Low-grade fever: how to distinguish organic from non-organic forms

The relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes: a retrospective cohort study

BACKGROUND

Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial.

OBJECTIVE

This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature.

STUDY DESIGN

This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm2), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g.

RESULTS

This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission.

CONCLUSION

In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.

Risk, Predictive, and Preventive Factors for Noninfectious Ventriculitis and External Ventricular Drain Infection

BACKGROUND

External ventricular drain (EVD) is used for monitoring intracranial pressure or diverting cerebrospinal fluid. However, confirmation of an infection is not immediate and requires obtaining culture results, often leading to the excessive use of antibiotics. This study aimed to compare noninfectious ventriculitis and EVD infection in terms of the risk factors, predictors, prognosis, and effectiveness of care bundle interventions.

METHODS

This retrospective study was conducted at a medical center with 1,006 beds in northern Taiwan between January 2018 and July 2022. Standard EVD insertion protocols and care bundles have been implemented since 2018, along with the initiation of chlorhexidine.

RESULTS

In total, 742 EVD cases were identified. Noninfectious ventriculitis typically presents with fever approximately 8 days following EVD placement, whereas EVD infection typically manifests as fever after 20 days. Aneurysmal subarachnoid hemorrhage was strongly associated with the development of noninfectious ventriculitis (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.4). Alcoholism (adjusted OR 3.5, 95% CI 1.1-12.3) and arteriovenous malformation (adjusted OR 13.1, 95% CI 2.9-58.2) significantly increased the risk of EVD infection. The EVD infection rate significantly decreased from 3.6% (14 of 446) to 1.0% (3 of 219) (p = 0.03) after the implementation of chlorhexidine gluconate bathing.

CONCLUSIONS

Aneurysmal subarachnoid hemorrhage or fever with neuroinflammation within 2 weeks of EVD placement is indicative of a higher likelihood of noninfectious ventriculitis. Conversely, patients with arteriovenous malformation, alcoholism, or fever with neuroinflammation occurring after more than 3 weeks of EVD placement are more likely to necessitate antibiotic treatment for EVD infection. Chlorhexidine gluconate bathing decreases EVD infection.

'Functional hyperthermia': a historical overview

The management of low-grade fever in adults has not been codified. This gap is related not only to the numerous possible aetiologies but also to the difficulty of escaping the monocausal model of diseases. This article explores the complex issue of positive signs in 'psychogenic fever' through Reimann's 1930s series. The discussion emphasises Canguilhem's positions regarding vital signs and proposes (1) a semantic clarification of 'habitual hyperthermia' and (2) an amendment of the Belgian diagnostic criteria based on the concept of functional disorder. This paper also suggests following Peirce's pragmatism in the face of an uncommon clinical picture.

An integrated intervention combining cognitive-behavioural stress management and progressive muscle relaxation improves immune biomarkers and reduces COVID-19 severity and progression in patients with COVID-19: A randomized control trial

COVID-19 is a world disaster. In response to COVID-19 quarantine, stress, anxiety, and depression may easily develop which negatively affect immunity and decrease the patient's response against the COVID-19 virus. This study investigated the effect of an integrated intervention combining cognitive-behavioural stress management (CBSM) and progressive muscle relaxation (PMRs) on immune biomarkers and disease severity and progression in patients with COVID-19 and the period to which these changes last. Thirty patients with mild or moderate COVID-19 were randomly distributed into intervention and control groups. The intervention group performed an integrated intervention combining CBSM and PMRs. There were three outcome measures including blood immune markers, salivary immunoglobulin A, and Wisconsin scale (WIS). Two-week post-intervention, there were significant differences between groups in the WIS total score, Leucocytes, Lymphocytes, Interleukin-6, and Immunoglobulin-A. While there were non-significant differences between both groups in Interleukin-10 and TNF-α. The significant differences between groups in the WIS total score, Leucocytes, Lymphocytes, Interleukin-6, and Immunoglobulin-A significantly continued 1 week as a follow-up. This study concluded that performing an integrated intervention combining CBSM and PMRs for 2 weeks significantly increases immune biomarkers mainly Leucocytes, Lymphocytes, Interleukin-10, and Interleukin-6 along with S-IgA. Also, this protocol significantly decreases disease severity and associated stress, anxiety, and depression; and enhances the quality of life in patients with COVID-19. The study was retrospectively registered with NCT04998708.

Patient Self-Report Superior to Electronic Medical Record Abstraction for Identifying Positive COVID-19 Symptoms at Illness Onset

Introduction

Most initial COVID-19 research focused on hospitalized patients. Presenting symptomatology in the outpatient setting was poorly characterized, making it difficult for primary care physicians to predict which patients would require hospitalization. The purpose of this study was to characterize the presenting symptoms of COVID-19 infection and baseline patient characteristics and evaluate for correlation with disease severity, duration, and chronicity in the outpatient setting.

Methods

A total of 107 adult, English-speaking patients with suspected and confirmed COVID-19 cases at the 3 primary care practices of Stony Brook University Hospital were studied between March and December 2020. Survey data were collected from patient telephone interviews and electronic medical record abstraction. The potential risk factors assessed included participant demographics, medical comorbidities, and the number and type of symptoms at illness onset. Outcome measures included symptom duration, hospitalizations, and persistence of symptoms at 12 weeks from study enrollment.

Results

Patient self-report survey elicited nearly twice as many symptoms described at illness onset as those recorded in the electronic medical record (p<0.0001). A higher number of symptoms at illness onset was positively associated with symptom duration and chronicity. The presence of fever and hypoxia at the onset of illness were each positively associated with eventual hospitalization for COVID-19 disease.

Conclusions

Early in the setting of newly emerging infectious diseases, particularly those such as COVID-19 that involve multiple organ systems, patient self-report of symptoms using a complete review of systems rather than electronic medical record abstraction alone may be key for accurate disease identification and characterization as well as prediction of eventual disease severity, duration, and chronicity.

Optimal use of the FDG-PET/CT in the diagnostic process of fever of unknown origin (FUO): a comprehensive review

Numerous studies have clarified the usefulness of ¹⁸F-fluorodeoxyglucose (FDG)-PET/CT (positron emission tomography) for diagnosing the cause of fever of unknown origin (FUO). Various types of disease can cause FUO, but the cause remains unknown in a certain proportion of FUO, even when the advanced diagnostic methodologies are used. FDG-PET/CT is regarded as a second-line modality in the diagnostic process of FUO, and its potential to identify the cause of FUO will be maximized when the appropriate clinical considerations are understood. Accordingly, this review presents basic knowledge regarding FUO, and reports the current status of FDG-PET/CT applied to diagnosing the cause of FUO, including diagnostic performance, test protocols, possible factors influencing the diagnostic result, outcomes, and cost-effectiveness. This knowledge will enable effective future use of FDG-PET/CT to improve outcomes in patients with FUO.

Fever of Unknown Origin (FUO) - A Call for New Research Standards and Updated Clinical Management

Prolonged fever of 38.3°C or higher for at least 3 weeks' duration has been termed fever of unknown origin if unexplained after preliminary investigations. Initially codified in 1961, classification with subgroups was revised in 1991. Additional changes to the definition were proposed in 1997, recommending a set of standardized initial investigations. Advances in diagnosis and management and diagnostic testing over the last 3 decades have prompted a needed update to the definition and approaches. While a 3-week fever duration remains part of the criteria, a lower temperature threshold of 38°C and revised minimum testing criteria will assist clinicians and their patients, setting a solid foundation for future research.

The effect of aerobic exercise on immune biomarkers and symptoms severity and progression in patients with COVID-19: A randomized control trial

BACKGROUND

The World Health Organization in March 2020 has announced that COVID-19 is a world pandemic because the number of infected cases increases rapidly. however, there are several available vaccines, their protection is limited to a certain period. Thus, the role of modalities that improve immune functions should be performed to counter COVID-19 viral load and decrease mortality rates.

OBJECTIVE

To investigate the effect of aerobic exercise on immune biomarkers, disease severity, and progression in patients with COVID-19.

DESIGN

A randomized controlled study.

PARTICIPANTS

Thirty patients with COVID-19 participated in this study. Participants' age ranged from 24 to 45 years old. Participants had a mild or moderate COVID-19. Participants were assigned randomly into two groups, exercise and control groups. There were two main dependent variables including blood immune markers and severity of respiratory symptoms.

INTERVENTIONS

All participants performed 2 weeks of moderate-intensity aerobic exercise for 40 min/session, 3 sessions/week. The measurements were performed at baseline, and after 2-weeks.

RESULTS

At baseline measurements, there were non-significant differences between both groups in the Wisconsin scale total score, Leucocytes, Lymphocytes, Interleukin-6, Interleukin-10, Immunoglobulin-A, and TNF-α (P > .05). After the intervention, the Wisconsin scale (patient-oriented illness-specific quality-of-life) total score significantly decreased in the intervention group (P < .05); while, Leucocytes, Lymphocytes, and Immunoglobulin-A significantly increased in the intervention group (P < .05).

CONCLUSION

The current study indicated that 2 weeks of moderate-intensity aerobic exercise decreased the severity and progression of COVID-19 associated disorders and quality of life. Also, a 2-weeks of aerobic exercise positively affected immune function by increasing the amounts of Leucocytes, Lymphocytes, Immunoglobulin A.

Habitual Hyperthermia: An Interpretive Paradigm of the 20th Century? Not Really

Prolonged and unexplained fevers in young adults are uncommon, especially when access to diagnostic tests is simplified. Therefore, the definition of unexplained fever depends on the volume of tests performed. However, low-grade fever has not been a priority in research. Management of low-grade fever [eg, an oral temperature of ≥37.8°C (100°F) and <38.3°C (101°F) at any time of the day] is not codified. The presented case of a 37-year-old nurse with an intermittent fever for three months, with no clear diagnostic evidence and no elevated markers of inflammation, illustrates “habitual hyperthermia” (HH)—retained after ordering tests sequentially in town and at the hospital. HH was made known by Prof. H.A. Reimann (1897–1986) an American virologist, although the diagnostic criteria are fallible. The article reviews the criteria and then discusses how to select diagnostic tests in family practice for prolonged fever in young adults without clinical signs of orientation. Given the polymorphism of febrile illnesses, the principle of parsimony must be transgressed, and in the event of an early suspicion of HH, surveillance is a rule to be further amended.

Feasibility and Predictive Performance of a Triage System for Patients with Cancer During the COVID-19 Pandemic

BACKGROUND

Triage procedures have been implemented to limit hospital access and minimize infection risk among patients with cancer during the coronavirus disease (COVID-19) outbreak. In the absence of prospective evidence, we aimed to evaluate the predictive performance of a triage system in the oncological setting.

MATERIALS AND METHODS

This retrospective cohort study analyzes hospital admissions to the oncology and hematology department of Udine, Italy, during the COVID-19 pandemic (March 30 to April 30, 2020). A total of 3,923 triage procedures were performed, and data of 1,363 individual patients were reviewed.

RESULTS

A self-report triage questionnaire identified 6% of triage-positive procedures, with a sensitivity of 66.7% (95% confidence interval [CI], 43.0%-85.4%), a specificity of 94.3% (95% CI, 93.5%-95.0%), and a positive predictive value of 5.9% (95% CI, 4.3%-8.0%) for the identification of patients who were not admitted to the hospital after medical review. Patients with thoracic cancer (odds ratio [OR], 1.69; 95% CI, 1.13-2.53, p = .01), younger age (OR, 1.52; 95% CI, 1.15-2.01, p < .01), and body temperature at admission ≥37°C (OR, 9.52; 95% CI, 5.44-16.6, p < .0001) had increased risk of positive triage. Direct hospital access was warranted to 93.5% of cases, a further 6% was accepted after medical evaluation, whereas 0.5% was refused at admission.

CONCLUSION

A self-report questionnaire has a low positive predictive value to triage patients with cancer and suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) symptoms. Differential diagnosis with tumor- or treatment-related symptoms is always required to avoid unnecessary treatment delays. Body temperature measurement improves the triage process's overall sensitivity, and widespread SARS-CoV-2 testing should be implemented to identify asymptomatic carriers.

IMPLICATIONS FOR PRACTICE

This is the first study to provide data on the predictive performance of a triage system in the oncological setting during the coronavirus disease outbreak. A questionnaire-based triage has a low positive predictive value to triage patients with cancer and suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) symptoms, and a differential diagnosis with tumor- or treatment-related symptoms is mandatory to avoid unnecessary treatment delays. Consequently, adequate recourses should be reallocated for a triage implementation in the oncological setting. Of note, body temperature measurement improves the overall sensitivity of the triage process, and widespread testing for SARS-CoV-2 infection should be implemented to identify asymptomatic carriers.

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

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.

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.