Fever of unknown origin as a primary presentation of chronic aortic dissection

Fever of unknown origin in aortic dissection

Aortic dissection is the most devastating sequela of thoracic aortic disorder. Patients with acute aortic dissection typically manifest as an acute onset of severe chest pain, but occasionally present with atypical symptoms including fever of unknown origin. A total of 50 patients from 41 articles based on a complete literature retrieval were included in this study. More patients had a fever prior to pain. The time to presentation was 40.7 ± 105.6 days, the time to diagnosis was 52.9 ± 110.1 days, and the time to surgery/intervention was 1.8 ± 5.6 days. The patients' temperature on admission was 38.2 ± 0.6 °C and the maximal temperature recorded was 38.8 ± 0.4 °C. Laboratory findings showed increased white blood cell counts, cardiac enzymes, and inflammatory biomarkers. More pronounced laboratory findings of the infectious type than the inflammatory type aortic dissection could be helpful in the differential diagnosis. Half of patients warrant aortic repair with or without valve replacement, less than half of patients were conservatively managed, and a few were interventionally treated or were being followed up. The mortality rate was 9.5 %. Physicians should always bear in mind aortic dissection when patients present with fever of unknown origin particularly in those without chest pain. Laboratory findings may offer inflammatory evidence for the diagnosis. An early diagnosis as well as subsequent treatment is indispensable for patients' outcomes.

Left pleural effusion and fever of unknown origin--a clue to thoracic arterial pathology

The subset of patients who have both fever of unknown origin (FUO) and a nondiagnostic pleural effusion on presentation has not been previously investigated. A retrospective search of all patients classified as 'classic' FUO one week after admission to a department of general internal medicine identified 71 patients over 15 years. Seven were found to have associated pleural effusion(s) on admission (9.8%). In three patients thoracic large vessel pathology was diagnosed (chronic aortic dissection, giant cell arteritis and Takayasu arteritis). In these patients, the pleural effusion was predominantly left-sided, small to moderate in amount and nondiagnostic on thoracentesis. The effusions resolved spontaneously or with appropriate treatment. Thus, in patients with prolonged fever and systemic symptoms, a 'bland' left-sided pleural effusion may be a diagnostic clue to underlying inflammation of large thoracic arteries. Pleural irritation due to its anatomical proximity to the large arteries on the left side of the thorax may underlie the pathogenesis. Recognition of this sign may lead to a more timely diagnosis of occult thoracic large vessel pathology.