Fever of unknown origin in the HIV-infected patient: new scenario for an old problem

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.

Evolution of the incidence and aetiology of fever of unknown origin (FUO), and survival in HIV-infected patients after HAART (Highly Active Antiretroviral Therapy)

BACKGROUND

Fever of unknown origin (FUO) is common among HIV-infected patients with a CD4+ T-lymphocyte cell count below 200 cells/ml. The use of HAART has transformed the evolution of AIDS and related diseases.

DESIGN AND METHOD

Case-control study, nested on a historical cohort of 3777 HIV-infected patients who were attended at "12 de Octubre" University Hospital in Madrid, Spain, between 1994 and 2000.

RESULTS

276 FUO episodes were recorded, 58 of which occurred in patients receiving HAART. The significant decrease on the accumulated FUO incidence along the study period of 7.3 episodes per 100 HIV-infected patients after 1997 corresponded with the introduction of HAART. FUO was more frequent in patients who did not receive HAART. The aetiological spectrum of FUO was transformed by the introduction of HAART: the incidence of tuberculosis decreased while that of leishmaniasis increased. The four year survival in the non-FUO group increased when compared to that of patients who had had FUO. Similarly, this four year survival increased in patients who received HAART at the time of FUO versus those not receiving it.

CONCLUSIONS

Our results confirm that the incidence of FUO has significantly decreased with the introduction of HAART. HAART has also transformed the aetiological spectrum related to FUO considerably. The most frequent cause of FUO in non-HAART patients on this study was the disseminated infection by Mycobacterium avium intracellulare (MAI), followed by tuberculosis, while leishmaniasis was its most common cause in patients receiving HAART. Survival decreased in patients who developed FUO; however, patients who received HAART at the time of FUO had longer survival than patients who did not.

Management of pyrexia of unknown origin in HIV-positive patients

Recently, we managed the case of a young HIV-positive man with a pyrexial illness and severe constitutional symptoms, the cause of which was elusive for several weeks. Here we review the causes of pyrexia of unknown origin in HIV-positive individuals, review appropriate investigations and discuss possible empirical treatment when this is required.

Fever of unknown origin in HIV/AIDS patients

Fever of unknown or uncertain origin (FUO) constitutes a common clinical challenge in patients infected with HIV. It is usually caused by disseminated opportunistic infection, and the relative frequency of each cause of FUO is influenced by multiple factors including CD4 count, geographic setting, and local prevalences of infectious agents, which may provide clues to the diagnosis. Infections presenting as FUO in the HIV population occur most often in the late stages of the disease and high diagnostic suspicion for mycobacterial disease should be maintained when evaluating these patients, particularly in areas of high prevalence. This article discusses the causes, diagnosis, and treatment of FUO in HIV-infected individuals.

The Utility of a Bone Marrow Biopsy in Diagnosing the Source of Fever of Unknown Origin in Patients With AIDS

A bone marrow (BM) aspiration and biopsy is often believed to be a needed diagnostic procedure in the work-up of patients with fever of unknown origin (FUO), especially in the setting of AIDS. Is it worthwhile to proceed with this invasive diagnostic method? Clinical information obtained on 104 patients in whom AIDS had been previously diagnosed and who had been admitted with a presumptive diagnosis of FUO was retrospectively analyzed. Seventy-two cases met the inclusion criteria. A BM aspiration and biopsy had a low sensitivity as a diagnostic tool even in patients who had abnormal hematologic parameters. BM biopsy was also not helpful in diagnosing non-Hodgkin lymphoma (NHL) cases in this study. Although the incidence of NHL has risen since the emergence of HIV, the predominant types of lymphoma seen in AIDS patients are intermediate/high-grade lymphomas rather than low grade, and consequently, the incidence of BM involvement is low, decreasing the sensitivity of a BM biopsy as a diagnostic tool. These observations were validated in this study. The majority of BM biopsies in this series revealed diagnostic features of infections. This observation can likely be related to the high prevalence of HIV/AIDS patients in this community and opportunistic infections associated with this disease.

Hodgkin's lymphoma as a cause of fever of unknown origin in HIV infection

The risk of Hodgkin's lymphoma is increased in HIV-infected patients. In these patients Hodgkin's lymphoma is an aggressive disease with poor clinical outcome. Complete remission and survival rates are far below that reported in HIV-uninfected population. Since the widespread use of highly active antiretroviral therapy, malignancies are the major cause of mortality in HIV-infected patients. We report a case of a 29-year-old HIV-positive male who presented with fever of unknown origin, pancytopenia, and hemophagocytic syndrome. The diagnosis of Hodgkin's lymphoma with bone marrow involvement was made on bone marrow biopsy, 5 months after the onset of fever. The patient was treated with chemotherapy and achieved a complete remission. Relapse occurred 28 months later and he died 31 months after initial diagnosis. Prolonged fever is frequently observed in HIV-infected patients and could represent a diagnostic challenge. Infectious diseases are the most common causes, however lymphomas are the third most common cause of fever of unknown origin in HIV disease. This case illustrates the difficulties in accurately diagnosing Hodgkin's lymphoma in patients presenting with prolonged, unexplained fever, and emphasizes the use of bone marrow biopsy to confirm Hodgkin's lymphoma, particularly if cytopenia and hemophagocytic syndrome are present.

Patients with HIV infection and fever: a diagnostic approach

Fever is a common sign among patients with HIV infection and frequently leads to a medical consultation. It is generally caused by infections. The type of infection depends on the stage of the disease. Opportunistic infections occur only in the presence of severe immunodeficiency. A systematic approach will identify most causes of fever. Since the incidence of opportunistic infections has dramatically decreased with the use of highly active antiretroviral treatments, other causes of fever including immune restoration disease, neoplasm and drug-fever should be considered.

Fever of unknown origin in the setting of HIV infection: guidelines for a rational approach

Fever of unknown origin constitutes a common problem in HIV-infected patients that, paradoxically, has received little attention in the literature. A review on this topic collecting data from different series showed that mycobacterial infections, particularly tuberculosis, were responsible for the fever in more than half of the patients. However, the relative frequencies of the different etiologies may vary substantially depending on the local prevalences of certain infections. With the notable exception of tuberculosis, which may develop at any stage of HIV infection, fever of unknown origin usually presents in patients with advanced disease when the CD4 cell count is below 100/microliter. In this overview we stress, from a practical point of view, some points to be considered in the evaluation of the HIV-infected patient who presents with fever of unknown origin, as well as the usefulness and yield of several diagnostic procedures.