Fever of unknown origin and splenomegaly: A case report of blood culture negative endocarditis

RATIONALE

Fever of unknown origin (FUO) can be determined by different conditions among which infectious diseases represent the main cause.

PATIENT CONCERNS

A young woman, with a history of aortic stenosis, was admitted to our unit for a month of intermittent fever associated with a new diastolic heart murmur and splenomegaly. Laboratory tests were negative for infectious screening. The total body computed tomography (CT) scan excluded abscesses, occulted neoplasia, or lymphadenopathy.

DIAGNOSES

The transthoracic and transesophageal echocardiogram showed an aortic valve vegetation. Three sets of blood cultures were negative for all microorganisms tested. According to these findings, Bartonella endocarditis was suspected and the serology tests performed were positive. Finally, real-time polymerase chain reaction (RT-PCR) detected Bartonella henselae DNA on tissue valve.

INTERVENTIONS

The patient underwent heart valve surgery and a treatment of Ampicillin, Gentamicin, and oral Doxycycline was prescribed for 16 days and, successively, with Doxycycline and Ceftriaxone for 6 weeks.

OUTCOMES

After surgery and antibiotic therapy, patient continued to do well.

LESSONS

Bartonella species are frequently the cause of negative blood culture endocarditis. Molecular biology techniques are the only useful tool for diagnosis. Valvular replacement is often necessary and antibiotic regimen with Gentamicin and either Ceftriaxone or Doxycycline is suggested as treatment.Echocardiogram and blood cultures must be performed in all cases of FUO. When blood cultures are negative and echocardiographic tools are indicative, early use of Bartonella serology is recommended.

Necrotizing Polyarteritis Nodosa-like Vasculitis in a Child with Systemic Lupus Erythematosus

A 10-year-old child presented with prolonged fever, lymphadenopathy, weight loss, oral ulcers, alopecia and parotitis. She later developed arterial thrombosis, poly-serositis, nephritis, myocarditis, sacro-ilitis, autoimmune hemolytic anemia and refractory thrombocytopenia. Though anti-dsDNA was negative, she was diagnosed to have systemic lupus erythematosus (SLE). Terminally, she had pulmonary symptoms and succumbed to her illness. The autopsy showed lupus nephritis-Class II, polyserositis, myocarditis, inflammatory myositis, immune mediated vasculitis involving renal, coronary, pancreatic, adrenal, dermal and intramuscular arteries, and pulmonary hemorrhages and edema.

Lesson of the month 1: Subacute thyroiditis: a rare cause of fever of unknown origin

Fever of unknown origin (FUO) is sometimes a diagnostic dilemma for clinicians. Endocrine causes reported in the literature include subacute thyroiditis, thyrotoxicosis, adrenal insufficiency and pheochromocytoma. Among these, subacute thyroiditis is often overlooked as it can occasionally lack typical symptoms. This case illustrates the fact that subacute thyroiditis should be considered as a possible cause of fever even if signs and symptoms of hyperthyroidism and thyroid tenderness are absent.

[Muscle tissue lymphoma presenting only with fever of unknown origin: a case report and literature review]

Extra-nodal malignant lymphoma is often characterized by a lack of typical symptoms and positive results of auxiliary examinations, which make diagnosis difficult. In some cases, fever can be the only clinical manifestation. For the lymphoma patients presenting with persistent fever with a duration over 3 weeks, characteristics of fever including time of fever attack, fever type and effects of drugs may have significant value in the diagnosis, especially in the early stage of the disease or in rare cases.

[Febrile episodes of unknown origin, elevated level of plasma ferritin and rapidly developed multiorgan dysfunction]

A previously healthy 40-year-old man developed febrile episodes of unknown origin, articular symptoms, venous occlusion of the lower limb and transient elevation of hepatic enzymes, and cutaneous symptoms. Computed tomography scanning revealed enlarged lymph nodes, but no sample was collected. In addition to microcytic anemia, a high serum ferritin level and an increased IL-2 receptor value in serum were found. Drug therapy against tuberculosis and borreliosis was started, but febrile episodes continued and in a few days the patient developed multiorgan dysfunction. Hemophagocytic lymphohistiocytosis associated with T-cell lymphoma was revealed as the underlying condition.

Evaluation of diagnostic performance of 18F-FDG-PET compared to CT in detecting potential causes of fever of unknown origin in an academic centre

Determining the cause of fever of unknown origin (FUO) often proves challenging to attending physicians and the role of conventional imaging in this setting has been uncertain. In this retrospective study, we examined the role of fluorine-18 fluorodesoxyglucose-positron emission tomography ((18)F-FDG-PET) compared to computed tomography (CT) in diagnosing the potential etiology of FUO. To accomplish this task, we identified patients with FUO who underwent (18)F-FDG-PET for detecting the source of fever. Twenty-four patients (16 males and 8 females, age range = 17-80, mean age = 49.5) were examined with (18)F-FDG-PET of which 18 were also assessed with a diagnostic CT (within 3 weeks, mean interval = 7.5 days). The PET and CT findings were reviewed and the presence of focal (18)F-FDG uptake or gross CT lesions was considered a potential site causing FUO. Of patients who underwent PET alone, ⅚ were reported as positive. Of the 18 who had both PET and diagnostic CT, PET was positive in 18 and CT was positive in only 7 cases. Of positive findings on PET, etiologies included infection (11), non-infectious inflammation (8), lymphoma (3), and other cancers (1). Of positive findings on CT, etiologies included infection (3), lymphoma (1), non-infectious inflammation (2) and other cancers (1). Importantly, we found no cases with positive CT and negative PET findings. In conclusion, accordingly to our findings, (18)F-FDG-PET appears to be of great value in assessing patients with FUO, especially when caused by infection or inflammation. Fluorine-18 FDG-PET is more sensitive than diagnostic CT in detecting and localizing diseased sites, and is the optimal imaging modality to evaluate patients with FUO.

[Comparison between two educative strategies for clinical aptitude in unknown origin fever]

OBJECTIVE

to evaluate the benefit of a participative educative strategy (PES) in the development of clinical skills to study patients with fever of unknown origin (CAFUO) by internal medicine residents (IMR).

METHODS

twenty-two IMR participated. They were distributed at random in two groups; group I received passive strategy and group II received PES. Assessment tool consisted of 144 items of multiple choice questions using six clinical cases. The assessment was discussed and answered by 10 internal medicine specialists and a pilot test with 15 medical students was performed. The tests were applied pre- and post-exhibition of the strategy.

RESULTS

there were no differences between groups, or in pre- and post-strategy, neither in the same group. Pre-strategy did not demonstrate differences between both groups. In group II, the post-strategy showed difference in the global results. The evaluation of each clinical case by group showed in group I there was statistical difference in case 2; in group II (experimental) there was difference in cases 1, 2, 4 and 6.

CONCLUSIONS

both strategies were useful, the residents developed comparable aptitude.

Inflammatory pseudotumour of the liver: a diagnostic dilemma

Inflammatory pseudotumour is a rare, focal, benign inflammatory lesion of the liver parenchyma. It is largely a self-limiting entity and has favorable prognosis; it is thus important to preoperatively distinguish this lesion from malignancy, which it closely imitates. Inflammatory pseudotumour may present variously. We present the case of a 54-year old gentleman who presented with a three-month history of low-grade intermittent fever. Ultrasonography and computed tomography revealed a mass in the left lobe of the liver and the erythrocyte sedimentation rate was raised with coincident hypergammaglobulinaemia. A diagnostic laparotomy with left lateral hepatectomy was performed and histopathological evaluation of the specimen along with special staining and tissue culture revealed an inflammatory pseudotumour. On the second day post-operative the fever subsided and following an uneventful five days the patient was discharged and remains well at one-year follow up with no recurrence or relapse.

Infectious complication in 314 patients after high-dose therapy and autologous hematopoietic stem cell transplantation: risk factors analysis and outcome

BACKGROUND

Infectious complications occur in most of the patients receiving high-dose therapy (HDT) and autologous hematopoietic stem cell transplantation (HSCT). The objective of the study was to analyze of the type and incidence of infectious complications during neutropenia after HDT and autologous HSCT with respect to risk factors related to stem cell transplant setting in patients treated for hematological malignancies in a single center.

PATIENTS AND METHODS

A total number of 314 patients diagnosed for Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), acute myeloid leukemia (AML), multiple myeloma (MM) or acute lymphoblastic leukemia (ALL) were included in the study. Analysis of risk factors and outcome of infections after HDT and autologous HSCT was performed.

RESULTS

Infectious complications during neutropenia after HDT occurred in 92.3% patients. Microbiologically documented infections (MDI) accounted for 38.9% of febrile episodes, clinically documented infections (CDI) for 9.3%, and fever of unknown origin (FUO) for 51.7% cases. Median time to defervescence with antibiotic therapy was seven days for FUO and nine days for documented infections (p < 0.001). Duration of infection correlated with the length of very severe neutropenia (p < 0.001). Response to first-line antibiotic therapy was seen in 34% patients. Infections were fatal in 12 (3.8%) patients. The highest probability of infection was observed for ALL and AML patients, especially these conditioned with total body irradiation (TBI).

CONCLUSION

Patients at high risk of infection after autologous HSCT were identified as those with acute leukemia and those after conditioning with TBI, all with prolonged neutropenia. We suggest that newer prophylactic strategies should be administered to these groups of patients.

Lofgren's syndrome presenting as a case of fever of unknown origin

A 29-year-old black male had multiple hospital admissions for fever (101 degrees F-104 degrees F) of unknown origin. Over six months, the patient had a constellation of symptoms, including pleuritic chest pain, dry cough, arthralgias of hand joints and marked constitutional symptoms including weigh loss. Patient had erythema nodosum, generalized lymphadenopathy, multiple subcutaneous nodules over the epigastric region and a nodule in his left eye. The patient had bilateral hilar lymphadenopathy, mildly enlarged mediastinal lymph nodes, right upper and lower lobes infiltrate and right side pleural effusion. Patient also had cardiomyopathy with EF 35 percent. Workup for HIV, TB, atypical mycobacterium, infectious mononucleosis, CMV, toxoplasmosis, syphilis and fungal etiologies were negative. Initial rheumatological workup was also negative. Despite a broad spectrum of empiric antibiotics, the patient was having a daily spike of temperature. A left supraclavicular lymph node biopsy showed small non-caseating granuloma typical for sarcoidosis. This patient had fever of unknown origin secondary to a sub acute form of sarcoidosis, with marked constitutional symptoms, bilateral hilar and mediastinal lymphadenopathy, erythema nodosum, and arthralgias--a setof findings sometimes referred to as Lofgren's syndrome.

Dengue virus infections in the first 2 years of life and the kinetics of transplacentally transferred dengue neutralizing antibodies in thai children

BACKGROUND

Understanding dengue virus infection in children and the kinetics of maternal dengue neutralizing antibodies is essential for effective dengue immunization of children in endemic areas.

METHODS

Serum samples from 219 mother-child pairs and 140 children at 3, 6, 9, 12, 18, and 24 months of age from Bangkok, Thailand, were tested for serotype-specific dengue antibodies. Febrile episodes in the children were recorded.

RESULTS

Antibodies were found in 97% of cord serum samples and disappeared in 27%, 80%, and 95% of the children by the age of 6, 9, and 12 months, respectively. Geometric mean titers (GMTs) of the antibodies to 4 dengue serotypes decreased to 5.4-15.5 in 6-month-old infants. Eleven of 12 children acquired dengue virus infection at 6 months of age and beyond; 1 had the infection at 3 months of age. Two exhibited undifferentiated febrile illnesses, and 10 had subclinical infections.

CONCLUSIONS

Evidence of dengue virus infection and very low GMTs against all dengue serotypes in children at 6 months of age and beyond was demonstrated. There was no evidence that maternal antibodies were harmful to infants. Dengue virus infection rates increase from 12 months of age onward. These data provide information for supporting the optimal age at vaccination.