantime, this review covers some important early 21st century lessons to be shared in avoiding diagnostic pitfalls and choosing empirical therapy.
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Gerfaud-Valentin M, Sève P, Hot A, Broussolle C, Jamilloux Y. Données actualisées sur la physiopathologie, les phénotypes et les traitements de la maladie de Still de l’adulte. Rev Med Interne 2015; 36:319-27. [DOI: 10.1016/j.revmed.2014.10.365] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/25/2014] [Indexed: 12/27/2022]
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Muñoz-Gómez S, Cunha BA. Fever of unknown origin (FUO) due to Legionnaire's disease. Heart Lung 2015; 44:72-4. [PMID: 25444558 DOI: 10.1016/j.hrtlng.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 09/19/2014] [Accepted: 09/24/2014] [Indexed: 10/24/2022]
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