1
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Usami J. Giant-cell arteritis with toothache. J Gen Fam Med 2024; 25:162-163. [PMID: 38707696 PMCID: PMC11065150 DOI: 10.1002/jgf2.684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/17/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Jun Usami
- Primary Care Center/General MedicineAichi Medical University HospitalNagakuteJapan
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2
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Goldberg CG, López Alarcón AF, Salocha ML, Otero MF, Jiménez M, Medina A, de Sousa Serro R. Dengue fever in a 32-day-old patient. A rare case report. ARCH ARGENT PEDIATR 2024; 122:e202310144. [PMID: 37871006 DOI: 10.5546/aap.2023-10144.eng] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Dengue fever is a viral disease transmitted by the Aedes aegypti mosquitoes. In Argentina, dengue fever is an epidemic disease; most cases are reported during the hot months. Until epidemiological week (EW) 20/2023, 106 672 cases were reported across 18 of the 24 provinces of Argentina. Children younger than 2 years are among the main groups at risk. Recognizing signs and symptoms and identifying risk factors is fundamental for the management of cases at a higher risk of severity. Here we describe the case of a 32-day-old female patient who was hospitalized due to febrile syndrome without a source, who had a differential diagnosis of viral meningitis and sepsis and progressed to leukocytosis, thrombocytopenia, hypoalbuminemia in association with rash and edema. The diagnosis of dengue fever was established based on clinical, epidemiological, and positive IgM data.
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Affiliation(s)
- Carolina G Goldberg
- Hospital General de Agudos Dr. Cosme Argerich, City of Buenos Aires, Argentina
| | | | - María L Salocha
- Hospital General de Agudos Dr. Cosme Argerich, City of Buenos Aires, Argentina
| | - María F Otero
- Hospital General de Agudos Dr. Cosme Argerich, City of Buenos Aires, Argentina
| | - Mairena Jiménez
- Hospital General de Agudos Dr. Cosme Argerich, City of Buenos Aires, Argentina
| | - Andrea Medina
- Hospital General de Agudos Dr. Cosme Argerich, City of Buenos Aires, Argentina
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3
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Wilding HE, Hays A. Secondary syphilis presenting as fever of unknown origin. Clin Case Rep 2024; 12:e8583. [PMID: 38464585 PMCID: PMC10923698 DOI: 10.1002/ccr3.8583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/12/2024] Open
Abstract
A thirty-eight year-old male presented with a seven-week history of persistent fever accompanied by recurrent night sweats, chills, arthralgias, headache, and chest tightness.Initial laboratory testing showed non-specific elevation of inflammatory markers, but was otherwise unremarkable.A palmar rash developed one week later, prompting testing for syphilis. Fluorescent treponemal antibody absorption (FTA-ABS) and rapid plasma reagin (RPR) tests were both positive.Penicillin G was administered and the patient recovered uneventfully.Our case emphasizes the need for increased syphilis screening to ensure proper diagnosis and prompt treatment.
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Affiliation(s)
| | - Amy Hays
- Department of Family and Community Medicine Penn State College of Medicine Hershey Pennsylvania USA
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4
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Oliveira Miranda D, Magalhães JN, Carvalho Sá D, Neves P, Gonçalves F. Pulmonary and Urologic Sarcoidosis as a Cause of Intermittent Fever of Unknown Origin. Cureus 2024; 16:e55709. [PMID: 38586756 PMCID: PMC10998438 DOI: 10.7759/cureus.55709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Diagnosing fever of unknown origin (FUO) presents a substantial challenge due to its potential association with various diseases affecting different organs. In 1961, Petersdorf and Beeson initially defined FUO as a condition characterized by a temperature exceeding 38.3 °C on at least three occasions over a minimum three-week period. Despite a week of inpatient investigation, a definitive diagnosis remains unclear. Sarcoidosis, a granulomatous disease impacting multiple systems, is among the causes of FUO. While the lungs are commonly affected, any organ can be involved, leading to diverse manifestations and clinical courses. Diagnosis relies on clinicopathologic findings and the exclusion of alternative causes of granulomatous disease. The hallmark of sarcoidosis is the development of granulomas in affected organs. Here, we present the case of a 61-year-old man with a history of recurrent spontaneous periurethral abscesses who underwent multiple urological interventions. He developed FUO during hospitalization following treatment for the infectious condition.
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Affiliation(s)
| | - José N Magalhães
- Department of Medicine, Unidade Local de Saúde de Santo António, Porto, PRT
| | - Diogo Carvalho Sá
- Department of Pathology, Unidade Local de Saúde de Santo António, Porto, PRT
| | - Patricia Neves
- Department of Medicine, Unidade Local de Saúde de Santo António, Porto, PRT
| | - Fabienne Gonçalves
- Department of Semiology, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, PRT
- Department of Medicine, Unidade Local de Saúde de Santo António, Porto, PRT
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5
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Yamamoto K, Ishii T, Takasaki T, Doi E, Kashima J, Shiota S, Miyazaki E. An Unusual Case of Sarcoidosis with a Prolonged Fever and Progressive Arthropathy. Intern Med 2024; 63:601-605. [PMID: 37380457 PMCID: PMC10937121 DOI: 10.2169/internalmedicine.1890-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/23/2023] [Indexed: 06/30/2023] Open
Abstract
A 70-year-old man had developed a high fever and arthralgia in his right elbow 6 months prior. Loxoprofen improved the symptoms temporarily, but arthropathy developed in other joints. Long-term recurrent arthropathy and the fever caused activity reduction and progressive debilitation. We performed fluorine-18 fluorodeoxyglucose-positron emission tomography and detected a positive accumulation in multiple joints and lymph nodes. A lymph node biopsy revealed epithelioid cell granulomas, which, along with elevated angiotensin-converting enzyme levels, led to the diagnosis of sarcoid arthropathy. After prednisolone administration, the fever and arthralgia resolved, and his activities of daily living improved. Clinicians should be aware of this type of sarcoid arthropathy.
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Affiliation(s)
- Kyoko Yamamoto
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Medical Education, Oita University Faculty of Medicine, Japan
| | - Toshihiro Ishii
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Tomomi Takasaki
- Department of General Medicine, Oita University Faculty of Medicine, Japan
| | - Eri Doi
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Jin Kashima
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Seiji Shiota
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
| | - Eishi Miyazaki
- Department of General Medicine, Oita University Faculty of Medicine, Japan
- Center for Community Medicine, Oita University Faculty of Medicine, Japan
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6
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Noiperm P, Saelue P. Predictive model for diagnostic yield of bone marrow examination in patients with HIV infection having fever of unknown origin. AIDS 2024; 38:185-192. [PMID: 37792352 PMCID: PMC10734777 DOI: 10.1097/qad.0000000000003744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Bone marrow examination is valuable for identifying the cause of fever of unknown origin (FUO) in HIV-infected patients. Based on the outcomes of bone marrow examination of patients with FUO, we aimed to develop a predictive model for identifying the factors that can increase the diagnostic yield of bone marrow examination. DESIGN For this retrospective cohort study, we enrolled HIV-infected patients, aged more than 15 years and diagnosed with FUO, at Songklanakarind Hospital in Southern Thailand, between January 2009 and December 2019. METHODS Evaluations were based on bone marrow aspiration, biopsy, and culture; any missing data were imputed with regression imputation. RESULTS Among the final 108 included patients, 44 (40.74%) showed positive bone marrow results. The diagnoses mainly comprised histoplasmosis, penicilliosis, and tuberculosis. Bone marrow examination led to treatment modifications in approximately 33% patients. Platelet count less than 150 000 cells/μl, alkaline phosphatase (ALP) level at least 200 U/l, and no previous antibiotic treatment were significantly associated with higher diagnostic yields. The HIV bone marrow (HIVBM) model, comprising of spleen size, hematocrit (Hct), platelet count before bone marrow examination, ALP level at admission, and previous antibiotic treatment, was generated as a nomogram to predict the diagnostic yield of bone marrow examination in HIV-infected patients with FUO. CONCLUSION The results of this study indicate that the HIVBM model can be used to predict the diagnostic yield of bone marrow examination, and therefore assist in clinical decision-making regarding bone marrow procedures, to be performed for identifying the origin of fever in HIV-infected patients.
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Affiliation(s)
- Panarat Noiperm
- Hematology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
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7
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Wright WF, Betrains A, Stelmash L, Mulders-Manders CM, Rovers CP, Vanderschueren S, Auwaerter PG. Development of a Consensus-Based List of Potential Quality Indicators for Fever and Inflammation of Unknown Origin. Open Forum Infect Dis 2024; 11:ofad671. [PMID: 38333881 PMCID: PMC10853001 DOI: 10.1093/ofid/ofad671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 02/10/2024] Open
Abstract
With a growing emphasis on value-based reimbursement, developing quality indicators for infectious diseases has gained attention. Quality indicators for fever of unknown origin and inflammation of unknown origin are lacking. An assembled group of international experts developed 12 quality measures for these conditions, which could be validated with additional study.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Albrecht Betrains
- General Internal Medicine Department, University Hospitals Leuven, Leuven, Belgium
| | - Lauren Stelmash
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Catharina M Mulders-Manders
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Steven Vanderschueren
- General Internal Medicine Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium
| | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Sola D, Smirne C, Bruggi F, Bottino Sbaratta C, Tamen Njata AC, Valente G, Pavanelli MC, Vitetta R, Bellan M, De Paoli L, Pirisi M. Unveiling the Mystery of Adult-Onset Still's Disease: A Compelling Case Report. Life (Basel) 2024; 14:195. [PMID: 38398704 PMCID: PMC10890189 DOI: 10.3390/life14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder. Diagnosis can take a long time, especially in the presence of confounding factors, and it is, to some extent, a process of exclusion. AOSD has life-threating complications ranging from asymptomatic to severe, such as macrophage activation syndrome (MAS), which is also referred to as hemophagocytic lymphohistocytosis (HLH). This condition is correlated with cytokine storm production and monocyte/macrophage overactivation and typically occurs with rash, pyrexia, pancytopenia, hepatosplenomegaly and systemic involvement. Exitus occurs in approximately 10% of cases. For the treatment of MAS-HLH, the Histiocyte Society currently suggests high-dose corticosteroids, with the possible addition of cyclosporine A, anti-interleukin (IL)-1, or IL-6 biological drugs; the inclusion of etoposide is recommended for the most severe conditions. In all cases, a multidisciplinary collaboration involving the resources and expertise of several specialists (e.g., rheumatologist, infectiologist, critical care medicine specialist) is advised. Herein, we provide a detailed description of the clinical case of a previously healthy young woman in which MAS developed as a dramatic onset manifestation of AOSD and whose diagnosis posed a real clinical challenge; the condition was finally resolved by applying the HLH-94 protocol (i.e., etoposide in combination with dexamethasone).
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Affiliation(s)
- Daniele Sola
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Carlo Smirne
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Francesco Bruggi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Chiara Bottino Sbaratta
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Aubin Cardin Tamen Njata
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Guido Valente
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Pathology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | | | - Rosetta Vitetta
- Rheumatology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | | | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
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9
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Iheagwara C, Ajayi F, Otaluka ON, Cantu Lopez C, Slim J, Shaaban HS, Muhanna A, Tewoldemedhin B, Szabela M, Boghossian J. A Rare Case of Acute Myeloid Leukemia Initially Presenting With Fever of Unknown Origin and Rapidly Progressing Pericardial Effusion. Cureus 2024; 16:e51505. [PMID: 38304636 PMCID: PMC10831924 DOI: 10.7759/cureus.51505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
This case report highlights a patient who had persistent fevers for weeks and rapidly progressing pericardial effusion following a positive test for coronavirus disease 2019 (COVID-19) two weeks before presentation to the hospital. The initial thought was that her fever was of infectious etiology, but relevant investigations led to the diagnosis of acute myeloid leukemia (AML). AML, which is characterized by clonal expansion of immature "blast cells" in the peripheral blood and bone marrow resulting in ineffective erythropoiesis and bone marrow failure, is the most prevalent form of leukemia. It is the most aggressive form of leukemia, which has varying prognoses determined by the subtypes. This report explores the association between AML, fever of unknown origin, and pericardial effusion, shedding light on a notable clinical aspect. Fever in AML may be attributed to underlying inflammatory processes, cytokine dysregulation, or bone marrow failure. Recognition of fever as a potential indicator of AML contributes to enhanced clinical vigilance. Pericardial effusions and cardiac tamponade, although rare, can be a presenting feature of AML, and can present side by side with fever of unknown origin as seen in this case report.
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Affiliation(s)
| | - Folasade Ajayi
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | | | | | - Jihad Slim
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
| | - Hamid S Shaaban
- Hematology and Oncology, Saint Michael's Medical Center, Newark, USA
| | - Ala Muhanna
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
| | - Bereket Tewoldemedhin
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
| | - Maria Szabela
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
| | - Jack Boghossian
- Infectious Diseases, St. Michael Medical Center, Newark, USA
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10
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Trapani S, Fiordelisi A, Stinco M, Resti M. Update on Fever of Unknown Origin in Children: Focus on Etiologies and Clinical Approach. Children (Basel) 2023; 11:20. [PMID: 38255334 PMCID: PMC10814770 DOI: 10.3390/children11010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024]
Abstract
Fever of unknown origin (FUO) can be caused by four etiological categories of diseases. The most common cause of FUO in children is represented by infections, followed by inflammatory conditions and neoplastic causes; a decreasing quote remains still without diagnosis. Despite the fact that several diagnostic and therapeutic approaches have been proposed since the first definition of FUO, none of them has been fully validated in pediatric populations. A focused review of the patient's history and a thorough physical examination may offer helpful hints in suggesting a likely diagnosis. The diagnostic algorithm should proceed sequentially, and invasive testing should be performed only in select cases, possibly targeted by a diagnostic suspect. Pioneering serum biomarkers have been developed and validated; however, they are still far from becoming part of routine clinical practice. Novel noninvasive imaging techniques have shown promising diagnostic accuracy; however, their positioning in the diagnostic algorithm of pediatric FUO is still not clear. This narrative review aims to provide a synopsis of the existent literature on FUO in children, with its major causes and possible diagnostic workup, to help the clinician tackle the complex spectrum of pediatric FUO in everyday clinical practice.
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Affiliation(s)
- Sandra Trapani
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
- Pediatric Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy; (A.F.); (M.R.)
| | - Adele Fiordelisi
- Pediatric Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy; (A.F.); (M.R.)
| | | | - Massimo Resti
- Pediatric Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy; (A.F.); (M.R.)
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11
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Oda Y, Ishioka K, Ohtake T, Oki R, Taguchi S, Matsui K, Mochida Y, Moriya H, Hidaka S, Kobayashi S. Dialysis-related Amyloidosis Presenting as a Fever of Unknown Origin: Symptoms and Management. Intern Med 2023; 62:3669-3677. [PMID: 37164661 PMCID: PMC10781552 DOI: 10.2169/internalmedicine.1095-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/26/2023] [Indexed: 05/12/2023] Open
Abstract
A 74-year-old woman with a 34-year history of hemodialysis presented with an intermittent fever, which later coincided with recurrent bilateral shoulder and hip joint pain. Imaging studies suggested amyloid arthropathy, which was histologically confirmed by a synovial biopsy. Increasing β2-microglobulin clearance during dialysis alone attenuated the intermittent fever and joint pain, but the symptoms did not disappear until the administration of prednisolone 10 mg/day. Reported cases of dialysis-related amyloidosis with a fever imply that changing to blood purification methods with high β2-microglobulin clearance is crucial for controlling the condition long-term, whereas concurrent use of anti-inflammatory agents promptly alleviates the symptoms.
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Affiliation(s)
- Yasuhiro Oda
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Kunihiro Ishioka
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Takayasu Ohtake
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Rikako Oki
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Shinya Taguchi
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Kenji Matsui
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Yasuhiro Mochida
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Hidekazu Moriya
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Sumi Hidaka
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
| | - Shuzo Kobayashi
- Department of Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Japan
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12
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Chen K, Guo M, Chen J, Zheng S, Deng Q. Multidisciplinary approach to diagnosis and management of fever of unknown origin: A case report. Medicine (Baltimore) 2023; 102:e36628. [PMID: 38115262 PMCID: PMC10727603 DOI: 10.1097/md.0000000000036628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION Fever of unknown origin (FUO) poses a diagnostic challenge, often requiring a systematic evaluation to uncover its elusive cause. This case study delves into the presentation of a 42-year-old Chinese male with persistent fever, muscle pain, and a perplexing rash. PATIENT CONCERNS The patient's symptoms included a prolonged fever, chills, muscle pain, and throat discomfort, with a history of pulmonary tuberculosis. Initial diagnoses of upper respiratory infection and unspecified infection were followed by antibiotic treatments, yet the fever persisted, accompanied by an exacerbating rash. DIAGNOSIS Extensive diagnostic investigations, including laboratory tests, imaging studies, and skin dermoscopy, provided valuable insights. The patient exhibited elevated inflammatory markers, hepatosplenomegaly, lymphadenopathy, and lung nodules. Differential diagnoses included adult-onset Still disease and drug-induced hypersensitivity syndrome. INTERVENTIONS The patient received a series of antibiotic treatments, which initially had limited success. Upon considering an autoimmune etiology, corticosteroids were introduced, followed by cyclosporine. The patient exhibited a positive response to this immunosuppressive therapy. OUTCOMES Treatment adjustments were made, and the patient responded positively to a combination of corticosteroids and cyclosporine. His fever subsided, and laboratory markers normalized. One month after discharge, the patient showed continued improvement. CONCLUSION FUO cases often demand a multidisciplinary approach, considering rare and uncommon diseases. This case underscores the importance of thorough evaluation, collaboration between specialties, and vigilant monitoring of treatment responses. The patient's unique presentation emphasizes the need to consider drug-induced reactions, even when symptoms deviate from typical disease patterns, highlighting the complexities in diagnosing and managing FUO.
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Affiliation(s)
- Kai Chen
- Department of General Practice, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Meizi Guo
- Department of General Practice, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Jun Chen
- Department of General Practice, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Shuqian Zheng
- Department of General Practice, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Quanwen Deng
- Department of General Practice, Shenzhen Hospital of Southern Medical University, Shenzhen, China
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Ishihara M, Abe S, Imaoka K, Nakagawa T, Kadota K, Oguro H, Nakajima H, Yamaguchi S, Nagai A. Meningoencephalomyelitis Caused by Brucella Canis: A Case Report and Literature Review. Intern Med 2023:2664-23. [PMID: 37926538 DOI: 10.2169/internalmedicine.2664-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Human brucellosis, one of the most common zoonoses worldwide, is rare in Japan. Brucella canis is the specific pathogen of human brucellosis carried by dogs. According to an epidemiological study of B. canis infection in Japan, B. canis is the specific pathogen of human brucellosis in dogs. We herein report a rare case of meningoencephalomyelitis caused by B. canis in a 68-year-old Japanese man. Neurobrucellosis was diagnosed based on a serum tube agglutination test and abnormal cerebrospinal fluid findings. The patient was started on targeted treatment with a combination of doxycycline and streptomycin. Although extremely rare, neurobrucellosis should be considered in patients with a fever of unknown origin and unexplained neurological symptoms.
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Affiliation(s)
- Masaki Ishihara
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Japan
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
| | - Satoshi Abe
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
| | - Koichi Imaoka
- Department of Veterinary Science, National Institute of Infectious Diseases, Japan
| | - Tomonori Nakagawa
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
- Department of Neurology, Masuda Red Cross Hospital, Japan
| | - Katsuhiko Kadota
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
- Department of Emergency and Disaster Medicine, Graduate School of Medicine, Juntendo University, Japan
| | - Hiroaki Oguro
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
- Department of Neurology, Heisei Memorial Hospital, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Shuhei Yamaguchi
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
- Shimane Prefecture Bureau, Shimane Prefectural Central Hospital, Japan
| | - Atsushi Nagai
- Department of Neurology, Faculty of Medicine, Shimane University, Japan
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14
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Ng TTW, Davel S, O’Connor KD. Sulfasalazine-Induced Delayed Hypersensitivity Reaction Presenting as Fever, Aseptic Meningitis, and Mesenteric Panniculitis in a Patient with Seronegative Arthritis. Am J Case Rep 2023; 24:e941623. [PMID: 37924204 PMCID: PMC10630587 DOI: 10.12659/ajcr.941623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/26/2023] [Accepted: 09/12/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND An 82-year-old woman presented with acute pyrexial illness and mesenteric panniculitis and developed biochemical aseptic meningitis (cerebrospinal fluid pleocytosis with no identifiable pathogen). Investigation determined her illness was likely a delayed hypersensitivity reaction caused by sulfasalazine. Sulfasalazine-induced aseptic meningitis is a rare condition often diagnosed late in a patient's admission owing to initial non-specific illness symptomatology requiring the exclusion of more common "red flag" etiologies, such as infection and malignancy. CASE REPORT An 82-year-old woman with a history of recurrent urinary tract infections and seronegative arthritis presented with a 3-day history of fatigue, headache, dyspnea, and lassitude. On admission, she was treated as presumed sepsis of uncertain source owing to pyrexia and tachycardia. Brain computer tomography (CT) revealed no acute intracranial abnormality. Furthermore, CT of the chest, abdomen, and pelvis did not reveal any source of sepsis or features of malignancy. After excluding infective etiologies with serological and cerebrospinal fluid testing, sulfasalazine-induced aseptic meningitis (SIAM) was diagnosed. The patient was then commenced on intravenous steroids, resulting in immediate defervescence and symptom resolution. CONCLUSIONS SIAM remains a diagnostic challenge since patients present with non-specific signs and symptoms, such as pyrexia, headaches, and lassitude. These patients require a thorough investigative battery starting with anamnesis, physical examination, biochemical testing, and radiologic imaging. This case illustrates the need for a high suspicion index of drug-induced hypersensitivity reaction in a rheumatological patient with pyrexial illness where infective etiologies have been confidently excluded. Prompt initiation of intravenous steroids in SIAM provides a dramatic recovery and resolution of symptoms.
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Affiliation(s)
- Tristen Tze Wei Ng
- Department of General Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia
- Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sue Davel
- Department of General Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Kevin David O’Connor
- Stroke Unit, Joondalup Health Campus, Joondalup, Western Australia, Australia
- Department of Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
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15
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Kanitthamniyom C, Osorio A, Saowapa S, Siladech P. A Case of Subcutaneous Panniculitis-Like T-cell Lymphoma With Hemophagocytic Lymphohistiocytosis in an HIV Patient. Cureus 2023; 15:e49564. [PMID: 38156150 PMCID: PMC10754025 DOI: 10.7759/cureus.49564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Subcutaneous panniculitis-like T-cell lymphoma (SPTL) is a rare subtype of non-Hodgkin lymphoma that manifests as panniculitis-like skin lesions. It frequently co-occurs with hemophagocytic lymphohistocytosis, a life-threatening hyperinflammatory syndrome. The majority of SPTL cases express αβ T-cell receptors (SPTL-AB) and have a favorable prognosis with oral immunosuppressive agents. We report a 37-year-old male patient with HIV infection who had a history of low-grade fever for one year, multiple tender subcutaneous nodules on both thighs, and cytopenia. He received several courses of antibiotics without significant improvement. A random skin biopsy showed lobular panniculitis and he was treated with steroids, but his fever recurred after steroid withdrawal. A second skin biopsy confirmed the diagnosis of SPTL. A bone marrow examination revealed hemophagocytic lymphohistiocytosis. He was successfully treated with cyclosporin A and prednisolone and achieved a complete response after one year of drug discontinuation. Panniculitis-like skin lesions have various etiologies and may present as a clinical mimic of lupus erythematosus panniculitis. The selection of an optimal site for skin biopsy is crucial to avoid erroneous diagnoses and adverse outcomes. We report a case of SPTL in an HIV-positive patient, which illustrates this diagnostic challenge.
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Affiliation(s)
| | - Alejandra Osorio
- Internal Medicine, University of Alabama at Birmingham (UAB) Hospital, Birmingham, USA
| | - Sakditad Saowapa
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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16
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Kattel T, Kc S, Schick J, Ng SJ, Lanade O. Fever of Unknown Origin in a Patient With Human Immunodeficiency Virus. Cureus 2023; 15:e49356. [PMID: 38143617 PMCID: PMC10749187 DOI: 10.7759/cureus.49356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/26/2023] Open
Abstract
Fever of unknown origin (FUO) presents a diagnostic challenge, particularly in patients with human immunodeficiency virus (HIV) due to their immunocompromised state. We report a case of a 21-year-old male with HIV who presented with persistent fever and was found to have a positive proteinase-3 antibody, raising suspicion of granulomatosis with polyangiitis (GPA). The patient's symptoms, negative infectious workup, and elevated proteinase-3 levels prompted consideration of non-infectious etiologies. Despite the absence of renal involvement, corticosteroid therapy was initiated, leading to the resolution of fever. However, the false positive association of proteinase-3 in HIV patients introduces uncertainty regarding the definitive diagnosis of GPA. A tissue biopsy would have provided further clarity, but it was not performed in this case. Our workup aligns more closely with a diagnosis of GPA, considering the patient's response to treatment and the absence of clinical deterioration. This case highlights the complexity of diagnosing non-infectious causes of FUO in HIV-infected individuals. It emphasizes the need for a multidisciplinary approach involving infectious disease specialists and rheumatologists to ensure accurate diagnosis and appropriate management.
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Affiliation(s)
- Trishna Kattel
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Shreeyanta Kc
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Jacob Schick
- Radiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sze Jia Ng
- Internal Medicine, Crozer-Chester Medical Center, Upland, USA
| | - Oladimeji Lanade
- Internal Medicine, University of Tennessee Health Science Center, Memphis, USA
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17
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Rowe SP, Auwaerter PG, Sheikhbahaei S, Solnes LB, Wright WF. Molecular Imaging of Infections: Emerging Techniques for Pathogen-Specific Diagnosis and Guided Therapy. J Infect Dis 2023; 228:S241-S248. [PMID: 37788504 DOI: 10.1093/infdis/jiad092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Evaluation of patients that may be infected is challenging. Imaging to identify or localize a site of infection is often limited because of the nonspecific nature of the findings on conventional imaging modalities. Available imaging methods lack the ability to determine if antibiotics are reaching the site of infection and are not optimized to follow response to therapy. Positron emission tomography (PET) is a method by which radiolabeled molecules can be used to detect metabolic perturbations or levels of expression of specific targets. The most common PET agent is the glucose analog 2-deoxy-2-[18F]fluoro-D-glucose (18F-FDG). 18F-FDG has some applicability to localizing a site of infection, but its lack of specificity limits its usefulness. There is a need for the development of pathogen-specific PET radiotracers to address the imaging shortcomings noted above. Preclinical and clinical progress has been made, but significant challenges remain.
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Affiliation(s)
- Steven P Rowe
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara Sheikhbahaei
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lilja B Solnes
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William F Wright
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Kakehi M, Amano S, Sano C, Ohta R. Atypical Adult Still's Disease Complicated by Hemophagocytic Syndrome in an Older Patient: A Case Report. Cureus 2023; 15:e46922. [PMID: 38021678 PMCID: PMC10640387 DOI: 10.7759/cureus.46922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Hyperferritinemia can occur in various diseases, making the differential diagnoses diverse and often fatal. The macrophage-activated syndrome (MAS) is a differential diagnosis of hyperferritinemia in which systemic macrophages are activated and cause various symptoms. Many cases are complicated by hemophagocytic syndrome, causing pancytopenia, which can be fatal. Furthermore, it is challenging to diagnose hyperferritinemia in elderly patients, and the disease may develop into a fever of unknown origin. We report the case of a 93-year-old man with aspiration pneumonia, followed by intermittent prolonged fever complicated by abnormal hyperferritinemia and leukopenia. Based on his general condition, he was diagnosed with atypical adult Still's disease and treated with steroid pulses and tocilizumab, temporarily relieving his symptoms. However, the patient eventually developed sepsis and could not be saved. Diagnosis of hyperferritinemia in the elderly population is complex and requires immediate attention. However, invasive intervention may lead to the deterioration of an elderly patient's condition. In the context of medical care for the elderly at a community hospital, it is necessary to provide comprehensive care for those in critical condition, considering the degree of invasiveness of examinations and procedures.
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Affiliation(s)
- Minami Kakehi
- Family Medicine, Shimane University Medical School, Izumo, JPN
| | - Shiho Amano
- Community Care, Unnan City Hospital, Unnan, JPN
| | - Chiaki Sano
- Community Medicine, Shimane University Faculty of Medicine, Izumo, JPN
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19
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Lee SY, Er C. Subacute Thyroiditis Causing Fever of Unknown Origin: A Reminder of the Uncommon Cause. Cureus 2023; 15:e47037. [PMID: 37965385 PMCID: PMC10643017 DOI: 10.7759/cureus.47037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/16/2023] Open
Abstract
Subacute thyroiditis (SAT) is a transient inflammation of the thyroid gland that often occurs following a viral infection. It is an infrequent cause of fever of unknown origin (FUO). We present a 46-year-old gentleman who presented with two weeks of fever and some non-specific left-sided neck pain. His initial investigations and microbiological workup were unremarkable. He did not report any hyperthyroid symptoms. A computed tomography of the neck, chest, abdomen, and pelvis showed a heterogeneous appearance of his thyroid gland. Thyroid function was then performed, and it showed primary hyperthyroidism. His thyroid autoantibodies were negative. Ultrasonography of his thyroid showed features consistent with thyroiditis. He was treated with a course of oral steroids. His fever lysed. His thyroid function turned from a primary hyperthyroid pattern to subclinical hypothyroidism. His anti-thyroglobulin antibody level remained elevated after the steroid treatment. Our case highlights that SAT is an uncommon cause of FUO in patients without specific localizing symptoms. It can present without overt hyperthyroid clinical features. Steroid treatment is useful. There may be value in monitoring the anti-thyroid antibodies in SAT's management.
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Affiliation(s)
- Sin Yin Lee
- General Medicine, National University of Singapore, Singapore, SGP
| | - Chaozer Er
- General Medicine, Woodlands Health, Singapore, SGP
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20
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Unnikrishnan S, Ingle V, Singhai A, Pandita K, Atlani M. Takayasu Arteritis in the Pre-Pulseless Phase Presenting as Pyrexia of Unknown Origin. Cureus 2023; 15:e45855. [PMID: 37881385 PMCID: PMC10597183 DOI: 10.7759/cureus.45855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Pyrexia of unknown origin (PUO) or fever of unknown origin (FUO) is clinically challenging for a treating physician; it is also a conundrum for the patient until a definitive diagnosis is made. Despite extensive investigations, many cases of PUO may remain undiagnosed for a long time. In a resource-limited country like India, due to the limited availability of various diagnostic tests, a great many fever cases are classified as PUO. Here, we present a case report of Takayasu arteritis in its pre-pulseless phase, presented as PUO. Takayasu arteritis presenting as PUO in the absence of a pulse deficit is uncommon and rarely reported. The patient's fever responded to steroids with methotrexate. The patient didn't develop any vascular complications during the follow-up.
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Affiliation(s)
- Sooraj Unnikrishnan
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Vaibhav Ingle
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Abhishek Singhai
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Kawal Pandita
- Department of Hospital Administration, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Mahendra Atlani
- Department of Nephrology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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21
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Ko JW, Lee SE, Park JH, Kim B. Risk factors that are associated with adrenal insufficiency among patients with fever of unknown origin. Postgrad Med 2023; 135:734-740. [PMID: 37725479 DOI: 10.1080/00325481.2023.2261355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Adrenal insufficiency is one of the causes of fever of unknown origin (FUO). The purpose of this study is to find out risk factors that are associated with adrenal insufficiency in FUO patients. METHODS This study was conducted retrospectively in a tertiary hospital with 846 beds in South Korea. All adult inpatients (age ≥19 years) who have requested a consult with the department of infectious disease for FUO between 1 July 20191 July 2019 and 30 June 202030 June 2020 were included in the study. Among them, those who underwent an adrenocorticotropic hormone (ACTH) stimulation test and had a fever of 37.8°C or higher within 48 hours of the ACTH stimulation test were finally included in the study subjects. RESULTS A total of 202 FUO patients were enrolled and 61 (30.1%) were finally diagnosed with adrenal insufficiency. In a multivariate analysis, use of immunosuppressant within 3 months (OR 6.06, 95% CI 1.82-20.13, P = 0.003), use of corticosteroid within 3 months (OR 8.23, 95% CI 1.35-50.17, P = 0.022), sodium ≥ 136.7 (OR 3.43, 95% CI 1.49-7.88, P = 0.004), and calcium ≥ 8.4 (OR 0.31, 95% CI 0.14-0.71, P = 0.005) were proven to be factors associated with adrenal insufficiency in FUO patients. CONCLUSION In conclusion, 30.1% of FUO patients were diagnosed with adrenal insufficiency. The risk factors that are associated with adrenal insufficiency in FUO patients were immunosuppressive prescription or systemic steroid prescription within 3 months, or with sodium ≥ 136.7 or calcium < 8.4.
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Affiliation(s)
- Ji Won Ko
- School of Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Infectious Diseases, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
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22
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El Labban M, Rauf I, Mir M, Jin Z, Khan SA. Fever As the Exclusive Presenting Symptom in a Case of Colon Cancer. Cureus 2023; 15:e46120. [PMID: 37900544 PMCID: PMC10612539 DOI: 10.7759/cureus.46120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
The definition of fever of unknown origin (FUO) has evolved overtime. Most recently, FUO is recognized as fever with uncertain diagnosis despite three days of hospital admission or three or more outpatient visits. Despite diagnostic medical advancements, FUO remains quite a challenge. In the past, infections, such as abscesses, endocarditis, tuberculosis, and complicated urinary tract infections, were common etiologies of FUO; however, at present, such conditions are readily diagnosed. FUO secondary to malignancy has also been decreasing as a result of radiological advancements. Patients with colon cancer usually present with symptoms secondary to the local anatomy of the tumor. Conversely, fever is an uncommon presentation, especially if it is the sole symptom. Here, we report a unique presentation of colon cancer. Our patient only had intermittent fever for one year before being diagnosed with colon cancer. The fever subsided after resection of the tumor. Despite breakthroughs in diagnostic medicine, FUO remains a challenging diagnosis. Practicing clinicians should have a high level of suspicion to rule out underlying malignancy in the setting of recurrent fevers or FUO.
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Affiliation(s)
| | - Ibtisam Rauf
- Medical School, St. George's University School of Medicine, True Blue, GRD
| | - Mikael Mir
- Medical School, University of Minnesota Medical School, Minneapolis, USA
| | | | - Syed Anjum Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
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23
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Mostafa SH, Saleh SE, Khaleel EF, Badi RM, Aboshanab KM, Hamed SM. Phenotypic and Genotypic Analysis of Bacterial Pathogens Recovered from Patients Diagnosed with Fever of Unknown Origin in Egypt. Antibiotics (Basel) 2023; 12:1294. [PMID: 37627714 PMCID: PMC10451874 DOI: 10.3390/antibiotics12081294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Fever of unknown origin (FUO) is a medical term describing fever that lasts for at least three weeks without a diagnosis being reached after extensive diagnostic evaluation. Therefore, this study aimed to identify the common pathogens causing FUO in patients admitted to Abbasia Fever Hospital in Egypt from January 2020 to December 2022, their antimicrobial susceptibility profiles, and associated resistance genes. The study also aimed to investigate the burden of multidrug-resistant (MDR) pathogens and the priority pathogens nominated by the World Health Organization (WHO) for posing the greatest threat to human health due to antibiotic resistance. During the study period, about 726 patients were diagnosed with FUO. After extensive investigations, the cause of the FUO was found to be infectious diseases in 479/726 patients (66.0%). Of them, 257 patients had positive bacterial cultures, including 202 Gram-negative isolates that comprised Klebsiella pneumoniae (85/202; 42.1%), Escherichia coli (71/202; 35.1%), Acinetobacter baumannii (26/202; 12.9%), and Pseudomonas aeruginosa (14/202; 6.9%) and 55 Gram-positive isolates, including Staphylococcus aureus (23/55; 41.8%), Streptococcus pneumoniae (7/55; 12.7%), and Enterococcus spp. (25/55; 45.5%). The MDR phenotype was shown by 68.3% and 65.5% of the Gram-negative and Gram-positive isolates, respectively. Carbapenem resistance (CR) was shown by 43.1% of the Gram-negative isolates. Of the 23 S. aureus isolates obtained from research participants, 15 (65.2%) were methicillin-resistant S. aureus (MRSA). A high-level aminoglycoside resistance (HLAR) phenotype was found in 52.0% of the Enterococcus sp. isolates. The PCR screening of resistance genes in the MDR isolates showed that blaOXA-48 was the most prevalent (84%) among the carbapenemase-coding genes, followed by blaVIM (9%) and then blaIMP (12%). The ESBL-coding genes blaTEM, blaCTX-M,aac(6')-Ib, and blaSHV, were prevalent in 100%, 93.2%, 85,% and 53.4% of the MDR isolates, respectively. This study updates the range of bacteria that cause FUO and emphasizes the burden of multidrug resistance and priority infections in the region. The obtained data is of relevant medical importance for the implementation of evidence-based antimicrobial stewardship programs and tailoring existing empirical treatment guidelines.
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Affiliation(s)
- Shimaa H. Mostafa
- Microbiology Lab Department, Abbasia Fever Hospital, Cairo 11566, Egypt;
| | - Sarra E. Saleh
- Department of Microbiology and Immunology, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt;
| | - Eman F. Khaleel
- Department of Medical Physiology, College of Medicine, King Khalid University, Abha 61421, Saudi Arabia; (E.F.K.); (R.M.B.)
| | - Rehab Mustafa Badi
- Department of Medical Physiology, College of Medicine, King Khalid University, Abha 61421, Saudi Arabia; (E.F.K.); (R.M.B.)
| | - Khaled M. Aboshanab
- Department of Microbiology and Immunology, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt;
| | - Samira M. Hamed
- Department of Microbiology and Immunology, Faculty of Pharmacy, October University for Modern Sciences and Arts (MSA), 6th of October, Giza 12451, Egypt;
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24
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Yaman F, Kimiaei A. A case of adult-onset Still's disease in a patient after a car accident. Clin Case Rep 2023; 11:e7510. [PMID: 37614293 PMCID: PMC10442471 DOI: 10.1002/ccr3.7510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/20/2023] [Accepted: 05/29/2023] [Indexed: 08/25/2023] Open
Abstract
Key Clinical Message Adult-onset Still's disease is a rare inflammatory condition with diverse clinical features. Yamaguchi criteria aid diagnosis, and pleural effusion and elevated ferritin levels are important markers. Steroids are the first-line treatment. Abstract Adult-onset Still's disease (AOSD) is a rare systemic inflammatory condition with an unknown etiology. It is characterized by, spiking fever, arthritis, evanescent rash, sore throat, serositis, hepatomegaly, splenomegaly, and lymphadenopathy. It is a diagnosis of exclusion and has infections, systemic autoimmune and inflammatory rheumatic diseases, malignancy, and adverse drug reactions as its differential diagnosis. Because of these characteristics, diagnosis is frequently delayed, posing a significant challenge for physicians. While several classification criteria can be used to diagnose Still's disease, they have limitations in terms of sensitivity and specificity. The Yamaguchi criteria are considered the most sensitive and commonly used, requiring the presence of at least five characteristics, with at least two being major diagnostic criteria. Steroid therapy is the first-line treatment for AOSD patients. In this case report, we present a 56-year-old female patient who developed pleurisy a few months after a car accident, subsequently diagnosed with adult-onset Still's disease.
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Affiliation(s)
- Feride Yaman
- Department of PulmonologyBahcesehir University School of MedicineİstanbulTurkey
| | - Ali Kimiaei
- Bahcesehir University School of MedicineİstanbulTurkey
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25
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Utpat N, Nookala V, Singh SP, Sharma A. Subacute Thyroiditis Masking as Fever of Unknown Origin: An Intriguing Case Report. Cureus 2023; 15:e43525. [PMID: 37719522 PMCID: PMC10501461 DOI: 10.7759/cureus.43525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
This study presents a unique case of subacute thyroiditis, which presents as prolonged high-grade fever without any other symptoms except for mild throat pain. A 46-year-old, otherwise healthy male presented with high-grade fever for more than two to three weeks and was found to have hyperthyroidism, with elevated free thyroxine levels (free T4), low thyroid-stimulating hormone (TSH) levels, elevated c-reactive protein (CRP) an inflammatory marker, and heterogeneous bilateral thyroid nodules on imaging studies. His workup was negative for infectious etiology of fever, thus favoring the diagnosis of subacute thyroiditis as the cause of fever of unknown origin (FUO). This case highlights the importance of considering subacute thyroiditis as a potential etiology in patients with FUO and the significance of a comprehensive workup to guide appropriate management.
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Affiliation(s)
- Nishka Utpat
- Internal Medicine, Rutgers Health/Community Medical Center, Newark, USA
| | - Vinod Nookala
- Internal Medicine, Community Medical Center, Toms River, USA
| | | | - Anil Sharma
- Internal Medicine, Community Medical Center, Toms River, USA
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26
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Sayed AG, Badghaish T, Abdo N, Nasir A. Diffuse Xanthogranulomatous pyelonephritis: A Rare Disease With A Common Presentation. Cureus 2023; 15:e44118. [PMID: 37750147 PMCID: PMC10518206 DOI: 10.7759/cureus.44118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023] Open
Abstract
Xanthogranulomatous pyelonephritis (XGP) is a distinct entity characterized by chronic granulomatous changes in the renal parenchyma associated with renal destruction and urinary tract abnormalities, most often from obstruction or infection in the urinary tract. We have presented the case report of a girl with fever, abdominal pain, vomiting, anorexia, and weight loss. Computed tomography of the abdomen showed multiloculated cystic lesions with calcifications and a psoas muscle abscess, which tested positive for Escherichia (E.) coli. Histopathology revealed lipid-laden macrophages, multinucleated giant cells, and fibrosis. Nephrectomy and drainage of the psoas abscess were done. XGP, although rare, should not be confused with renal tumors and should be considered in children presenting with fever and urinary tract symptoms. Early diagnosis can be reached with CT. Nephrectomy is the definitive treatment.
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Affiliation(s)
| | | | - Nivan Abdo
- Pediatrics, Maternity and Children Hospital Makkah, Makkah, SAU
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Palestro CJ, Brandon DC, Dibble EH, Keidar Z, Kwak JJ. FDG PET in Evaluation of Patients With Fever of Unknown Origin: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023; 221:151-162. [PMID: 36722759 DOI: 10.2214/ajr.22.28726] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fever of unknown origin (FUO) is a diagnostic challenge, with its cause remaining undiagnosed in approximately half of patients. Nuclear medicine tests typically are performed after a negative or inconclusive initial workup. Gallium-67 citrate and labeled leukocytes were previous mainstays of radionuclide imaging for FUO, although they had limited diagnostic performance. FDG PET/CT has subsequently emerged as the nuclear medicine imaging test of choice, supported by a growing volume of evidence. A positive FDG PET/CT result contributes useful information by identifying potential causes of fever, localizing sites for further evaluation, and guiding further management; a negative result contributes useful information by excluding focal disease as the cause of fever and predicts a favorable prognosis. In 2021, CMS rescinded a prior national noncoverage determination for FDG PET for infection and inflammation, leading to increasing national utilization of FDG PET/CT for FUO workup. This article reviews the current status of the role of FDG PET/CT in the evaluation of patients with FUO. The literature reporting the diagnostic performance and yield of FDG PET/CT in FUO workup is summarized, with comparison with historically used nuclear medicine tests included. Attention is also given to the test's clinical impact; protocol, cost, and radiation considerations; and application in children.
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Affiliation(s)
- Christopher J Palestro
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
- Division of Nuclear Medicine & Molecular Imaging, Northwell Health, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040
| | - David C Brandon
- Department of Radiology, Division of Nuclear Medicine, Emory University School of Medicine, Atlanta VA Medical Center, Atlanta, GA
| | - Elizabeth H Dibble
- Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Jennifer J Kwak
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, University of Colorado Anschutz Medical Campus, Aurora, CO
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Maita H, Kobayashi T, Akimoto T, Ota S, Sakuraba H, Kato H. Takayasu arteritis presenting with fever of unknown origin and bilateral carotid artery tenderness: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231190493. [PMID: 37539356 PMCID: PMC10395173 DOI: 10.1177/2050313x231190493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023] Open
Abstract
A 51-year-old otherwise healthy woman was referred to our hospital with a fever of unknown origin, liver dysfunction, and anemia. One month prior, she had persistent and spontaneous anterior neck pain, with no exacerbation during swallowing or neck movements. Physical examination revealed no pharyngeal or tonsillar abnormalities, heart murmur, arthritis, skin rash, or lymphadenopathy, except for mild bilateral common carotid artery tenderness at the level of the thyroid cartilage. Blood tests showed nonspecific chronic inflammatory findings, anemia, and liver damage, whereas blood cultures, viral antibodies, interferon-γ release assay, and antibodies specific for any collagen disease showed negative results. Echocardiography and computed tomography without contrast of the neck, chest, abdomen, and pelvis showed no apparent abnormalities. She was subsequently diagnosed with Takayasu arteritis using positron emission tomography. Identifying a characteristic history of bilateral carotid artery tenderness and subsequent positron emission tomography can be useful for diagnosing Takayasu arteritis.
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Affiliation(s)
- Hiroki Maita
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Tadashi Kobayashi
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
| | - Takashi Akimoto
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
| | - Shinji Ota
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroyuki Kato
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
- General Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan
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EID M, Ghanem A, Saloum E. Cytomegalovirus viremia in an 11-year-old child with sickle cell disease manifested only with fever: a case report. Ann Med Surg (Lond) 2023; 85:3666-3669. [PMID: 37427240 PMCID: PMC10328612 DOI: 10.1097/ms9.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/14/2023] [Indexed: 07/11/2023] Open
Abstract
Cytomegalovirus (CMV) is a widespread virus, and it affects people of all ages. Infection with this virus causes severe life-threatening disease in immunocompromised patients and newborns. While CMV infection is asymptomatic or present as a mild illness in most cases of immunocompetent patient, it may cause severe diseases in 10% of cases. Case presentation Here, the authors describe the case of an 11-year-old male presented with an ischemic stroke due to sickle cell disease; who, during hospitalization, developed a prolonged fever. After excluding bacterial infections, infiltrating diseases, rheumatologic diseases, malignancies, and other possible causes, he was diagnosed with CMV infection, which not checked initially, because most cases are asymptomatic. Conclusion This case highlights the need to consider CMV infection in the differential diagnosis of every case of fever of unknown origin, regardless of the patient's immune status.
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Affiliation(s)
| | | | - Elias Saloum
- Faculty of Human Medicine, Tishreen University, Latakia, Syria
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30
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Zambrano-Infantino RDC, Piñerúa-Gonsálvez JF, Alvarez-Mena N, Izquierdo-Santervás S, Alcaide N, Garcia-Aragon M, Ruano-Pérez R. Unusual Case of Pseudomembranous Colitis Presenting as Fever of Unknown Origin Diagnosed by Tc-99m-HMPAO-labeled Leukocytes SPECT/CT. Mol Imaging Radionucl Ther 2023; 32:168-170. [PMID: 37337874 DOI: 10.4274/mirt.galenos.2022.59354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
The fever of unknown origin (FUO) represents a complex diagnostic challenge due to the wide range of etiologies that could cause it, including neoplastic, infectious, rheumatic/inflammatory, and miscellaneous disorders. Several nuclear medicine techniques have proven to be valuable tools for guiding etiologic diagnosis in the setting of FUO. One of these is technetium-99m (Tc-99m)-hexamethylpropylene amine oxime (HMPAO)-labeled leukocyte scintigraphy, which is a diagnosis method that allows in most cases the localization and evaluation of the extension of an occult infection. This paper presents an uncommon case of pseudomembranous colitis without diarrhea as etiology of FUO diagnosed by Tc-99m-HMPAO-labeled leukocytes.
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Affiliation(s)
| | | | - Noelia Alvarez-Mena
- Hospital Clínico Universitario de Valladolid, Department of Nuclear Medicine, Valladolid, Spain
| | | | - Noelia Alcaide
- Hospital Clínico Universitario de Valladolid, Department of Gastroenterology, Valladolid, Spain
| | - Maria Garcia-Aragon
- Hospital Clínico Universitario de Valladolid, Department of Nuclear Medicine, Valladolid, Spain
| | - Ricardo Ruano-Pérez
- Hospital Clínico Universitario de Valladolid, Department of Nuclear Medicine, Valladolid, Spain
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31
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Margini C, Maldonado R, Keller P, Banz Y, Escher R, Waldegg G. Fever of Unknown Origin, a Vascular Event, and Immunosuppression in Tick-Endemic Areas: Think About Neoehrlichiosis. Cureus 2023; 15:e40617. [PMID: 37476120 PMCID: PMC10354681 DOI: 10.7759/cureus.40617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Three patients were referred to our hospital because of fever of unknown origin (FUO) and thrombosis or thrombophlebitis. All of them had been under immunosuppression (IS) with rituximab. Intensive diagnostics for FUO and blood cultures remained negative. Finally, the association of fever, immunosuppression, and a vascular event led to the suspicion of Candidatus Neoehrlichia mikurensis (CNM) infection. The diagnosis was confirmed by species-specific polymerase chain reaction (PCR) in the peripheral blood. Therapy with doxycycline or rifampicin led to the resolution of the disease. A liver biopsy was performed in one patient due to hepatomegaly and elevated liver enzymes demonstrating hemophagocytosis. To our knowledge, this is the first histopathological study of liver tissue in CNM infection. The evidence of hemophagocytosis raises the question of whether symptomatic CNM infection might be in part related to host inflammatory and immune responses.
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Affiliation(s)
| | | | - Peter Keller
- Infectious Disease, University of Bern, Bern, CHE
| | - Yara Banz
- Pathology, University of Bern, Bern, CHE
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Leelaviwat N, Armin S, Mekraksakit P, Nugent K. Reactivation of Parvovirus B19 Infection: An Uncommon Trigger of Macrophage Activation Syndrome in Adult-Onset Still's Disease. Cureus 2023; 15:e37231. [PMID: 37162784 PMCID: PMC10164221 DOI: 10.7759/cureus.37231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/11/2023] Open
Abstract
A 40-year-old woman presented with four weeks of intermittent high-grade fever, cough, and joint pain, and two weeks of a generalized rash. She was found to have adult-onset Still's disease (AOSD) and rapidly developed macrophage activation syndrome (MAS) on the second day of admission. Among infectious etiologies, Epstein-Barr virus and members of the herpes virus family are common triggers of MAS. However, our patient was found to have reactivation/recurrence of parvovirus B19 infection as the cause; this is an uncommon trigger reported infrequently in the medical literature. Despite intensive treatment, the patient passed away.
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Affiliation(s)
- Natnicha Leelaviwat
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Sabiha Armin
- Internal Medicine, University of Texas Health Science Center at Houston, Houston, USA
| | | | - Kenneth Nugent
- Internal Medicine/Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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Nagashima H, Abe K, Owada Y, Yakuwa K, Katagiri H, Chiba S, Matsumoto A, Akiyama M, Utsumi Y, Maemondo M. A Case of Mediastinal Tuberculous Lymphadenitis in a Chronic Dialysis Patient Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA). Medicina (Kaunas) 2023; 59:medicina59040677. [PMID: 37109635 PMCID: PMC10142725 DOI: 10.3390/medicina59040677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
A 54-year-old woman on dialysis due to chronic renal failure had a fever lasting 2 weeks and was referred to a hospital. Non-enhanced CT and blood tests showed no remarkable findings. She was hospitalized and received an antibacterial drug. Although she was discharged after the fever subsided, she was hospitalized again due to a fever a few days later. A contrast-enhanced CT revealed mediastinal lymphadenopathy, and she was transferred to our hospital for a bronchoscopy. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) for subcarinal lymph nodes was performed in our hospital. The Polymerase Chain Reaction (PCR) test of the obtained specimen was positive for mycobacterium tuberculosis, and histologically, caseous granulomas were found in the specimen. She was diagnosed with mediastinal tuberculous lymphadenitis, and HREZ (isoniazid, rifampicin, ethambutol, and pyrazinamide) treatment was started. The fever subsided immediately, and she was discharged from our hospital 2 weeks after the initiation of treatment. Thereafter, she received treatment as an outpatient. Since the use of a contrast medium was complicated by dialysis, a non-enhanced CT was performed at first, and it was difficult to make a diagnosis from this. We report this as an informative case that could be diagnosed with EBUS-TBNA, which was easily performed on a patient weakened by prolonged fever and dialysis.
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Affiliation(s)
- Hiromi Nagashima
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Kazuyuki Abe
- Department of Respiratory Medicine, Iwate Prefectural Yamada Hospital, Iwate 028-1352, Japan
| | - Yukihiro Owada
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Kazuhiro Yakuwa
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Hiroshi Katagiri
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Shinji Chiba
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Ami Matsumoto
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Masachika Akiyama
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Yu Utsumi
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
| | - Makoto Maemondo
- Department of Respiratory Medicine, Iwate Medical University, Iwate 028-3694, Japan
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Thompson A, Banerjee S, Churchill D, Knight M. Haemophagocytic lymphohistiocytosis in pregnancy and the postpartum period: A retrospective case series analysis. NIHR Open Res 2023; 3:12. [PMID: 37881456 PMCID: PMC10593314 DOI: 10.3310/nihropenres.13339.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 10/27/2023]
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is an extremely rare condition characterised by excessive immune activation leading to haemophagocytic activity and has seldom been reported in pregnancy. HLH manifests as relapsing fevers with features of multi- organ failure and has a high mortality. Methods A retrospective case series analysis using national data from MBRRACE-UK maternal death reports (n=5) and case notes from patients diagnosed with HLH during pregnancy at New Cross Hospital, Wolverhampton (n=2) between 2012 and 2021. Results A total of seven cases were included. Cases uniformly presented with fever and experienced prodromal illnesses consisting of lymphadenopathy, fevers, and malaise. Gestation at presentation ranged from 9/40 to 11 months postpartum. All patients had multiple cytopaenias. Other common features included elevated liver enzymes (n=5), hyperferritinaemia (n=5), splenomegaly (n=4), hypofibrinogenemia (n=4) and elevated soluble interleukin-2 receptor α (CD25) levels (n=3). Underlying causes were identified in four cases. Median time from presentation to diagnosis was 35 days. Bone marrow biopsy was diagnostic in a majority of cases. Corticosteroids and ciclosporin were the most frequently used treatments. In some cases early delivery by caesarean section or termination of pregnancy was necessary to permit maternal treatment. Progression to multi-organ failure resulting in maternal death occurred in five cases: two cases survived. Pregnancy outcomes were: livebirth at term (n=2), preterm livebirth (n=3), termination of pregnancy (n=1), and miscarriage (n=1). Of the surviving infants, one had bone marrow suppression with anaemia at birth and sensorineural deafness. Conclusions Due to the rarity of the condition, diagnosis is often delayed. In view of the high mortality, clinicians should consider HLH early when reviewing pregnant patients with unexplained pyrexia and multi-organ dysfunction. Early involvement of haematology should be sought, as prompt diagnosis is crucial for meaningful attempts at curative therapy. Important treatment considerations include fetal viability, maternal condition and treatment toxicity.
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Affiliation(s)
- Amy Thompson
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Sudipta Banerjee
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - David Churchill
- Obstetrics and Gynaecology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Marian Knight
- Maternal and Child Population Health, National Perinatal Epidemiology Unit (NPEU) Nuffield Department of Population Health, Oxford, OX3 7LF, UK
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35
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Kim DW, Park SA, Kim MH. The utility of F-18 FDG PET/CT for diagnosis and response evaluation of hepatosplenic tuberculosis. Liver Int 2023; 43:733-734. [PMID: 36721981 DOI: 10.1111/liv.15530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/25/2023] [Indexed: 02/02/2023]
Abstract
A 77-year-old woman underwent F-18 FDG PET/CT for evaluation of fever focus. Diffuse and intense hepatosplenic uptake was noted and lymphoma or tuberculosis was proposed. Liver biopsy revealed chronic granulomatous inflammation with Langerhans-type giant cells and necrosis. A follow-up PET/CT after anti-tuberculosis treatment revealed that the hepatosplenic uptake had resolved.
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Affiliation(s)
- Dae-Weung Kim
- Department of Nuclear Medicine and Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, South Korea
| | - Soon-Ah Park
- Department of Nuclear Medicine and Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, South Korea
| | - Myoung Hyoun Kim
- Department of Nuclear Medicine and Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, South Korea
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36
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Bunnag N, Phuangmali K, Vachatimanont S. Positive FDG-PET/CT uptake guiding diagnosis in a patient with microscopic polyangiitis: A case report. Int J Rheum Dis 2023; 26:535-538. [PMID: 36502518 DOI: 10.1111/1756-185x.14525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/23/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022]
Abstract
Microscopic polyangiits (MPA) is an autoimmune vasculitis that is challenging to diagnose because it can present with myriad of manifestations. We present a case of a woman who presented with prolonged fever. Her diagnosis of MPA was realized after fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG-PET/CT) showed abnormal diffuse renal uptake in the cortex, leading to a kidney biopsy. Our report supported the value of FDG-PET/CT as a diagnostic tool in a patient with febrile illness without localizing symptoms or signs.
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Affiliation(s)
- Napisa Bunnag
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Kitwiwat Phuangmali
- King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Sira Vachatimanont
- King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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37
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Lee J, Pham B, Karanjawala ZE, Adesina O. Postpartum fevers, a rare presentation of secondary hemophagocytic lymphohistiocytosis. Clin Case Rep 2023; 11:e7070. [PMID: 36941837 PMCID: PMC10023518 DOI: 10.1002/ccr3.7070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/20/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of excessive immune system activation. We report a case of HLH in a 20-year-old primigravid woman who presented with postpartum fevers. She was successfully treated with dexamethasone and anakinra, a deviation from the HLH-94 protocol, to preserve her ability to breastfeed.
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Affiliation(s)
- Jacqueline Lee
- Department of Internal Medicine University of California Davis School of Medicine Sacramento California USA
| | - Brian Pham
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
| | - Zarir E Karanjawala
- Division of Hematopathology University of California Davis School of Medicine Sacramento California USA
| | - Oyebimpe Adesina
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
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38
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Wright WF, Wang J, Auwaerter PG. Investigator-Determined Categories for Fever of Unknown Origin (FUO) Compared With International Classification of Diseases-10 Classification of Illness: A Systematic Review and Meta-analysis With a Proposal for Revised FUO Classification. Open Forum Infect Dis 2023; 10:ofad104. [PMID: 36949875 PMCID: PMC10026547 DOI: 10.1093/ofid/ofad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
Background Classifying fever of unknown origin (FUO) into categorical etiologies (ie, infections, noninfectious inflammatory, oncologic, miscellaneous, and undiagnosed disorders) remains unstandardized and subject to discrepancies. As some disease classifications change, a systematic review of studies would help physicians anticipate the frequency of illness types they may encounter that could influence care. Methods We systematically reviewed prospective FUO studies published across the Medline (PubMed), Embase, Scopus, and Web of Science databases from January 1, 1997, to July 31, 2022. We performed a meta-analysis to estimate associated pooled proportions between the investigator-determined choice of disease category and those determined by the International Classification of Diseases, 10th edition (ICD-10), methodology. Results The proportion of patients with a difference between the investigator and ICD-10-adjusted noninfectious inflammatory disorder category was 1.2% (95% CI, 0.005-0.021; P < .001), and the proportion was similar for the miscellaneous category at 1.5% (95% CI, 0.007-0.025; P < .001). The miscellaneous and noninfectious inflammatory disorders categories demonstrated significant across-study heterogeneity in the proportions of patients changing categories, with 52.7% (P = .007) and 51.0% (P = .010) I2 , respectively. Conclusions Adjusting FUO-associated diagnoses by ICD-10 methodology was associated with a statistically significant risk of over- or underestimation of disease category frequency approximation when using a 5 FUO category system. An FUO diagnostic classification system that better reflects mechanistic understanding would assist future research and enhance comparability across heterogenous populations and different geographic regions. We propose an updated FUO classification scheme that streamlines categorizations, aligns with the current understanding of disease mechanisms, and should facilitate empirical decisions, if necessary.
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Affiliation(s)
- William F Wright
- Correspondence: William F. Wright, DO, MPH, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205 (); or Paul G. Auwaerter, MD, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 725 North Wolfe Street, Baltimore, MD 21205 ()
| | - Jiangxia Wang
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Şahin Ö, Ataş B, Metin Akcan Ö, Şen AE. 18F-FDG PET/CT Findings Overlapping Lymphoma in a Patient with Systemic Juvenile Idiopathic Arthritis. Mol Imaging Radionucl Ther 2023; 32:90-93. [PMID: 36820811 PMCID: PMC9950687 DOI: 10.4274/mirt.galenos.2021.30922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is an important autoinflammatory disease whose first symptom is usually fever, and life-threatening conditions such as macrophage activation syndrome can develop when diagnosis and treatment is delayed. sJIA is an exclusion diagnosis, and there is no specific test that distinguishes it from other febrile diseases. We report the positron emission tomography/computed tomography (PET/CT) findings of sJIA in a 12-year-old girl who presented with fever, rash, and arthralgia. 18F-fluorodeoxyglucose (FDG) uptake was observed in the spleen, bone marrow, and lymph nodes in 18F-FDG PET/CT performed to investigate the etiology of fever of unknown origin. The result of excisional biopsy performed with the suspicion of lymphoma from the left cervical lymph node with intense 18F-FDG uptake was reported as reactive hyperplasia. PET/CT is an alternative diagnostic method for patients with fever of unknown origin. In this case report, we emphasize that in patients with sJIA, there may be intense fluorodeoxyglucose-avid lymph nodes that may lead to the consideration of lymphoproliferative disease, and PET/CT findings along with spleen and bone marrow involvement may overlap with lymphoma.
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Affiliation(s)
- Özlem Şahin
- Necmettin Erbakan University, Meram Faculty of Medicine, Department of Nuclear Medicine, Konya, Turkey,* Address for Correspondence: Necmettin Erbakan University, Meram Faculty of Medicine, Department of Nuclear Medicine, Konya, Turkey Phone: +90 505 240 12 92 E-mail:
| | - Bülent Ataş
- Necmettin Erbakan University, Meram Faculty of Medicine, Department of Pediatric Nephrology, Konya, Turkey
| | - Özge Metin Akcan
- Necmettin Erbakan University, Meram Faculty of Medicine, Department of Pediatric Infectious Diseases, Konya, Turkey
| | - Ahmet Eren Şen
- Necmettin Erbakan University, Meram Faculty of Medicine, Department of Nuclear Medicine, Konya, Turkey
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Jiang D, Chen X, Li J, Zhao L, Dai H. Case report: Corticosteroid-resistant acute fibrinous and organizing pneumonia with myelodysplastic syndrome. Front Med (Lausanne) 2023; 9:1047783. [PMID: 36714123 PMCID: PMC9877430 DOI: 10.3389/fmed.2022.1047783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
Acute fibrinous and organizing pneumonia (AFOP) is a lung disease with an unusual pathological pattern. The definitive diagnosis of AFOP relies on pathological evidence of intra-alveolar fibrin exudate, lymphoplasmacytic infiltrate, and the absence of a hyaline membrane. Furthermore, its etiology is difficult to confirm, and corticosteroids are usually effective. Herein, we report the case of a young male who presented with high fever, hemocytopenia, and consolidation in both lungs. The initial misdiagnosis was community-acquired pneumonia. Subsequently, a lung biopsy revealed abundant fibrin and fibroblast exudates in the alveolar spaces, indicating AFOP. In addition, bone marrow biopsy and karyotype analysis demonstrated that the patient simultaneously had myelodysplastic syndrome (MDS) and hemophagocytic lymphohistiocytosis. In this case, the AFOP was considered secondary to MDS; however, the disease did not respond to glucocorticoid treatment or chemotherapy. Hence, AFOP should be considered in patients with underlying hematological diseases, and early identification and diagnosis are important. Furthermore, the management of patients with severe AFOP requires further investigation.
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Affiliation(s)
- Dingyuan Jiang
- National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medicine Sciences, Beijing, China
| | - Xueying Chen
- National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medicine Sciences, Beijing, China
| | - Jun Li
- National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medicine Sciences, Beijing, China
| | - Ling Zhao
- Laboratory Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Huaping Dai
- National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medicine Sciences, Beijing, China,*Correspondence: Huaping Dai ✉
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41
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Yoshida M, Zoshima T, Hara S, Takahashi Y, Nishioka R, Ito K, Mizuhima I, Inoue D, Nakada S, Kawano M. Case report: Rosai-Dorfman disease with rare extranodal lesions in the pelvis, heart, liver and skin. Front Oncol 2023; 12:1083500. [PMID: 36686758 PMCID: PMC9846742 DOI: 10.3389/fonc.2022.1083500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023] Open
Abstract
Rosai-Dorfman disease (RDD), a rare form of non-Langerhans cell histiocytosis, can involve systemic extranodal lesions. Skin lesions are the most common, whereas intrapelvic, cardiac, and hepatic lesions are infrequent. The present study describes a 74-year-old woman with multiple extranodal lesions in the pelvis, heart, liver, and skin that were successfully treated with glucocorticoid therapy. She had experienced fever and persistent inflammation without cervical lymphadenopathy for several months and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) showed abnormal FDG uptake in the left cheek; cervical, axillary, inguinal lymph nodes; periatrium; and pelvis. She was diagnosed with RDD based on skin and pelvic biopsies. Although this was an atypical case without bilateral cervical lymphadenopathy, the FDG-PET detection of inflammatory lesions led to selection of suitable biopsy sites, and pathological examination led to a correct diagnosis. Findings in this patient indicate that RDD can present with an atypical distribution of infrequent extranodal lesions, with attention required to prevent a delayed diagnosis.
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Affiliation(s)
- Misaki Yoshida
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takeshi Zoshima
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yoshinori Takahashi
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Ichiro Mizuhima
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satoko Nakada
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan,*Correspondence: Mitsuhiro Kawano,
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42
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Gamalero L, Giani T, Ferrara G, Cimaz R. Autoinflammatory diseases with Kawasaki-like onset: A case series. Pediatr Int 2023; 65:e15410. [PMID: 36326348 DOI: 10.1111/ped.15410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 10/18/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Teresa Giani
- Department of Clinical Sciences and Community Health and RECAP-RD, University of Milan, Milan, Italy
| | | | - Rolando Cimaz
- Department of Clinical Sciences and Community Health and RECAP-RD, University of Milan, Milan, Italy
- ASST G. Pini, Milan, Italy
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Zlotogwiazda II, Leone CS, Cuba MA, Amado VA, Celso P, Ferronato F, Romay S. [Multicentric Castleman disease and tuberculosis in HIV positive patient]. Medicina (B Aires) 2023; 83:298-302. [PMID: 37094200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
We present the case of a 40-year-old man, HIV positive with regular adherence to treatment, who consulted for intermittent febrile episodes during a two-years period, progressive diffuse abdominal pain and painless generalized lymphadenopathy in the last two months. Laboratory analysis showed pancytopenia, altered coagulation tests, hypoalbuminemia, and increased acute phase reactants. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepato-splenomegaly and generalized lymphadenopathy. Multiple microbiological tests were performed, including cultures for Mycobacterium sp. from different samples, with negative results, except for the RT-PCR for HHV-8. An excisional biopsy of the left iliac lymph node was taken with findings compatible with Castleman's disease. Despite restarting antiretroviral therapy, the symptoms progressed, starting treatment with steroids and ganciclovir. After a week, he developed multiple organ failure and anasarca, which contraindicated the drugs previously started. A new CT of the chest showed infiltrates with a tree-in-bud pattern in the right upper lobe with bilateral pleural effusion, and at the abdominal level, progression of hepatosplenomegaly and ascites. He was transferred to the intensive care unit 48 hours later due to fulminant hepatic failure. The patient died within a few hours. Postmortem recieved culture results of the tracheal aspirate were positive for tuberculosis (TB) and the histopathology of the liver biopsy showed non-necrotizing granulomas. Our objective is to highlight the importance of screening for active TB, in our country, when Castleman's disease is suspected, before starting treatment, and to stand out that TB can also present as an infectious complication, increasing morbidity and mortality.
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Affiliation(s)
- Iara I Zlotogwiazda
- Servicio de Medicina Interna, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina. E-mail:
| | - Cinthia S Leone
- Servicio de Medicina Interna, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - María A Cuba
- Servicio de Hematología, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - Viviana A Amado
- Servicio de Medicina Interna, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - Paula Celso
- Servicio de Medicina Interna, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - Francisco Ferronato
- Servicio de Anatomía Patológica, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - Salvador Romay
- Servicio de Medicina Interna, Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
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Muacevic A, Adler JR, O'Connell N, Conway R. Lessons Learned From a Case of Behcet's Disease Presenting With Fever and Life-Threatening Venous Thromboembolism. Cureus 2022; 14:e32546. [PMID: 36654597 PMCID: PMC9840407 DOI: 10.7759/cureus.32546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Infection mimics pose a challenge in the world of infectious diseases. Fever of unknown origin (FUO) requires careful consideration for a broad range of diagnoses. The answer often lies in a careful history and dedicated clinical examination. A delay in diagnosis can result in greater morbidity for the patient. We present the diagnostic challenges in a patient with an infection mimic, Behcet's disease (BD), who presented with recurrent venous thromboembolism (VTE) and fever of unknown origin (FUO). We present the case of a 53-year-old male of Irish Caucasian ethnicity who presented with a history of fevers and recurrent VTE at a university hospital in Dublin, Ireland. Past medical history includes schistosomiasis, which was treated following a trip to sub-Saharan Africa. Our patient was previously diagnosed with a provoked deep vein thrombosis (DVT). He went on to experience four subsequent episodes of VTE, including DVT, pulmonary embolism (PE), and cerebral venous sinus thrombosis (CVST) while on different forms of anticoagulation. On each of these occasions, there was a concern for sepsis due to fevers > 38°C and a C-reactive protein (CRP) > 200 mg/L. The infection workup included routine laboratory tests, blood and urine cultures, CT of the abdomen and pelvis (CTAP), echocardiogram, and PET-CT, all of which were unrevealing. However, a focused clinical examination revealed evidence of subtle scrotal and oral ulceration, pustulation, and erythema at several sites in his upper limb following venesection and cannulation. In this context, a diagnosis of Behcet's disease was considered. A diagnosis of Behcet's disease can only be confidently made after the exclusion of other potential etiologies. In this case, we had to consider a broad range of infectious (malaria, schistosomiasis, rickettsial disease, and endocarditis) and noninfectious (malignancy, antiphospholipid syndrome (APS), myeloproliferative disorders, and paroxysmal nocturnal hemoglobinuria (PNH)) diseases. A delay in diagnosis comes at the cost of increased morbidity and mortality for the patient. A detailed history and clinical examination are key, in addition to a high index of suspicion. Following the induction of high-dose steroid, our patient is doing very well on maintenance adalimumab. From an anticoagulation perspective, he is warfarinized and has not had any further episodes of VTE.
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45
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Muacevic A, Adler JR. Fever of Unknown Origin and Atrial Fibrillation: A Case Report. Cureus 2022; 14:e32472. [PMID: 36644072 PMCID: PMC9835392 DOI: 10.7759/cureus.32472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Fever of unknown origin describes a temperature greater than 100.9°F which is present on multiple instances for a period over three weeks with no confirmed diagnosis despite a minimum of three outpatient visits, three days of inpatient testing, or one week of extensive outpatient testing. This diagnosis presents challenges in clinical management due to the unknown etiology. This case highlights a fever of unknown origin presenting with new-onset atrial fibrillation in a patient with no previous cardiac history. A 62-year-old Caucasian male presented to the ED with a nine-day history of intermittent fevers and chills. He returned from a rafting trip in North Carolina two weeks ago but reported no tick bites, animal encounters, or river water ingestion. Further evaluation was significant for an elevated white blood cell count and elevated inflammatory markers. Laboratory and radiologic testing for a wide array of infectious and malignant etiologies were unremarkable. Soon after hospital presentation, he developed a fever of 102.9°F with new onset palpitations and chest tightness due to atrial fibrillation. Episodes of atrial fibrillation continued for his seven-day hospital course with more severe symptoms in the evenings. He was administered broad-spectrum antibiotics and tested extensively with no definitive etiology. His fever curve downtrended with max temperatures below 100.9°F on hospital days six and seven with asymptomatic episodes of atrial fibrillation, prompting discharge. He continued to have low-grade fevers measured below 100.9°F for several days post-discharge with no associated symptoms, resulting in a diagnosis of fever of unknown origin following the 21st day. Fever of unknown origin is a clinical challenge, particularly in cases with no diagnosis discovered and cases with potentially life-threatening complications such as atrial fibrillation. This patient had multiple potential etiologies for his condition, but none had sufficient evidence for diagnosis, resulting in uncertainty regarding the ideal management. As a result, constant monitoring with supportive treatments and broad-spectrum antibiotics was utilized. These measures allowed for symptom remission and hospital discharge for outpatient follow-up. This case highlights a rare presentation of fever of unknown origin with new-onset atrial fibrillation in an otherwise healthy adult.
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46
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Toriumi R, Yaegashi H, Kadomoto S, Iwamoto H, Iijima M, Kawaguchi S, Nohara T, Shigehara K, Izumi K, Kadono Y, Mizokami A. Decreased febrile neutropenia during inpatient chemotherapy for urologic cancer during coronavirus disease 2019 pandemic. Cancer Sci 2022; 114:201-210. [PMID: 35838191 PMCID: PMC9349703 DOI: 10.1111/cas.15490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/08/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023] Open
Abstract
Since 2020, the coronavirus disease 2019 pandemic has led to the widespread practice of hand hygiene and wearing face masks, not only among medical personnel, but also among the general population. Thus, the impact of the coronavirus disease 2019 pandemic on the incidence of febrile neutropenia should be verified. This study aimed to examine the incidence of febrile neutropenia in hospitalized patients receiving chemotherapy at Kanazawa University Hospital. Among inpatients at the Department of Urology receiving chemotherapy, we compared the incidence of febrile neutropenia between 317 cases in 2018-2019 and 276 cases in 2020. We retrospectively analyzed the factors of febrile neutropenia via binomial logistic regression analysis based on patient characteristics and the characteristics of primary diseases, with statistical significance set at p < 0.05. Febrile neutropenia occurred in 20/317 cases in 2018-2019 and 1/276 cases in 2020, with a significant decrease in the latter (p = 0.005). In a multivariate analysis, we identified the following independent risk factors for febrile neutropenia: non-coronavirus disease 2019 era (p = 0.005), first course of therapy (p = 0.005), malnutrition (p = 0.032), and past history of febrile neutropenia (p = 0.018). Due to the coronavirus disease 2019 pandemic, hygiene policies for medical personnel and quarantine measures for patients were thoroughly implemented. Therefore, the incidence of febrile neutropenia in 2020 decreased to 1/15 of the previous incidence. Thus, the hygiene for medical personnel and patients during the expected period of chemotherapy-induced neutropenia is important for febrile neutropenia prevention.
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Affiliation(s)
- Ren Toriumi
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Hiroshi Yaegashi
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Suguru Kadomoto
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Hiroaki Iwamoto
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Masashi Iijima
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Shohei Kawaguchi
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Takahiro Nohara
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Kazuyoshi Shigehara
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Kouji Izumi
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Yoshifumi Kadono
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
| | - Atsushi Mizokami
- Department of Integrative Cancer Therapy and UrologyKanazawa University Graduate School of Medical ScienceKanazawaJapan
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Möhler R, Jenetzky E, Schwarz S, Gwiasda M, Rathjens L, Szoke H, Martin D. Parental Confidence in Relation to Antipyretic Use, Warning Signs, Symptoms and Well-Being in Fever Management-Results from an App-Based Registry. Int J Environ Res Public Health 2022; 19:14502. [PMID: 36361379 PMCID: PMC9654195 DOI: 10.3390/ijerph192114502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/27/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
Parents' confidence regarding their children's fever is a key factor in its management and there is still unnecessary anxiety and associated antipyretic overuse. The FeverApp application collects naturalistic real-time data on febrile infections and educates parents on fever management. Logistic regression examined the associations between (1) parental confidence and (2) antipyretics use with fever relevant parameters. First entry data of 3721 children (mean age 21 months; SD 22.97) was assessed. A total of 58.0% of parents felt confident upon first fever documentation. Warning signs [OR = 0.49, 95% CI: 0.40-0.61], dehydration [OR = 0.65, 95% CI: 0.52-0.81], fever [OR = 0.67, 95% CI: 0.57-0.80] and having a female child [OR = 0.77, 95% CI: 0.66-0.90] had the highest negative association with parental confidence. Antipyretics were used initially in 14.7% of children. Fever had the highest positive [OR = 2.58, 95% CI: 1.89-3.50] and well-being the highest negative association with antipyretic use [OR = 0.37, 95% CI: 0.22-0.63). In the first entry data, parental confidence was related to children's health condition in a reasonable medical manner. The use of antipyretics was mostly associated with febrile temperature, but also low well-being. Thus, associations were partly in accordance with recent guidelines.
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Affiliation(s)
- Ricarda Möhler
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Ekkehart Jenetzky
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes-Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Silke Schwarz
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Moritz Gwiasda
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Larisa Rathjens
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Henrik Szoke
- Department of Integrative Medicine, Faculty of Health Sciences, University of Pécs, 7622 Pecs, Hungary
| | - David Martin
- Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
- Department of Pediatrics, Eberhard-Karls University Tübingen, 72076 Tübingen, Germany
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48
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Maita H, Kobayashi T, Akimoto T, Osawa H, Kato H. Pseudo-fever caused by predictive electronic thermometers: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221129772. [PMID: 36225225 PMCID: PMC9548687 DOI: 10.1177/2050313x221129772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
A 33-year-old man was referred to our hospital with chief complaints of fever, dizziness, and headache. Although he had recurring fever and dizziness for 7 months, neurological examination, magnetic resonance imaging, computed tomography, electrocardiograms, and blood tests were normal. He was diagnosed with functional hyperthermia, cervical vertigo, and tension headache and was treated with oral medication and physical therapy. After treatment, the dizziness and headache resolved; however, the fever and anxiety did not. During follow-up, he noticed differing results from different electronic thermometers. The physician decided to use an accurate analog thermometer, a gallium thermometer, in combination with the other thermometers. The results differed significantly among the thermometers, and the electronic thermometer readings were found to be inappropriately high. The physician made a diagnosis of pseudo-fever, and the patient recognized that the gallium thermometer's results were the most accurate reflection of his physical condition, resolving his anxiety.
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Affiliation(s)
- Hiroki Maita
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Aomori, Japan,Hiroki Maita, Development of Community Healthcare, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki-shi, Aomori 036-8562, Japan
| | - Tadashi Kobayashi
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
| | - Takashi Akimoto
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
| | - Hiroshi Osawa
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan
| | - Hiroyuki Kato
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Aomori, Japan,Department of General Medicine, Hirosaki University School of Medicine and Hospital, Aomori, Japan,General Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan
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49
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Kano Y, Sugihara M. Schnitzler Syndrome Presenting as a Fever of Unknown Origin with Elevated Alkaline Phosphatase Levels. Intern Med 2022; 62:1361-1364. [PMID: 36171123 DOI: 10.2169/internalmedicine.0359-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Schnitzler syndrome (SchS) is a rare, acquired, autoinflammatory disease that is sometimes associated with a fever of unknown origin (FUO). Elevated alkaline phosphatase (ALP) stemming from abnormal bone remodeling is a characteristic laboratory finding of SchS and is included in the diagnostic criteria. However, its utility as a clue to the diagnosis of SchS has been under-emphasized. We herein report a case of SchS presenting with a FUO and highly elevated ALP concentration, which led to repeated, unnecessary liver biopsies.
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Affiliation(s)
- Yasuhiro Kano
- Department of General Internal Medicine, Tokyo Metropolitan Tama Medical Center, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama-Hokubu Medical Center, Japan
| | - Makoto Sugihara
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama-Hokubu Medical Center, Japan
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50
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Krase IZ, Woodward J, Bauer CS, Miller H, Sacco K. Seronegative Mediastinal Coccidioidomycosis as a Novel Presentation of CTPS1 Combined Immunodeficiency. Open Forum Infect Dis 2022; 9:ofac403. [PMID: 35983265 PMCID: PMC9379812 DOI: 10.1093/ofid/ofac403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/02/2022] [Indexed: 11/14/2022] Open
Abstract
Inborn errors of immunity may present with susceptibility to coccidioidomycosis. This is especially so in disorders impairing the interferon-γ and interleukin 12 signaling axis. We describe the first case of cytidine nucleotide triphosphate synthetase 1 (CTPS1) deficiency, a combined immunodeficiency impairing lymphocyte proliferation, presenting with coccidioidomycosis.
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Affiliation(s)
- Ifat Z Krase
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - James Woodward
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Cindy S Bauer
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Holly Miller
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Keith Sacco
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
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