Fever of unknown origin

Nasal NK/T cell lymphoma presents with long-term nasal blockage and fever: a rare case report and literature review

NK/T cell lymphoma (NKTCL) is a common disease which is a threat to human health. Nasal NKTCL is a rare but serious type of systemic lymphoma because of its high mortality rate and serious complications. In this case report, we describe a male who presented with nasal blockage in the right side, a fever of one month duration and a soy-like, painless and gradually increasing mass in the right submandibular region due to nasal NKTCL. The patient had no significant medical history and the initial clinical symptoms were nasal blockage. Contrast computed tomography showed that the nasopharyngeal mucosa was thickened and that the celiac and retroperitoneal lymphaden was intumescent. Finally a biopsy, guided by nasal endoscopy and examined using flow cytometry confirmed a diagnosis of NKTCL. Nasal NKTCL is rare and has no unique characteristics at first presentation, such as epidemiology and obvious clinical manifestation. As no effective therapy is currently available for this disease, early diagnosis and therapy of nasal NKTCL remains challenging.

Fever of unknown origin: a clinical approach

Fevers of unknown origin remain one of the most difficult diagnostic challenges in medicine. Because fever of unknown origin may be caused by over 200 malignant/neoplastic, infectious, rheumatic/inflammatory, and miscellaneous disorders, clinicians often order non-clue-based imaging and specific testing early in the fever of unknown origin work-up, which may be inefficient/misleading. Unlike most other fever-of-unknown-origin reviews, this article presents a clinical approach. Characteristic history and physical examination findings together with key nonspecific test abnormalities are the basis for a focused clue-directed fever of unknown origin work-up.

A Rationale for the Use of F18-FDG PET/CT in Fever and Inflammation of Unknown Origin

This review focuses on the diagnostic value of hybrid F18-FDG Positron Emission Tomography/Computerized tomography (PET/CT) in fever of unknown origin (FUO) and inflammation of unknown origin (IUO). Due to the wide range of possible causes both FUO and IUO remain a clinical challenge for both patients and physicians. In addition, the aetiology of IUO shows the same variation in diseases as the FUO spectrum and probably requires the same diagnostic approach as FUO. There are numerous historically used diagnostic approaches incorporating invasive and non-invasive, and imaging techniques, all with relative high specificity but limited sensitivity. This hampers the generalization of these diagnostic approaches. However, recently published reports show that F18-FDG PET/CT in FUO and IUO has a high sensitivity and a relative non-specificity for malignancy, infection and inflammation. This makes F18-FDG PET/CT an ideal diagnostic tool to start the diagnostic process and to guide subsequent focused diagnostic approaches with higher specificity. In addition, F18-FDG PET/CT has a relative high negative predictive value. Therefore F18 FDG PET/CT should be incorporated in the routine diagnostic work-up of patients with FUO and IUO, preferably at an early stage in the diagnostic process.

Fever of unknown origin (FUO) and a renal mass: renal cell carcinoma, renal tuberculosis, renal malakoplakia, or xanthogranulomatous pyelonephritis?

Often patients with fevers of unknown origin (FUOs) present with loss of appetite, weight loss, and night sweats, without localizing signs. Some are found to have a renal mass during diagnostic evaluation. In patients with FUOs and a renal mass, the differential diagnosis includes renal tuberculosis, renal cell carcinoma (hypernephroma), renal malakoplakia, and xanthogranulomatous pyelonephritis. A 68-year-old woman presented with an FUO during her diagnostic workup. She manifested an irregularly enlarged kidney on abdominal computed tomography (CT) scan, as well as a highly elevated erythrocyte sedimentation rate of more than 100 mm/hour, an elevated serum ferritin level, and chronic thrombocytosis, which favored a diagnosis of renal cell carcinoma. Renal malakoplakia and renal tuberculosis comprised further differential diagnostic considerations. Microscopic hematuria may be present with any of the disorders in the differential diagnosis, but was absent in this case. An abdominal CT scan was suggestive of xanthogranulomatous pyelonephritis. Because of concerns regarding renal cell carcinoma, the patient received a nephrectomy. The pathologic diagnosis was of xanthogranulomatous pyelonephritis, without renal cell carcinoma.

Recurrent fever of unknown origin (FUO): aseptic meningitis, hepatosplenomegaly, pericarditis and a double quotidian fever due to juvenile rheumatoid arthritis (JRA)

BACKGROUND

Fever of unknown origin (FUO) has been defined as a fever of ≥101°F that persists for 3 weeks or more. It is not readily diagnosed after 1 week of intensive in-hospital testing or after intensive outpatient or inpatient testing. Fevers of unknown origin may be caused by infectious diseases, malignancies, collagen vascular diseases, or a variety of miscellaneous disorders. The relative distribution of causes of FUOs is partly age-related. In the elderly, the preponderance of FUOs is attributable to neoplastic and infectious etiologies, whereas in children, collagen vascular diseases, neoplasms, and viral infectious disease predominate. The diagnostic approach to FUOs depends on a careful analysis of the history, physical findings, and laboratory tests. Most patients with FUOs exhibit localizing findings that should direct the diagnostic workup and limit diagnostic possibilities. The most perplexing causes of FUOs involve those without specific diagnostic tests, e.g., juvenile rheumatoid arthritis (JRA) or adult Still's disease. In a young adult with FUO, if all of the cardinal symptoms are present, JRA may present either a straightforward or an elusive diagnosis, if key findings are absent or if the diagnosis goes unsuspected.

METHODS

We present a 19-year-old man with a recurrent FUO. His illness began 3 years before admission and has recurred twice since. In the past, he did not manifest arthralgias, arthritis, or a truncal rash. On admission, he presented with an FUO with hepatosplenomegaly, aseptic meningitis, and pericarditis. An extensive diagnostic workup ruled out lymphoma and leukemia. Moreover, a further extensive workup eliminated infectious causes of FUO appropriate to his clinical presentation, ie, tuberculosis, histoplasmosis, brucellosis, Q fever, typhoid fever, Epstein-Barr virus, infectious mononucleosis, cytomegalovirus, human herpes virus (HHV)-6, babesiosis, ehrlichiosis, viral hepatitis, and Whipple's disease.

RESULTS

The diagnosis of JRA was based on the exclusion of infectious and neoplastic disorders in a young adult with hepatosplenomegaly, aseptic meningitis, pericarditis, and a double quotidian fever. With JRA, tests for rheumatic diseases are negative, as they were in this case. The only laboratory abnormalities in this patient included elevated serum transaminases, a mildly elevated erythrocyte sedimentation rate, and a moderately elevated level of serum ferritin.

CONCLUSION

Diagnostic fever curves are most helpful in cases where the diagnosis is most elusive, as was the case here. Relatively few disorders are associated with a double quotidian fever, ie, visceral leishmaniasis, mixed malarial infections, right-sided gonococcal acute bacterial endocarditis, and JRA. Because the patient received antipyretics during the first week of admission, fever was not present. After infectious disease consultation during week 2 of hospitalization, antipyretics were discontinued, and a double quotidian fever was present, which provided the key diagnostic clue in this case.

Clinical spectrum of fever of intermediate duration in the south of Spain

Fever of intermediate duration (FID) is a new nosologic entity defined as fever higher than 38 degrees C that has a duration of between 1 and 4 weeks and that after an initial approach has not been diagnosed. It has clinical similarities with fever of unknown origin, but because of characteristic etiologies it requires the term FID. We describe the clinical characteristics and etiology of FID in the south of Spain and create a treatment algorithm. Retrospective study of the medical charts of patients attending at our Service during 2000 and 2005 who had an initial diagnosis of FID and who had a complete follow-up until the resolution of symptoms. Two hundred and thirty-three patients met the inclusion criteria, of whom 164 were men. Median number of days before being referred to our service was 9 (range 2-28). Half of the patients had elevation of transaminases, and CRP and ESR were slightly elevated, 2.8 mg/dl (range 0.1-50) and 16 mm/h (range 1-131) respectively. A final diagnosis was made in 80 patients, with infection with coxiella (32 patients), CMV (16 patients), rickettsial species (11 patients), VEB virus (6 patients), and brucella (5 patients) being the more frequent entities. Doxycycline was the antibiotic most frequently prescribed. Among patients with Q fever, CMV, and rickettsial infection, the majority had abnormal hepatic function, (87%, 93%, and 55% respectively). In FID, a diagnosis is reached in a minority of patients, although the prognosis is excellent in most of them. In our patients the clinical picture of Q fever, CMV, and rickettsial infections included abnormal hepatic function. In addition, these three infections are the most frequently diagnosed so when treating a patient with FID, if elevation of liver enzymes is present patients should start on doxycycline.

A prospective multicenter study on fever of unknown origin: the yield of a structured diagnostic protocol

We conducted a prospective study to update our knowledge of fever of unknown origin (FUO) and to explore the utility of a structured diagnostic protocol. From December 2003 to July 2005, 73 patients with FUO were recruited from 1 university hospital (n = 40) and 5 community hospitals (n = 33) in the same region in The Netherlands. FUO was defined as a febrile illness of >3 weeks' duration, a temperature of >38.3 degrees C on several occasions, without a diagnosis after standardized history-taking, physical examination, and certain obligatory investigations. Immunocompromised patients were excluded. A structured diagnostic protocol was used. Patients from the university hospital were characterized by more secondary referrals and a higher percentage of periodic fever than those referred to community hospitals. Infection was the cause in 16%, a neoplasm in 7%, noninfectious inflammatory diseases in 22%, miscellaneous causes in 4%, and in 51%, the cause of fever was not found (no differences between university and community hospitals). There were no differences regarding the number and type of investigations between university and community hospitals. Significant predictors for reaching a diagnosis included continuous fever; fever present for <180 days; elevated erythrocyte sedimentation rate, C-reactive protein, or lactate dehydrogenase; leukopenia; thrombocytosis; abnormal chest computed tomography (CT); and abnormal F-fluorodeoxyglucose positron emission tomography (FDG-PET). For future FUO studies, inclusion of outpatients and the use of a set of obligated investigations instead of a time-related criterion are recommended. Except for tests from the obligatory part of our protocol and cryoglobulins in an early stage, followed by FDG-PET, and in a later stage by abdominal and chest CT, temporal artery biopsy in patients aged 55 years or older, and possibly bone marrow biopsy, other tests should not be used as screening investigations.

Fever of unknown origin due to preleukemia/myelodysplastic syndrome: The diagnostic importance of monocytosis with elevated serum ferritin levels

Fever of unknown origin (FUO) is a common clinical diagnostic dilemma. In the elderly, causes of FUO most commonly include malignancy or infection, and less commonly include collagen vascular diseases. Among the collagen vascular diseases causing FUO in the elderly, polymyalgia rheumatica/temporal arteritis, and adult Still's disease (adult juvenile rheumatoid arthritis) are difficult diagnoses to prove. Among the infectious causes of FUO in the elderly are subacute bacterial endocarditis, intra-abdominal abscesses, and extrapulmonary tuberculosis. In the elderly, neoplastic causes of FUO include lymphomas, hepatomas, renal cell carcinomas, and hepatic or central nervous system metastases. Acute leukemias, particularly during "blast" transformation, may present as acute fevers in the absence of infection, but are rare causes of FUO. Preleukemia/myelodysplastic syndromes are exceedingly rare causes of FUO. We present a case of an elderly man who presented with findings that initially suggested adult Still's disease. Prolonged and profound monocytosis provided the key clue to his subsequent diagnosis of preleukemia/myelodysplastic syndrome. In this patient, a positive Naprosyn test result also suggested a neoplastic cause for his FUO. After months of prolonged fevers, myelocytes/metamyelocytes were eventually demonstrated in his peripheral smear during hospital evaluation. These findings, in concert with the persistent monocytosis, highly elevated ferritin levels, polyclonal gammopathy on serum protein electrophoresis, and eventual presence of myelocytes/metamyelocytes on peripheral smear, prompted a bone marrow test that demonstrated blast cells confirming the diagnosis of preleukemia myelodysplastic syndrome as the cause of this patient's FUO.

Fever of unknown origin: Temporal arteritis presenting with persistent cough and elevated serum ferritin levels

BACKGROUND

Fever of unknown origin (FUO) at the present time is most frequently caused by neoplasm and less commonly by infection. Currently, collagen vascular diseases (CVDs) are an uncommon cause of FUO because most are readily diagnosable by serologic methods and do not remain undiagnosed for sufficient time to present as FUOs. CVDs presenting as FUOs not readily diagnosable with specific tests include late-onset rheumatoid arthritis, adult juvenile rheumatoid arthritis, and polymyalgia rheumatica/temporal arteritis (TA). TA, or giant cell arteritis, is an uncommon arteritis of the mid- and large-sized extracranial arteries of the head and neck and is a rare cause of FUO. TA is characterized by headache, scalp tenderness, jaw pain on chewing, and sudden loss of vision. Fever, anorexia, weight loss, and night sweats may also be present. With TA, respiratory symptoms occur in 9% and are the presenting feature in 4%. Laboratory abnormalities associated with TA include a highly elevated erythrocyte sedimentation rate, anemia, and thrombocytosis, and mildly increased alkaline phosphatase/serum transaminases.

PATIENT

We present a patient with FUO caused by TA whose predominant presenting symptom was persistent cough that overshadowed head and neck symptoms of TA. To the best of our knowledge, this is the first case of TA presenting as an FUO, with a highly elevated serum ferritin level.

RESULTS

We conclude that highly elevated serum ferritin levels in patients with FUO should alert the clinician to consider TA in the differential diagnosis.

Fever of unknown origin caused by late-onset rheumatoid arthritis

Fever of unknown origin (FUO) is always a diagnostic challenge. The causes of FUO are legion and may be due to malignancy, infection, collagen vascular disease, and a variety of other unusual disorders. Currently, malignancies-followed by infectious etiologies-are the most common cause of FUO. We present an elderly female patient with an FUO who was thought to have subacute bacterial endocarditis because of an antecedent history of recent dental work. Subacute bacterial endocarditis was ruled out on the basis of negative cultures and negative transesophageal echocardiography. No evidence for an infectious disease or neoplastic etiology could be demonstrated in this patient. The diagnosis of FUO is most difficult when there is a paucity of clues from the history and physical examination, as was the case in this patient. Nonspecific laboratory tests included highly increased erythrocyte sedimentation rate (>or=100 mm/h), highly increased C-reactive protein, relative lymphocytopenia, and chronic thrombocytosis. These findings are compatible with a variety of infectious and inflammatory disorders. No evidence could be found for vasculitis. The only laboratory diagnostic findings present in her case were a highly increased rheumatoid factor titer and perinuclear antineutrophilic cytoplasmic antibody level. Polymyalgia rheumatica/temporal arteritis, systemic lupus erythematosus, and adult Still's disease were ruled out. The patient's FUO was best explained by the finding of late-onset rheumatoid arthritis (LORA), which is characterized by acute onset in elderly patients without the usual musculoskeletal manifestations of rheumatoid arthritis. Both the highly increased rheumatoid factor titer and perinuclear antineutrophilic cytoplasmic antibody level in the absence of an alternate explanation indicate that the FUO in this patient was caused by LORA.

Fever of unknown origin: Chronic lymphatic leukemia versus lymphoma (Richter’s transformation)

Currently, malignancies are more common than infections as a cause of fever of unknown origin (FUO) in adults. Many malignant disorders are associated with fever, which may either be of the hectic-septic variety resembling an infectious disease or prolonged and low-grade. Neoplasms with either kind of fever may present as an FUO. The malignancies usually associated with fever are lymphoreticular malignancies involving the blood, liver, spleen, or bone marrow. Most malignancies do not have fever, e.g., chronic lymphatic leukemia (CLL), as part of their clinical presentation. We present a case of long-standing CLL in an elderly woman who presented with an FUO. Initially, it was thought that her FUO was caused by CLL or a CLL-related opportunistic infection. The naprosyn test was used in this patient with CLL and FUO to differentiate a malignant from an infectious etiology. Her response to naprosyn indicated that the etiology of her FUO was neoplastic rather than infectious. The absence of tonsillar enlargement and peripheral adenopathy, as well as the presence of fever, argued against CLL as the cause of her fever. Computed axial tomography scans showed central adenopathy in addition to splenomegaly. The presence of fever, splenomegaly, and central adenopathy indicated that the cause of her FUO was a lymphoma (Richter's transformation) and not CLL.

Carcinoma of Colon Presenting as Fever of Unknown Origin

Fever of unknown origin (FUO) is defined as fever of more than 38.3 degrees C, the cause of which remains elusive after 1 week of intensive investigation. Most cases of FUO are restricted to infections, malignancies, and inflammatory diseases. FUO was previously reported as the presenting symptom of a few solid tumors such as lymphoma, renal cell carcinoma, and hepatocellular carcinoma. Colon carcinoma manifesting as FUO has been rarely reported. We describe three female patients who presented with classical FUO and microcytic anemia. As a control, we retrospectively evaluated 28 matched patients with carcinoma of colon and no fever. The evaluation included review of patient files, clinical and laboratory data, and pathologic specimens. In the three patients (mean age, 58 years) who presented with FUO and had left-sided colon carcinoma and microcytic anemia, pathologic evaluation of the tumor tissues demonstrated a severe organized inflammatory process forming abscesses in the pericolic fat. The 28 control matched patients showed no such histopathologic changes. In patients presenting with FUO, especially those who present with microcytic anemia, even with no bowel disturbances or elevated carcinoembryonic antigen levels, diagnostic workup should include a search for occult colorectal carcinoma. In our three cases, it appears that microabscesses in the pericolic fat are the cause of fever.

Fever of unknown origin: Subacute thyroiditis versus typhoid fever

Fever of unknown origin (FUO) is not infrequently a diagnostic dilemma for clinicians. Common infectious causes include endocarditis and abscesses in adults, and noninfectious causes include neoplasms and certain collagen vascular diseases, for example, polymyalgia rheumatica, various vasculitides, and juvenile rheumatoid arthritis (adult Still's disease). Subacute thyroiditis is a rare cause of FUO. Among the infectious causes of FUO, typhoid fever is relatively uncommon. We present a case of FUO in a traveler returning from India whose initial complaints were that of left-sided neck pain and angle of the jaw pain, which initially suggested the diagnosis of subacute thyroiditis. After an extensive FUO workup, when typhoid fever is a likely diagnostic possibility, an empiric trial of anti- Salmonella therapy has diagnostic and therapeutic significance. The presence of relative bradycardia, and response to quinolone therapy, was the basis of the clinical diagnosis of typhoid fever as the explanation for this patients FUO. This case illustrates the diagnostic difficulties in assessing patients with FUO with few diagnostic findings.

Fever of unknown origin caused by adult juvenile rheumatoid arthritis: The diagnostic significance of double quotidian fevers and elevated serum ferritin levels

Fever of unknown origin (FUO) in adults is a commonly encountered clinical problem. Treatable causes of FUO in the adult should be the primary focus of the diagnostic workup. Neoplasms have replaced infectious diseases as being the most common cause of FUO in adults, and collagen vascular diseases are now relatively rare. The most important collagen vascular diseases presenting as an FUO include Takayasu's arteritis, Kikuchi's disease, polymyalgia rheumatica, and adult juvenile rheumatoid arthritis (JRA) (adult Still's disease). There are no specific diagnostic tests for these disorders, which commonly present as prolonged fevers that are not easily diagnosed (i.e., FUO). Adult JRA is a rare but important cause of FUO in adults. Typically, patients with adult Still's disease present with liver/spleen involvement, posi-articular arthritis, ocular involvement, and evanescent salmon-colored truncal rash. An important diagnostic finding in adult JRA is the presence of a double quotidian fever, which occurs in few other disorders. Only visceral leishmaniasis and adult JRA are causes of FUO in adults associated with double quotidian fevers. Highly elevated serum ferritin levels are the most important nonspecific diagnostic finding associated with adult JRA. We present a case of FUO caused by adult JRA presenting with diffuse polyarticular migrating arthritis, evanescent rash, and splenomegaly. The diagnosis of adult JRA was suggested by these findings in association with a double quotidian fever and a highly elevated serum ferritin level. Clinicians should appreciate the diagnostic significance of fever patterns and the diagnostic significance of elevated serum ferritin levels in patients with FUO.

[Recurrent fever as presenting from of colon carcinoma]

Fever of unknown origin (FUO) has been rarely associated with colonic cancer. In less than 1% of cases of FUO a colonic cancer is found as the main cause of fever. The authors reviewed 4 cases of colonic cancer whose first manifestation was FUO. Recurrent episodes of brief, self-limited fever, without a characteristic pattern, may be the first symptom of colonic cancer. On occassions, E. coli bacteremia may be the herald of an occult colonic malignancy.

Isolated jejunal Crohn's disease in a young adult presenting as fever of unknown origin

A 27-yr-old man was referred for fever, weight loss, fatigue, and occasional mild epimesogastric pain without diarrhea or vomiting. Laboratory tests were suggestive of an active inflammatory disease but serological, bacteriological, viral searches, markers of autoimmunity, and neoplasia were all negative. The following were also negative: ultrasonography; conventional x-rays; CT scans; esophagogastroduodenoscopy, pancolonoscopy with ileoscopy; cytohistology including duodenum and ileocolon. Empiric antibiotic regimens failed to control the temperature. Small bowel enema disclosed multiple proximal jejunal strictures. Jejunoscopy revealed erythema, friability, linear ulcerations, stenosis, and dilation in the proximal jejunum. Multiple directed biopsies showed inflammatory changes devoid of any specific features. The patient received steroid treatment and his temperature normalized. Six months later, he was readmitted on account of intestinal subocclusion that was managed conservatively. A few days later urgent laparotomy was performed with peritoneal lavage, repair of double perforated proximal jejunal ulcers, and stricturoplasty. Surgical jejunal biopsy confirmed the results of enteroscopic biopsies. The patient is presently without fever, in the absence of steroid treatment. There have been no reports of cryptogenic fever due to isolated jejunal Crohn's disease in the recent literature. Our patient's clinical picture resembled disease as seen in older children and adolescents, in whom it is a difficult diagnosis owing to the absence of diarrhea. In adults with Crohn's disease isolated jejunal involvement represents approximately 1% of cases. A thorough small bowel investigation is warranted in young adults with cryptogenic fever and low serum protein levels, even in the absence of major gastrointestinal complaints.

FEVER OF UNKNOWN ORIGIN

Forty six patients of fever of unknown origin in Service Hospitals who met the standard criteria were studied between 1989 and 1997. Infectious diseases contributed 21 patients (45.65%) of which 13 (28.26%) were diagnosed to have tuberculosis. Eight patients each (17.39%) of malignancies and collagen vascular diseases were seen, solid tumours were found in 5 patients. One (2.17%) patient had intrabdominal abscess. No diagnosis was made in 4 (8.69%) patients. The pattern and height of fever bore no correlation to aetiology. Serially repeated radiograph of chest was the most contributory investigation giving diagnostic information in 41.3%. Tissue/body fluid biopsy and cytology, serology, ultrasonography, computerised tomography and laparotomy were other useful investigations.

Fever of unknown origin (FUO). II. Diagnostic procedures in a prospective multicenter study of 167 patients. The Netherlands FUO Study Group

From January 1992 until January 1994, we used a standardized diagnostic protocol for the 167 immunocompetent patients with fever of unknown origin (FUO) admitted on the internal medicine wards in all 8 university hospitals in the Netherlands. This protocol consisted of a standardized coded history and standardized physical examination for all 167 patients. A number of additional obligatory investigations had to be performed in the first week of admission for all patients, and all potentially diagnostic clues (PDCs) thus retrieved had to be registered. In the presence of PDCs, specific investigations had to be performed based on the differential diagnosis. In the absence of PDCs or in the presence of only misleading PDCs, patients underwent a screening 2-staged diagnostic protocol. In 162 (97%) patients, PDCs were present after 1 week of admission. In 61 patients these PDCs were all misleading. The likelihood of reaching a diagnosis in patients with PDCs was not significantly higher than that in patients without PDCs, probably because of the high proportion of misleading PDCs. The likelihood of establishing a diagnosis was significantly lower (< 10%) only for patients with recurrent fever, normal erythrocyte sedimentation rate (ESR), and normal hemoglobin. All other PDCs were not significantly different in patients with a diagnosis compared with patients without a diagnosis. The screening 2-staged diagnostic protocol proved useful in 10 of 43 patients in whom it was used. The screening value of immunologic and microbiologic serology and endocrine investigations was nil; these investigations probably should be performed only when PDCs for the disease searched for are present. Scintigraphic techniques, echocardiography, and other imaging procedures were never helpful in our population in the absence of PDCs. Many patients with FUO had nonspecific anemia and disturbed liver chemistry. In the presence of these findings alone, without other more specific PDCs, the likelihood of reaching a diagnosis with help of bone marrow aspiration was nil, and with help of liver biopsy, it was low. Enteric biopsy was never helpful. If lymphadenopathy was confined to the cervical or inguinal region (with negative chest X-ray and abdominal ultrasound), lymph node biopsy was not helpful, in contrast to patients having generalized lymphadenopathy, in whom the technique had a yield of 79%. As shown in this study, the search for PDCs remains an important tool for establishing the diagnosis in patients with FUO, although in many cases these PDCs appear to be misleading. Directed diagnostic workup--using the PDCs retrieved by repeated, meticulous history taking and physical examination--remains the most efficient and intellectually satisfactory way to solve the problem of FUO in the individual patient. A standard protocol in patients with FUO in whom the obligatory investigations, as used by us, do not lead to the diagnosis can be limited to the tests that proved to be of some use as screening procedure: temporal biopsy in patients older than 55 years; fundoscopy; serology (Western blot) for Yersinia enterocolitica; serum for cryoglobulin at an early stage of the diagnostic process; and bone biopsy, liver biopsy, abdominal computed tomography (CT), and chest CT at a later stage. Repeating a thorough history-taking, physical examination, and obligatory investigations and waiting for PDCs to appear probably is better than ordering more screening investigations in the hope that something abnormal will come up. Supportive treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful at this stage. Only rarely do patients deteriorate while using NSAIDs without presenting new PDCs. In these rare patients, further diagnostic workup should be performed or a therapeutic trial with, for example, antibiotics, steroids, or antituberculous agents started.

Role of venous duplex imaging of the lower extremities in patients with fever of unknown origin

BACKGROUND

Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature.

METHODS

Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment.

RESULTS

A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO.

CONCLUSIONS

Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

Fever of unknown origin

Fever of unknown origin (FUO) is defined as a temperature elevation of 101 degrees F (38.3 degrees C) or higher for 3 weeks or longer, the cause of which is not diagnosed after 1 week of intensive in-hospital investigation. This article discusses the causes, diagnosis, and treatment of FUOs.

Fever of unknown origin in elderly patients

OBJECTIVE

To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients.

DESIGN

Subgroup analysis of a prospectively collected case series followed more than 2 years.

SETTING

General Internal Medicine Service based at University hospital, Leuven, Belgium.

PATIENTS

Forty-seven consecutive patients, older than 65 years, meeting the classic criteria of fever of unknown origin.

MEASUREMENTS

The final diagnosis established and the clinical value of diagnostic procedures.

RESULTS

Infections, tumors and multisystem diseases (encompassing rheumatic diseases, connective tissue disorders, vasculitis including temporal arteritis, polymyalgia rheumatica, and sarcoidosis) were found in 12 (25%), six (12%) and 15 patients (31%), respectively. Drug-related fever was the cause in three patients (6%), miscellaneous conditions were found in five patients (10%), and six patients (12%) remained undiagnosed. Microbiologic investigations were diagnostic in eight cases (16%), serologic tests yielded one diagnosis, immunologic investigations had a diagnostic value in four cases, standard X-rays yielded a diagnostic contribution in 10 cases, ultrasonography and computed tomography were diagnostic in 11 cases, Gallium scintigraphy had a diagnostic contribution in 17 cases, and biopsies yielded the final diagnosis in 18 cases.

CONCLUSIONS

Multisystem diseases emerged as the most frequent cause of fever of unknown origin in the elderly, and temporal arteritis was the most frequent specific diagnosis. Infections, particularly tuberculosis, remain an important group. The percentage of tumors was higher in our elderly patients than in the younger ones but still clearly lower than in other recent series of FUO in adults. The number of undiagnosed cases was significantly lower in elderly patients than in younger individuals (P < or = 0.01). The investigation of elderly patients with FUO should encompass routine temporal artery biopsy and extensive search for tuberculosis if the classic tests such as blood count, chemistry, urinalysis, cultures, chest X-rays, and abdominal ultrasonography do not yield any clue. Gallium scintigraphy should be considered as the next step and not as a last-resort procedure.

Pyrexia of unknown origin in association with bladder diverticulum tumour

A case of pyrexia due to a rapidly growing undifferentiated transitional cell carcinoma in a bladder diverticulum is described. The literature is reviewed and the causes of pyrexia associated with neoplasia briefly discussed.

Pyrexia of unknown origin: changing spectrum of diseases in two consecutive series

Comparison was made of the aetiology and methods of diagnosis in two series of patients meeting the classic criteria of pyrexia of unknown origin during 1968-1981 and during 1982-1989 seen in the Department of Internal Medicine at La Paz University Hospital, Madrid, Spain. There was a statistically significant decrease in the percentage of infections and an increase in neoplasms and connective tissue disorders in the second series. The percentage of patients diagnosed by laparatomy was similar in both series but the diagnosis yield at laparotomy was greater in the second period. Pyrexia of unknown origin continues to be a condition which can defy clinical expertise in in spite of advances in diagnostic techniques.

Adult-onset Still's disease with a significant rheumatoid factor: examining proper use of diagnostic and classification criteria

A case is presented of a 32-year-old man with classic clinical adult-onset Still's disease, who had an initially elevated (1:320) but not persistently high rheumatoid factor. Since lack of a high rheumatoid factor is one feature in the proposed classification criteria for adult-onset Still's disease, the patient was given a diagnosis of rheumatoid arthritis. The faulty reasoning behind this diagnosis of rheumatoid arthritis is discussed, focusing on the inappropriate use of classification criteria for individual clinical diagnosis, as well as the occasional need for longitudinal diagnosis.

Temporal arteritis: the silent presentation and delay in diagnosis

To determine the frequency of the so-called silent or occult presentation of temporal arteritis (presentation with mere constitutional symptoms) and the resulting delay in diagnosis in this particular group, the medical records of all patients (n = 82) with temporal arteritis or polymyalgia rheumatica, presenting between 1982 and 1988 at the Department of General Internal Medicine of the University Hospital, were retrospectively analysed. Only biopsy-proven cases (n = 34) were studied further. Of the 34 patients with temporal arteritis, 13 (38%) presented with the silent or occult form. In this group the mean delay in diagnosis was 21.5 d (range 2-105) in contrast to a delay of 8.5 d (range 1-40) in the other group (P less than 0.05). Increased awareness of this presentation should lead to earlier diagnosis and treatment of this potentially life-threatening disease, resulting in a shorter hospital stay and fewer technical investigations, with a considerable financial saving.