Neoplastic fever

Recurrent fever leading to the diagnosis of an angiosarcoma of the adrenal gland: a case report

BACKGROUND

Angiosarcoma of the adrenal gland is a very rare malignant vascular neoplasm. The clinical symptoms are atypical or completely absent. Angiosarcomas of the adrenal gland are therefore often discovered incidentally, and the diagnosis is made histologically after resection.

CASE PRESENTATION

A 46-year-old white Spanish male who was a previous smoker and nondrinker and was slightly overweight (92 kg, 176 cm, body mass index 29.7 kg/m2) with no relevant medical history presented to the internal medicine emergency department of our hospital with an unclear 12 cm tumor of the right adrenal gland. Prior to the computed tomography scan, he had had persistent evening fevers for 4 months and unintentional weight loss of 5 kg. The laboratory results showed anemia and an elevated C-reactive protein, but no hormone production. We performed an open adrenalectomy of the right adrenal gland. Finally, the histologic findings revealed an angiosarcoma of the adrenal gland.

CONCLUSION

Even though angiosarcomas of the adrenal gland are rare, the differential diagnosis of an angiosarcoma should be considered if a malignant tumor of the adrenal gland is suspected. Treatment decisions should be made on an interdisciplinary basis and preferably in a specialized center. Owing to the rarity of angiosarcomas of the adrenal gland, it is necessary to continue to share clinical experience to gain a better understanding of this particular tumor entity.

Exploring the therapeutic potential of "Xiaochaihu Decoction": a systematic review and meta-analysis on the clinical effectiveness and safety in managing cancer-related fever

Objective: This study aimed to conduct the first meta-analysis to comprehensively evaluate the clinical effectiveness and safety of Xiaochaihu Decoction in treating Cancer-related Fever (CRF). Methods: Eight databases were systematically searched in September 2023. The risk of bias (ROB) 2.0 tool recommended by Cochrane Handbook was applied to evaluate the ROB of the included randomized controlled trials (RCTs). Additionally, the quality of evidence was assessed using the Grading of recommendations assessment, development and evaluation (GRADE) tool. Results: We included 18 RCTs involving 1,424 patients. Compared to Western medicine or Xinhuang Tablets, Xiaochaihu Decoction significantly improved clinical effectiveness in CRF patients (risk ratio [RR] = 1.24, 95% confidence interval [CI]: 1.17, 1.32) and expedited the normalization of body temperature (mean difference [MD] = -5.29, 95%CI: -5.59, -4.99). It also demonstrated a reduction in tumor necrosis factor-α (TNF-α) levels (MD = -0.63, 95%CI: -0.84, -0.41) and an increase in IL-2 levels (MD = 1.42, 95%CI: -1.09, 1.74). Analysis of Karnofsky Performance Status (KPS) scores showed that the use of Xiaochaihu Decoction improved the quality of life in CRF patients (RR = 1.57, 95%CI: 1.11, 2.22) and reduced the incidence of adverse events. However, it is important to note that the majority of included studies showed "some concerns" in risk of bias based on ROB 2.0, and the evidence quality assessed by GRADE method was rated as "low". Conclusion: While this study suggests the clinical effectiveness and safety of Xiaochaihu Decoction in treating patients with CRF, confirming these findings will necessitate additional high-quality, large-scale RCTs in future research. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023484068.

A case-control study evaluating the unnecessary use of intravenous broad-spectrum antibiotics in presumed sepsis and septic-shock patients in the emergency department

Objectives

Recognition of sepsis frequently occurs in emergency departments. To evaluate the appropriateness of empiric antibiotic use in the setting of suspected sepsis in emergency department, the percentages of bacterial infection and antibiotic-related adverse drug effects were quantified in an emergency department at an academic medical center.

Methods

We retrospectively reviewed electronic medical records of adults who presented to the emergency department between January 2018 and June 2018 with suspected sepsis (defined as having ≥2 systemic inflammatory response syndrome [SIRS] criteria) and received ≥1 dose of intravenous broad-spectrum antibiotic.

Results

In total, 218 patients were included in the final analysis. Moreover, 19.3% of these patients had confirmed bacterial infections; 44.5% had suspected bacterial infections; and 35.9% did not have bacterial infection. Elevated SIRS score (ie, ≥2) and Quick Sequential Organ Failure Assessment (qSOFA) score (ie, ≥2) were not associated with the presence of bacterial infections. We identified 90-day Clostridioides difficile infections in 7 patients and drug-resistant organism infections in 6 patients, regardless of the presence of bacterial infections.

Conclusions

A high number of patients received intravenous broad-spectrum antibiotics in the emergency department without confirmed or suspected bacterial infections that were supported by microbiologic cultures, radiographic imaging, or other symptoms of infections. Most patients who were initially admitted to the emergency department with suspected sepsis were discharged home after receiving 1 dose of intravenous antibiotic. Patients who were initially screened using SIRS score and who received broad-spectrum antibiotics in the emergency department were without confirmed or suspected bacterial infection.

Tumor-related cytokine release syndrome in a treatment-naïve patient with lung adenocarcinoma: A case report

BACKGROUND

Cytokine release syndrome (CRS) is defined as systemic inflammation that usually occurs following chimeric antigen receptor T-cell therapy administration; however, it has not been reported in patients with untreated non-small cell lung cancer to date.

CASE SUMMARY

A 44-year-old nonsmoking woman presented to the hospital due to fever, palpitation, nausea, and cough for 1 mo and was diagnosed with stage cT3N3M0 (IIIc) adenocarcinoma of the lung. Auxiliary examinations revealed elevated cytokine [tumor necrosis factor-α, interleukin (IL)-1β, and IL-6] and inflammatory factor levels, which decreased after treatment with corticosteroids and immunoglobulin and when tumor growth was controlled following chemotherapy, radiotherapy, and antiangiogenesis therapy. However, tumor recurrence was observed. After administration of nivolumab as third-line treatment, the patient’s condition was transiently controlled; however, CRS-like symptoms suddenly emerged, which led to a resurgence of cytokines and inflammatory factors and rapid death.

CONCLUSION

CRS can develop in treatment-naïve lung cancer patients. Patients with tumor-related CRS may be at risk of CRS recurrence, aggravation, and onset of immune checkpoint inhibitor-related adverse events.

Multinodular Malignant Cutaneous Mast Cell Tumor in a Horse With Generalized Pruritus and Reactive Fibrosis: A Case Report

Mast cell tumor (MCT) has long been considered as an uncommon neoplasm in horses. Cytological and behavioral evidence of its malignancy is usually lacking, and only a few reports have described MCT displaying malignant behavior. An 18-year-old Friesian stallion presented with a one-year history of intermittent and progressive skin lesions on the left forelimb associated with intense, generalized pruritus and apathy temporarily responsive to glucocorticoids and antibiotics. The horse was alert and responsive with poor body condition and marked generalized pruritus. The left forelimb was markedly enlarged and surrounded by numerous firm 2- to 20-cm masses that were ulcerated and focally necrotic. A 7-cm round firm mass was observed on the left dorsal neck. Dermatological examination revealed generalized moth-eaten alopecia and scaling with erosions and ulcers secondary to pruritus. A direct skin smear from the affected leg showed severe eosinophilic inflammation and neutrophilic inflammation with pleomorphic bacteria. Histopathology of the skin and biopsies of the underlying tissues revealed an abundant population of atypical mast cells consistent with a malignant MCT. The horse was euthanized and necropsy revealed a marked fibrous reaction on longitudinal sections of the affected limb, and the tumor could be detected on only a few histological slides. Diagnosis of equine MCT can be challenging because of the massive accompanying fibrous reaction. Mast cell tumor should be suspected in the presence of eosinophilic infiltration of the affected tissue and in cases of generalized pruritus not attributable to other causes.

Neoplastic fever in patients with bone and soft tissue sarcoma

The development of fever is a common complication in the clinical course of cancer. If all other potential causes of fever are excluded, the possibility of neoplastic fever should be considered. The aim of the present study was to determine the incidence of neoplastic fever in patients with bone and soft tissue sarcomas. Between January 2009 and December 2014, 195 patients with bone and soft tissue sarcoma (111 men and 84 women; mean age, 55 years) were admitted to the Department of Orthopaedic Surgery of Mie University Graduate School of Medicine (Tsu, Japan). Episodes of fever were observed in 58 patients (30%), of whom 11 (5.5%) had neoplastic fever (mean maximum temperature, 38.9°C). The causes of neoplastic fever were as follows: Primary tumor (n=3), local recurrence (n=1), metastasis (n=5), and local recurrence with metastasis (n=2). Of the 11 patients, 9 were treated with naproxen and 8 exhibited a complete response, with their temperature normalizing to <37.3°C within 24 h. The 2 patients who were not treated with naproxen underwent surgical tumor resection, which resulted in prompt and complete lysis of the fever. In conclusion, neoplastic fever occurred in 5.5% of the 195 patients with bone and soft tissue sarcomas investigated herein. Naproxen may be effective for treating neoplastic fever in patients with bone and soft tissue sarcoma; however, radical tumor treatment may have to be considered to achieve permanent lysis of the fever.

Pancreatic carcinoma masked as fever of unknown origin: A case report and comprehensive review of literature

BACKGROUND

Pancreatic carcinoma is a highly lethal malignancy. Common presenting features of pancreatic cancer include anorexia, asthenia, weight loss, pain, and obstructive jaundice. Nevertheless, fever as a symptom, or even primary manifestation of pancreatic cancer is rather rare.

METHODS

Here, we report a 63-year-old male patient presenting with daily fevers, night sweats, and fatigue of 2-month duration. Laboratory findings showed elevated white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and serum C-reactive protein (CRP). A computed tomography scan demonstrated a tumor between the duodenum and pancreatic head. Chest radiograph was normal.

RESULTS

The patient underwent an uneventful tumor resection. Histological examination of a surgical specimen demonstrated an undifferentiated adenocarcinoma originated from pancreatic head. The tumor was compatible with TNM stage IIA (T3N0M0). Complete resolution of the fever was achieved on post-operative day 4 and no recurrence of the tumor or neoplastic fever happen during the 39-month follow-up.

CONCLUSION

Pancreatic adenocarcinoma could manifest as neoplastic fever at the time of diagnosis. If the tumor is resectable, surgical resection is a safe and curative form of therapy not only for the fever but also for the original carcinoma.

Malignant causes of fever of unknown origin

The presence of fever in malignancy usually indicates infection, though transfusion, thrombosis and drugs are also culprits. However, particularly in some tumour types, fever can also be a paraneoplastic syndrome, caused by the malignancy itself. This can be a difficult diagnosis to establish and presents a therapeutic challenge to the physician when the underlying malignancy is not easily treated.

Psychogenic fever in a patient with small cell lung cancer: a case report

Background

Fever is common in malignant tumors. We report an exceptional case of psychogenic fever in a patient with small cell lung cancer. This is the first case report of psychogenic fever in a patient with small cell lung cancer.

Case presentation

A 61-year-old Chinese man diagnosed with small cell carcinoma on June 30, 2012, came to our department with a complaint of fever lasting more than 1 month. He had undergone chemoradiotherapy for lung cancer 6 months previously. After admission, his body temperature fluctuated in the range of 37 °C to 39 °C. Somatic symptoms associated with anxiety were obvious. A 24-item Hamilton Anxiety Scale was used to assess the patient’s condition. A score of 32 confirmed a diagnosis of severe anxiety. After a week of antianxiety treatment, the patient’s temperature returned to normal.

Conclusion

Psychogenic fever is common in cancer patients and deserves more attention. Patients with psychogenic fever must be distinguished from patients with infectious fever (including neutropenic fever), and tumor fever. Additionally, antianxiety or antidepression treatment should be provided. A concern is that continual anxiety may adversely affect anticancer therapy.

Unexplained recurrent fever: when is autoinflammation the explanation?

Recurrent fever can be the sole or leading manifestation of a variety of diseases including malignancies, autoimmune diseases and infections. Because the differential diagnoses are manifold, no formal guidelines for the approach of patients with recurrent fever exists. The newly recognized group of autoinflammatory diseases are often accompanied by repetitive fever attacks. As these episodes are frequently associated by a variety of divergent presentations, the differentiation of other causes for febrile illnesses can be difficult. In this article, we first review disease entities, which frequently present with the symptom of recurrent fever. In a next step, we summarize their characteristic pattern of disease presentation. Finally, we analyse key features of autoinflammatory diseases, which are helpful to distinguish this group of diseases from the other causes of recurrent fever. Recognizing these symptom patterns can provide the crucial clues and, thus, lead to the initiation of targeted specific diagnostic tests and therapies.

Using vital sign flow sheets can help to identify neoplastic fever and other possible causes in oncology patients: a retrospective observational study

CONTEXT

It is important to determine the etiology of fever in cancer patients. Such patients often undergo extensive laboratory and radiographic investigations and prolonged anti-infective therapy that are time- and resource- consuming, risk drug toxicity, and postpone systemic chemotherapy.

OBJECTIVES

To investigate neoplastic fever (NF) patterns from vital sign flow sheets.

METHODS

Between September 1997 and February 2009, data on 150 consecutive hospitalized patients with advanced or metastatic solid tumors documented to have NF were retrospectively collected. Sixty patients with sepsis were used as a comparison group.

RESULTS

All patients with NF demonstrated intermittent fever patterns. Peak body temperature was 39.0+/-0.6 degrees C (38.0-40.8 degrees C). Baseline pulse rates in 139 (93%) patients showed no increase except during febrile periods. The remaining 11 (7%) patients had transiently elevated baseline pulse rates at the time of cessation of postchemotherapy dexamethasone. Once-daily fever spike patterns occurred in 108 (72%) patients. Fever spikes were most commonly found at 9 am (42%) and 5 pm (37%). Twice-daily fever spike patterns were noted in the 42 (28%) remaining patients. In the comparison group, baseline pulse rate elevated in all patients during febrile periods and 20 (33%) showed intermittent fever patterns.

CONCLUSION

We conclude that the NF pattern is characterized by intermittent fever without an obvious increase in baseline pulse rate except during febrile periods. Knowing NF patterns from vital sign flow sheets can help identify NF and other possible causes of fever in oncology patients.

Non-small cell lung cancer presenting with neoplastic fever at diagnosis and relapse

Fever occurs frequently in cancer patients, and neoplastic fever is a well-described paraneoplastic phenomenon in patients with lymphoma, acute leukemias, and renal cell carcinoma. It is also more commonly encountered in metastatic disease. Treatment options include disease-specific therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids. Lung cancer is one of the most common cancers, yet fever as a manifestation of this malignancy has not been emphasized. In this report, we describe an unusual case of non-metastatic non-small cell lung cancer (NSCLC) presenting with neoplastic fever at both diagnosis and relapse, responding on each occasion to disease-specific treatment, and provide a review of the management of neoplastic fever.

[Fever of unknown origin in malignancies]

Fever is a common symptom in patients with malignancies. On the one hand it may be an (initial) symptom of cancer, on the other hand it may occur as a side effect of chemotherapy. Often a precise cause of fever can not be established and in these cases febrile temperatures >38.3 degrees C without proof of infection or relapse/progress of tumor is defined as fever of unknown origin. Especially hematologic neoplasias are accompanied by fever. Here, neoplastic fever must be distinguished from fever following immunosuppressive chemotherapy. In the latter severe infections due to neutropenia induced by cytoreductive chemotherapy is often identified as the cause of fever. These patients display a high morbidity and mortality, especially if an empiric anti-infectious treatment is not administered in time. A meticulous diagnostic work-up is therefore necessary, and until proven otherwise, an infectious cause must be considered and empiric antibiotic treatment initiated.

Recombinant interferon alpha-2b and coenzyme Q10 as a postsurgical adjuvant therapy for melanoma: a 3-year trial with recombinant interferon-alpha and 5-year follow-up

Early surgical intervention remains the most successful therapy for melanoma. Despite better outcomes observed in soft tissue and lymph node metastases, the results of pharmacological therapies are still disappointing. Currently, there is no standard adjuvant therapy for melanoma. Low concentrations of coenzyme Q10 have been demonstrated in melanoma cell lines and in sera of melanoma patients. These data and the results of clinical trials of patients with other advanced cancers prompted this study of the long-term administration of an optimized dose of recombinant interferon alpha-2b and coenzyme Q10 to patients with stage I and II melanoma. A 3-year trial envisaging uninterrupted treatment with low-dose recombinant interferon alpha-2b (9 000 000 000 IU weekly) administered twice daily and coenzyme Q10 (400 mg/day) was conducted in patients with stage I and II melanoma (American Joint Committee on Cancer criteria 2002) and surgically removed lesions. Treatment efficacy was evaluated as incidence of recurrences at 5 years. All patients completed the treatment and the follow-up. Significantly different rates of disease progression were observed in the interferon+coenzyme Q10 and the interferon group for both stages. No patient withdrew from the study owing to side effects. Long-term administration of an optimized dose of recombinant interferon alpha-2b in combination with coenzyme Q10 seemed to induce significantly decreased rates of recurrence and had negligible adverse effects. A survival study could not be undertaken owing to the small patient sample and the short duration of follow-up.

Prognostic validation of the international classification of immunoglobulin M gammopathies: a survival advantage for patients with immunoglobulin M monoclonal gammopathy of undetermined significance?

PURPOSE

To verify the reliability of the new criteria for the diagnosis of IgM gammopathies recently proposed by an international panel of experts (Athens, 2002).

EXPERIMENTAL DESIGN

A retrospective series of 698 patients with IgM gammopathy was reviewed paying attention to symptoms, serum IgM concentration, bone marrow infiltration, blood cell count and clinical course. Four clinical entities can be identified: IgM monoclonal gammopathy of undetermined significance (IgM-MGUS), asymptomatic and symptomatic Wandenstrom's macroglobulinemia (A-WM and S-WM, respectively), and IgM-related disorders, although this last was excluded from the study because of the scarcity of patients due to probable selection biases. The observed mortality was studied related to that expected in the general population of comparable age and sex and over an equivalent period of follow-up (standardized mortality ratio, SMR).

RESULTS

IgM-MGUS, A-WM, and S-WM shared many clinical aspects but, with respect to the general population, patients with IgM-MGUS had a slight but definite survival advantage, those with A-WM had a mortality rate equivalent to that of the general population, whereas the SMR of patients with S-WM was 5.4. Within A-WM and S-WM the SMR values did not vary significantly in relation to marrow lymphocyte counts or serum IgM concentrations.

CONCLUSIONS

Our findings represent a prognostic validation of the applied diagnostic criteria for three of the four identifiable clinical entities and highlight the importance of symptoms over serum IgM concentration and marrow infiltration.

Neoplastic fever: a neglected paraneoplastic syndrome

Neoplastic fever, a paraneoplastic syndrome caused by cancer itself, represents a diagnostic challenge for the clinician and is an important issue in supportive oncology. Timely recognition of this febrile condition by differentiating it from other cancer-associated fevers, such as infection and drug reaction, is essential for effective patient management. Although the pathophysiology of neoplastic fever is not well understood, it is suspected to be cytokine mediated. In clinical practice, when a patient with cancer presents with unexplained fever, extensive diagnostic studies are needed to differentiate neoplastic fever from nonneoplastic fever. Only after excluding identifiable etiologies of fever can the diagnosis of neoplastic fever be suspected. According to our experience, the naproxen test is a safe and useful test in differentiating neoplastic fever from infectious fever in patients with cancer. In addition, naproxen and other nonsteroidal anti-inflammatory drugs have been effective in the management of neoplastic fever and offer a significant palliative benefit for the patient.

Fever After Zoledronic Acid Administration Is Due to Increase in TNF-αand IL-6

The most common adverse event typically associated with bisphosphonate therapy is transient fever. The aim of this study was to define the role of the main cytokines of the acute-phase reaction interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) involved in the pathogenesis of zoledronic acid-induced fever. Eighteen consecutive cancer patients with bone metastases were treated, for the first time, with a single dose of 4 mg zoledronic acid infusion. They were prospectively evaluated for circulating TNF-alpha, interferon-gamma (IFN-gamma), and IL-6 levels at different times, just before and 1, 2, 7, and 21 days after diphosphonate infusion. Clinical and standard laboratory parameters were recorded at the same time points. TNF-alpha circulating levels increased significantly 1 and 2 days after zoledronic acid infusion (respectively, p = 0.002 and p < 0.001) and then decreased to levels similar to the basal levels. IL-6 levels increased significantly 1 day after the infusion (p = 0.007), returning to values similar to the median basal values 2 days after zoledronic acid administration. Moreover, in patients who experienced fever, the TNF-alpha and IL-6 increases were higher than in patients without fever. No statistically significant differences in IFN-gamma were identified at different time points in patients with and without fever. Our results show that zoledronic acid induces transient TNF-alpha and IL-6 increases and that these increases are higher in patients who have developed fever, suggesting that these cytokines could be responsible for fever pathogenesis. The sharp reduction in serum calcium levels observed in patients with fever may be related to zoledronic acid pharmacokinetic modifications.

Bacterial infections in terminally ill hospice patients

Terminally ill patients are very susceptible to infections, which are the result of disease-related processes and/or therapy-induced mechanisms. These patients are already subject to multiple severe symptoms and associated comorbid conditions, with much resultant distress. Infection increases this symptom burden and further reduces quality of life. We have retrospectively investigated the prevalence of infection and clinical course in 102 consecutive patients who died after admission to a tertiary palliative care unit and assessed the site-specific frequency of infection, pathogenic organisms involved, and the pattern of antibiotic agents used. The prevalence of symptoms and comorbid conditions on admission and during the progress phase of care were noted. Median overall survival of the total cohort was 12 days. The median survival of patients with infections was 22 days. Thirty-seven patients (36.3%) were diagnosed with 42 separate infections. The sites of infections were the urinary tract (42.5%), the respiratory tract (22.9%), blood (12.5%), skin and subcutaneous tissues (12.5%), and the eyes (10.0%). There were 20 separate positive cultures isolated from specimens obtained from 13 individual patients. Three isolates were obtained from 1 patient, 2 isolates obtained from 5 patients, and 1 isolate was obtained from each of the 7 remaining patients. Escherichia coli was the most common pathogen isolated. Eleven patients with infections (31.4%) were diagnosed on admission, and antibiotic treatment was commenced within 48 hours of admission in 21 patients (60%). Overall antibiotic response and symptom control of infections was observed to be a minimum of 40%. Psychological distress was common in this group of patients (P = 0.001) as were disabling symptoms on admission, such as pain, immobility, and weakness. Symptoms indicating poor survival, such as severe pain and dyspnea, were not significantly associated with infection. Decreased patient survival in this cohort was not significantly associated with the presence of bacterial infection (P = 0.07), irrespective of whether or not a positive culture isolate was obtained. We conclude that appropriate management of infection resulted in enhanced palliative symptom control.

A retrospective review of the frequency of infections and patterns of antibiotic utilization on a palliative care unit

Various disease-related and therapy-induced factors make cancer patients susceptible to infections. The epidemiology and management of infections in neutropenic cancer patients and patients with primary hematological malignancies has been widely reported, but very few studies have characterized infections and their management in palliative care patients. We conducted a retrospective review of 100 consecutive admissions to an acute palliative care unit with the objective of assessing overall and site-specific frequencies of infections, the pathogens involved and their antibiotics sensitivities, and the pattern of antibiotic utilization. The mean age was 64 +/- 11.5 years, the mean length of stay was 29.8 +/- 28.2 days, and 70% of patients died on the unit. Only one case of neutropenia was identified. Fifty-five of the 100 patients were diagnosed with a total of 74 separate infections. The most frequent sites of infections were the urinary tract (39.2%), the respiratory tract (36.5%), skin and subcutaneous tissues (12.2%), and blood (5.4%). Fifty-four culture-positive infections were identified. Overall, the most common organisms were Escherichia coli (22.9%), Staphylococcus aureus (20%), and Enterococcus (11.4%). Fifty-three of the 74 (71.6%) infections were treated with antibiotics. The decision-making process regarding treatment versus nontreatment of an infection can be complex in terminally ill patients and needs to be individualized. Symptom control is the primary objective in the majority of cases. The appropriate management of infections, with specific attention to measures that would improve patients' quality of life, should be a research priority in patients with advanced cancer.