Interstitial Lung Disease as an Initial Manifestation of Giant Cell Arteritis

Interstitial lung disease (ILD) has rarely been reported as a manifestation of giant cell arteritis (GCA). We herein report a unique case of GCA in a 76-year-old woman who presented with ILD as an initial manifestation of GCA. Ten years before admission, she had been diagnosed with granulomatous ILD of unknown etiology. Corticosteroid therapy induced remission. One year after the cessation of corticosteroid therapy, she was admitted with a persistent fever. After admission, she developed left oculomotor paralysis. Positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (¹⁸F-FDG PET/CT) proved extremely useful in establishing the diagnosis. Our case promotes awareness of GCA as a possible diagnosis for granulomatous ILD with unknown etiology.

The ying and yang of fever in rheumatic disease

Fevers are relatively common in rheumatic disease, largely due to the fact that the inflammatory process is driven by inflammatory mediators that function as endogenous pyrogens. Since the immune system's sensors cannot accurately distinguish between endogenous and exogenous (pathogen-derived) pyrogens a major challenge for physicians and rheumatologists has been to decipher patterns of clinical signs and symptoms to inform clinical decision making. Here we describe some of the common pitfalls and clinical challenges, and highlight the importance of a systematic approach to investigating the rheumatic disease patient presenting with fever.

Kikuchi-Fujimoto disease as a rare cause of fever of unknown origin in a septuagenarian

We report the case of a 72-year patient presented with fever of unknown origin. Initial clinical and radiological findings suggested a diagnosis of lymphoma. However, subsequent histology revealed Kikuchi-Fujimoto disease (KFD). KFD is predominantly a self-limiting disease of the young, but should be considered in the differential diagnosis of older patients presenting with fever of unknown origin or features suggestive of lymphoma.

Primary cytomegalovirus infection in otherwise healthy adults with Fever of unknown origin: a 3-year prospective survey

BACKGROUND

Primary cytomegalovirus disease is probably still underestimated or missed in common clinical practice, and further prevalence studies should be performed, in particular in the setting of fever of under-determined origin (FUO) in adults.

PATIENTS AND METHODS

In a 3-year prospective survey of 123 consecutive adult patients referred for FUO often associated with a broad spectrum of constitutional signs and symptoms, 18 patients (14.6%) were found to have a primary cytomegalovirus infection, after a clinical, instrumental and laboratory workup.

RESULTS

In the majority of cases, this syndrome was consistently associated with altered white blood cell count, abnormal T-lymphocyte subsets and ultrasonography-confirmed hepatosplenomegaly. On the other hand, altered white blood cell differential and serum hepatic enzymes, and constitutional signs and symptoms were absent in 11.1-27.8% of cases, and an initial laboratory cross-reaction with anti-Epstein-Barr IgM antibodies was detected in 44.4% of episodes. Non-specific signs and symptoms were the only features in 27.8% of patients with adult cytomegalovirus disease, thus, confirming that this disorder may be still clinically underestimated, until virologic assays are performed. A prolonged and varied spectrum of subjective disturbances (similar to those encountered in infectious mononucleosis), which often limited daily activities, involved nearly 30% of subjects, and lasted for 3-15 months after recovery of acute cytomegalovirus disease.

CONCLUSION

In the clinical, laboratory, and instrumental workup for FUO, rapid recognition of a primary cytomegalovirus disease is useful to exclude alternative diagnoses, avoid non-necessary exposure to antibiotics, and reassure patients of their self-limiting, benign disorder.

Splenic tumor presenting as pyrexia of unknown origin

Pyrexia of unknown origin has always been a challenging problem to diagnose for physicians. Here we present a case of a splenic tumor, which after histopathology and immunohistochemistry, two possibilities were considered, a diffuse large cell lymphoma--plasmablastic variant and second an anaplastic plasmacytoma. The patient was treated with chemotherapy and on followup he has no evidence of recurrence or any residual lesion.

[18F]fluorodeoxyglucose positron emission tomography is a useful tool to diagnose the early stage of Takayasu's arteritis and to evaluate the activity of the disease

Takayasu's arteritis (TA) is a rare disease that can be difficult to diagnose in its early stage. A young woman with a fever and neck pain was thought to have TA, although computed tomographic angiography did not show any specific changes of the arteries. [(18)F]fluorodeoxyglucose positron emission tomography ([(18)F]FDG-PET) was performed to detect the source of the inflammation. Specific accumulation of [(18)F]FDG-6-phosphate in the thoracic aorta and its direct branches was observed, leading to a diagnosis of TA. [(18)F]FDG-PET is therefore considered to be useful for the diagnosis of early-stage TA.

Haemophagocytic syndrome presenting as pyrexia of unknown origin

Haemophagocytic syndrome (HPS) should be included in the differential diagnosis of pyrexia of unknown origin (PUO). The hallmark of HPS is the accumulation of activated macrophages that engulf haematopoietic cells in the reticuloendothelial system. We describe a patient with unexplained fever in which a final diagnosis of HPS was established in a bone marrow study.

Reverse Shapiro's syndrome--an unusual cause of fever of unknown origin

Reverse Shapiro's syndrome was first described by Hirayama et al. in a girl with periodic hyperthermia associated with complete agenesis of the corpus callosum. Here we report another such case in a 9-month-old girl presenting with fever of unknown origin since the age of 7 months. On examination, she had mild hypotonia with delayed developmental milestones. No other neurological or physical abnormalities were noted. The cause of her prolonged fever of unknown origin was investigated and all results were negative. Her brain magnetic resonance images showed agenesis of the corpus callosum. On the basis of the previous literature, we suggest that the periodic hyperthermia of this girl was caused by dopaminergic denervation of the hypothalamic thermoregulatory center. Treatment with dopamine agonists (levodopa plus carbidopa) failed to control the hyperthermia.

Fever of unknown origin: keys to determining the etiology in older patients

In light of improvements in imaging modalities and laboratory tests, fewer cases of fever of unknown origin (FUO) are being attributed to infectious causes and more are eventually being diagnosed as secondary to noninfectious causes, particularly tumors and connective tissue diseases. Older patients with FUO usually present with mild, nonspecific, normochromic, and normocytic anemia and an elevated erythrocyte sedimentation rate. The history, physical examination, and imaging studies are key to making a diagnosis. Although the results of laboratory tests are generally nonspecific, such tests are appropriate nonetheless. Obtaining repeat blood cultures is mandatory. However, before undertaking a diagnostic evaluation of geriatric FUO, it is important to consider the patient's overall health. In certain circumstances, it is more important to maintain a patient's quality of life than it is to initiate the process of identifying and treating a persistent fever. The work-up and treatment should not be worse than the disease.

[Contribution of recent physiopathogenic progresses to the diagnosis of recurrent fevers]

Recurrent fevers are characterized by fever lasting for a few days or few weeks and followed by a fever-free interval and state of well-being. It is first necessary to eliminate infections, which are the most common causes of fever. Several recurrent fevers belong to inflammatory diseases of unclear physiopathogeny. Recent advances are now available permitting to immunogenetically identify some of them. It also opens a better understanding and consequently the possibility of specific therapeutic approach.

Hyperthermia following traumatic brain injury: a critical evaluation

Hyperthermia, frequently seen in patients following traumatic brain injury (TBI), may be due to posttraumatic cerebral inflammation, direct hypothalamic damage, or secondary infection resulting in fever. Regardless of the underlying cause, hyperthermia increases metabolic expenditure, glutamate release, and neutrophil activity to levels higher than those occurring in the normothermic brain-injured patient. This synergism may further compromise the injured brain, enhancing the vulnerability to secondary pathogenic events, thereby exacerbating neuronal damage. Although rigorous control of normal body temperature is the current standard of care for the brain-injured patient, patient management strategies currently available are often suboptimal and may be contraindicated. This article represents a compendium of published work regarding the state of knowledge of the relationship between hyperthermia and TBI, as well as a critical examination of current management strategies.

Overt and occult rheumatic diseases: the child with chronic fever

Identification of the genes involved in hereditary periodic fever syndromes has led to the recognition of a new pathophysiological category, the autoinflammatory disorders. The main non-hereditary autoinflammatory disease in childhood is systemic juvenile idiopathic arthritis (sJIA), others being the chronic infantile neurological cutaneous arthropathy (CINCA) syndrome and the periodic fever, aphthous stomatitis, pharyngitis and adenopathy (PFAPA) syndrome. Familial Mediterranean fever (FMF) has been traced to mutations in the MEFV gene. Mutations in the MVK gene, encoding the enzyme mevalonate kinase, cause the hyper-IgD periodic fever syndrome (HIDS). The tumour necrosis factor(TNF)-receptor-associated periodic syndromes (TRAPS) have been linked to mutations in theTNFRSF1A gene, encoding a TNF-alpha receptor, and the CIAS1 gene is mutated in familial cold autoinflammatory syndrome. We discuss how this knowledge has influenced diagnosis and treatment of these rare genetic disorders and how it might change our approach to the more common rheumatic diseases.

Association of prolonged fever and hypernatremia: rare presentation of hypothalamic/third ventricle tumor in a toddler

The authors describe a 2-year-old boy with a clinical presentation of prolonged fever of unknown origin and severe hypernatremia. This rare association was the result of a hypothalamic/third ventricle tumor. The lesion was removed and was found to be a low-grade neuronal tumor. After surgery, the child did generally well, but hypothalamic thermoregulatory and osmoregulatory functions were not restored. These presenting symptoms, their pathophysiology, and the implications for pediatric practice are discussed.

Evidence of recurrent atypical meningioma with rhabdoid transformation and expression of pyrogenic cytokines in a child presenting with a marked acute-phase response: case report and review of the literature

Children presenting with acute systemic illnesses that lack specific clinical or serological defining features may be diagnosed as having a chronic infection, an atypical systemic vasculitis or a connective tissue disease, but often turn out to have occult neoplasias. Cytokines have been implicated in causing many of the systemic effects in such cases. In this study, we describe the case of a 9-year-old boy presenting at an interval of 18 months with a marked acute-phase response due to a recurrent atypical meningioma with rhabdoid transformation of the tentorium cerebelli. Resection of the recurrent tumor was curative. We evaluated in detail the local and systemic production of cytokines released by the primary and the recurrent tumor. Blood and CSF samples were taken pre-, intra-, and postoperatively, and the production of IL-6, IL-1beta, and TNF-alpha was measured by enzyme-linked immunosorbent assays (ELISA). The level of IL-6 in CSF was about 150-fold increased before tumor resection, normalizing postoperatively. On the contrary, the levels of IL-1beta and TNF-alpha in CSF and of IL-6, IL-1beta, and TNF-alpha in serum were pre-, intra-, and postoperatively within normal limits. Cytokine production was also evaluated immunohistochemically, and confirmed strong IL-6 and TNF-alpha expression in the primary and the recurrent tumor, while expression of IL-1beta was lacking. The scattered MHC class II- and leukocyte common antigen (LCA)-expressing inflammatory cells, which were infiltrating exclusively the tumoral stroma, had no detectable cytokine immunoreactivity. We conclude that chronic IL-6 and TNF-alpha production by the tumor cells in this patient was responsible for the severe systemic illness with which he presented.

Fever of unknown origin in patients undergoing chemotherapy

Drug fever refers to a febrile response to a drug, and its clinical picture often resembles an allergic reaction or infection. The fever most commonly occurs 7-10 days after drug administration, persists as long as the drug is continued, and disappears soon after stopping the drug (Tabor, 1986). The risks and benefits of continuing a drug that causes fever must be evaluated for every patient who experiences drug fevers. Quality-of-life issues arise for patients who experience them despite the concurrent use of steroids. Recognizing drug fever is of great clinical importance. If drug fever is not recognized, patients may be subjected to prolonged hospitalizations and unnecessary testing and medications (Johnson & Cunha, 1996). Oncology nurses play an important role in the early recognition of drug fever.

Fever without source in children. Recommendations for outpatient care in those up to 3

It is the author's goal to reduce risk to a minimum in children with fever without source at a reasonable cost with guidelines that are practical for office-based physicians. Recommendations are as follows: All febrile infants and children up to 36 months of age who have toxic manifestations are to be hospitalized for parenteral antibiotic therapy after an expeditious evaluation of their condition that includes cultures of blood, urine, and cerebrospinal fluid. All febrile infants 7 days of age or less should be hospitalized for empirical antibiotic therapy after a complete evaluation for sepsis and meningitis has been done. Some low-risk febrile infants 8 to 28 days of age who appear well may be observed closely, either in hospital (with or without empirical antibiotic therapy) or as outpatients if the physician believes that close follow-up is ensured. Febrile infants 28 to 90 days of age should have an evaluation to determine whether they are in a low-risk group. Those not meeting low-risk criteria should be hospitalized for a complete "sepsis workup" and close observation, with or without empirical antibiotic therapy. Those who are considered low-risk can be treated as outpatients, as described, if close follow-up is ensured. No laboratory tests or antibiotics are needed in a child over 90 days of age who has a temperature of less than 39 degrees C (102.2 degrees F) without identifiable source. A return visit is recommended if the child's fever persists for more than 2 to 3 days or if the condition deteriorates. A child with a fever of 39 degrees C or above can also be treated as an outpatient without antibiotics if close follow-up is ensured. Otherwise, a WBC count or ANC should be done. In those whose WBC count is 15,000/mm3 or more or whose ANC is 10,000 cells/mm3 or more, a blood culture should be done, and pending results, a single injection of ceftriaxone, 50 mg/kg, should be given.

[Experimental model of subfebrile condition of central origin]

Central model of subfebrility was experimentally developed using administration of fresh homologous blood from an unanesthetised donor into the rat brain lateral ventricle. Rectal temperature significantly increased by the end of the 1st day of the administration. Duration of the hyperthermic response was about 8 days. The body temperature rise varied from 0.45 to 0.7 degrees C. The central subfebrility had no initial fenrile phase. An increased level of glucose in the blood serum during central subfebrility suggests an altered activity of the sympathetic nervous system to be one of the causes of the subfebrility development.

Fever without apparent source on clinical examination, infectious diseases, and lower respiratory infections in children

This section focuses on issues in infectious diseases that are commonly encountered in pediatric office practice. Paul McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children, and the evaluation of children with prolonged fevers of unknown origin. Jean Klig reviews recent literature about lower respiratory tract infection in children. Jeffrey Kahn and Eugene Shapiro discuss recent developments in pediatric infectious diseases concerning neonatal herpes infections, poliovirus immunization schedule, and group B streptococcus screening and treatment.

Fever without apparent source on clinical examination, lower respiratory infections in children, other infectious diseases, and acute gastroenteritis and diarrhea of infancy and early childhood

This section focuses on issues in infectious disease that are commonly encountered in pediatric office practice. Paul McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children and the evaluation of children with prolonged fevers of unknown origin. Jean Klig reviews recent literature about lower respiratory tract infection in children. Eugene Shapiro discusses recent developments in the literature concerning several infectious diseases commonly facing practitioners in the office. Michael Baron reviews recent literature about gastroenteritis and diarrhea of infancy and early childhood.

Fever without apparent source on clinical examination, lower respiratory infections in children, bacterial infections, and acute gastroenteritis and diarrhea of infancy and early childhood

This section focuses on issues in infectious disease that are commonly encountered in pediatric office practice. Paul McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children and the evaluation of children with prolonged fevers of unknown origin. David Bachman reviews recent literature about lower respiratory tract infection in children and focuses on community-acquired lower respiratory infections and respiratory syncytial virus. Eugene Shapiro discusses literature concerning several infectious diseases commonly seen in office settings and concerning which recent developments are of interest: the hemolytic-uremic syndrome and enterohemorrhagic Escherichia coli. Streptococcus pneumoniae resistant to penicillin, infections in day care centers, and new antimicrobial drugs. Michael Baron reviews recent literature about gastroenteritis and diarrhea of infancy and early childhood and discusses diagnosis, complications, pathogenesis and physiology, epidemiology, and treatment.

Investigating the causes of fever in critically ill patients. Are you overlooking noninfectious causes?

Fever is common in the ICU because of patients' underlying chronic and critical illnesses, their tendency to receive multiple medications, and their frequent need for invasive procedures. Precise data on the etiology of fever in the ICU are lacking. However, common noninfectious causes include postoperative fever, drug fever, intramuscular injections, hemorrhage, and pulmonary atelectasis. Urinary tract infection appears to be the most common infectious cause, followed by pneumonia and sepsis. Many noninfectious conditions are potentially life-threatening; nevertheless, it is crucial to first exclude an infectious cause, since an untreated infection may cause rapid deterioration.

[Treatment of fever of unknown origin by homeopathy]

2 cases of fever of unknown origin (FUO) treated successfully by homeopathy are presented. The purpose is to show the effectiveness of homeopathy as adjuvant therapy for those in whom the full medical diagnostic process, assessment, and treatment are not effective. In a 12-year-old boy fever and abdominal pain persisted for several months despite various medical treatments. All symptoms disappeared following homeopathic treatment. In a 66-year-old man fever and other symptoms also disappeared after such treatment. We emphasize that homeopathy is not a substitute for the full conventional medical diagnostic investigation and treatment of FUO. Homeopathy should only be practiced by medical doctors to avoid, to the greatest extent, diagnostic and therapeutic errors.

The febrile patient

Fever has long been recognised as a manifestation of infection; on occasions, it may be a pointer to other underlying diseases including immune-mediated and neoplastic conditions. This article explores the causes of fever, especially prolonged fever, and provides a management plan.

Fever as the initial sign of malfunction in non infected ventriculoperitoneal shunts

Sixty eight children were treated for ventriculoperitoneal shunt malfunction in our department during the years 1984-1989. Fifteen (22%) developed fever above 37.5 degrees C as a presenting sign of their shunt malfunction. Physical examination did not reveal any reason for the fever. Cerebrospinal fluid, urine and blood cultures were all negative. All the children were operated upon and the malfunction corrected. Fever subsided twenty four to thirty six hours after the operation in all the patients. Fever of unknown origin in children with shunted hydrocephalus might be the first sign of a developing shunt malfunction and a neurosurgical examination should be requested.

Unexplained fever and chronic fatigue: abnormal circadian temperature pattern

OBJECTIVES

Standard clinical and biological investigations can be used to determine the origin of persistent and moderate fever in a large number of otherwise asymptomatic patients. However, in a small proportion of cases, isolated fever and fatigue persist despite the absence of detectable organic malfunction. This study was conducted to investigate the circadian thermic pattern in patients with apparently unexplainable fever and chronic fatigue and in those with fever of recognized origin.

METHODS

We recorded central temperature continuously for 24 hours in patients with moderate fever of both unexplained and recognized origin, and in a control group of healthy volunteers. A Fourier series was used for harmonic analysis.

RESULTS

Thermic patterns specific to the three groups were identified by statistical and factorial analysis. The patients with fever of unknown origin and chronic fatigue were clearly characterized in terms of the phase, amplitude of the first (fundamental) harmonic and minimum circadian temperature.

CONCLUSION

The abnormal central temperature pattern in these patients may prove to be an important step in the management of febrile patients.

[Fever of unknown origin (febris continua e causa ignota)]

Fever can be recognized as a higher set-point of the normal temperature regulation which is controlled by the center in the anterior part of hypothalamus. The change in this set-point is induced by interleukin-1 (IL-1) which is the common mediator of exogenic and endogenic pyrogenic factors. IL-1 is believed to act through an induction of a prostaglandin E cascade. The normal diurnal variation in temperature can often be recognized in infectious diseases but not always in non-infectious conditions. Four different fever curves can be defined but are without differential diagnostic importance, however, septic fever curves are more likely to occur in bacteremic patients. Comparison of the most important investigations about PUO since 1960 shows that the follow-up investigations revealed a high percentage of undiagnosed cases and that the mortality due to conditions related to PUO was 6-8%. Among the other investigations, a total of 83% were diagnosed: 23% had cancer, 33% had infections, 11% had collagenic diseases, 17% had other causes and 16% were undiagnosed. To establish the diagnosis in cases of PUO, liver biopsy can be of diagnostic value especially in patients with hepatomegaly. Abdominal CT-scan, ultrasonography and Gallium 67 scintigraphy are equal in sensitivity and specificity and can supplement each other with diagnostic information. Leucocyte scintigraphy can detect local inflammatory processes. Laparotomy or laparoscopy have high diagnostic values and can be considered in patients with signs of involvement of abdominal organs if no diagnosis has been established after noninvasive investigations. Lymphography gives only limited diagnostic information in cases of PUO.

Inflammatory pseudotumor of intra-abdominal lymph nodes manifesting as recurrent fever of unknown origin: a case report

A 27-year-old man presented with a 7-month history of debilitating recurrent fever and weight loss. Extensive clinical evaluation led to the discovery of splenomegaly and retroperitoneal lymphadenopathy. The patient underwent splenectomy as well as liver and lymph node biopsy. Histologic examination of the lymph nodes, but not the liver and spleen, revealed inflammatory pseudotumor of lymph nodes. The patient has remained asymptomatic for more than 3 years following the surgical procedure despite the absence of further intervention. Inflammatory pseudotumor of lymph nodes should be considered in the differential evaluation of prolonged or relapsing fever of unknown etiology.

Periodic febrile confusion as a presentation of complex partial status epilepticus

A 75-year-old woman was evaluated for recurrent episodes of fever she experienced periodically every 4-5 weeks over the last 12 months, lasting 2-3 days each. The fever was associated with continuous complex partial seizures, paralleled the seizure activity and returned to normal after the seizures had ceased. The ictal EEG recordings showed rhythmic bitemporal 3-4 Hz activity; the interictal recordings showed a spike and wave discharge over the right fronto-temporal region. Carbamazepine effectively controlled both the seizures and the fever; the latter was presumed to be an inherent manifestation of the seizure activity.

Extreme hyperpyrexia in childhood. Presentation similar to hemorrhagic shock and encephalopathy

The authors report the cases of five previously well children, aged 8 to 33 months, who were seen over a 14-year period, with admission temperatures in excess of 42.0 degrees C (107.6 degrees F). Four of the patients died. Each child had a similar clinical illness in which the hyperpyrexia played a critical role. Negative blood, cerebrospinal fluid, and stool cultures excluded bacterial sepsis as a possible etiology. This illness is similar, if not identical, to the newly described syndrome of hemorrhagic shock and encephalopathy (HSES) reported in European and American infants.

Sleep and symptoms in fibrositis syndrome after a febrile illness

Sleep physiology and symptoms of 9 patients with fibrositis syndrome secondary to a febrile illness were compared to 9 patients with fibrositis syndrome who did not attribute their symptoms to a febrile illness and to 10 healthy controls. Both patient groups showed an alpha EEG (7.5 to 11 Hz) nonrapid eye movement sleep anomaly, had similar observed tender points, and self-ratings of musculoskeletal pain. These findings suggest that patients with postfebrile fibrositis have a nonrestorative sleep disorder characteristic of patients with fibrositis syndrome and share similar symptoms with patients who have a "chronic fatigue syndrome."

Unexplained febrile illnesses after exposure to ticks. Infection with an Ehrlichia?

The Ehrlichia are tick-borne rickettsial organisms that cause disease in animals throughout the world but that have been previously recognized as human pathogens only in Asia. We have identified six patients with serological evidence of recent infection with an Ehrlichia: a fourfold or greater rise or fall in titer to Ehrlichia canis. All of the patients reported recent tick bites. Rigors, myalgia, headache, nausea, and anorexia were each reported by five patients. Fever was present in all patients and was accompanied by relative bradycardia and leukopenia in five patients, thrombocytopenia and abnormal liver function test results in four, and anemia in three. Five of the six patients were treated with tetracycline hydrochloride, and all recovered. Infection with Ehrlichia should be considered in patients with unexplained febrile illnesses after tick exposure.

Neuropathologic findings in idiopathic opsoclonus and myoclonus. Their similarity to those in paraneoplastic cerebellar cortical degeneration

The neuropathologic findings in an idiopathic case of the opsoclonus/myoclonus syndrome are reported. Although neurologic dysfunction may have been more widespread, structural lesions were limited to the cerebellum and inferior olives. Severe depletion of Purkinje cells with preservation of granular cells was evident throughout the neo- and paleocerebellum; however, groups of Purkinje cells were preserved in the archicerebellum. No abnormalities were evident in the paramedian pontine reticular formation of the caudal pons. Inflammation and evidence of anoxic damage were absent. These changes are very similar to those described in paraneoplastic cerebellar cortical degeneration.

[Vegetative hyperthermia: a thermoregulation disorder or a variant from the norm?]

A diagnosis of low-grade idiopathic fever was made in 85 women and 15 men, examined for subfebrile temperature of unknown origin, after organic disease had been excluded. Compared with 100 healthy control subjects these patients had inadequate movement-dependent temperature elevations with a usually pronounced discrepancy between the rectal temperature, predominantly more than 38 degrees C, and a normal or only slightly raised axillary temperature recorded after bodily movement. Other characteristics were that the elevated temperature was uninfluenced by antipyretic drugs. Almost all patients initially complained about general lassitude as well as frequently about atypical functional complaints and psychological symptoms. These observations indicate that low-grade fever is a functional syndrome due to a harmless faulty regulation of body temperature. In addition to a special constitutional reactivity, psychological factors and possibly previous febrile infections are likely to be involved as precipitating causes.

Clinically benign fever of unknown origin: a personal retrospective

The purpose of this discussion has been to bring to the attention of physicians the fact that all instances of etiologically undefined persistent fever are not associated with potentially serious or life-threatening organic disease, regardless of the height of the temperature. As has been pointed out, many patients with FUO clearly have disorders that are clinically benign, and the cause of these disorders is defined much more frequently on the basis of information obtained from a detailed historic inquiry than on the basis of findings made during the most meticulous physical examination and extensive laboratory studies. These individuals are usually seen first in an outpatient setting and seldom, if ever, require hospitalization because the cause of their FUO can, with uncommon exceptions, be identified as a physiologic or emotional dysfunction, a reaction to a drug or a chemical, or a disorder that is genetically determined. Failure to recognize that even a high elevation of the temperature can represent a clinically benign situation may lead to unnecessary hospitalization, during which the many investigations that are usually carried out may serve only to reinforce the patient's concern about a serious disease. It is most important for both patients and physicians to be aware that temperature, like all other physiologic and chemical measurements in humans, is expressed by a range of values and that a temperature of 98.6 degrees F is not normal for all persons. It must also be appreciated that "normal" temperature varies with age. The newborn infant may develop high-grade fever in the absence of disease because of marked instability of the vasomotor system.(ABSTRACT TRUNCATED AT 250 WORDS)

Fever of unexplained origin, biochemical Cushing's disease and cerebral dysrhythmia corrected by valproate sodium

A patient with cerebral dysrhythmia and fever of unexplained origin for 2 years is described. She had elevated and nonsuppressible levels of urinary 17-hydroxycorticosteroids but no clinical features of hypercortisolism. Treatment with valproate sodium corrected all the abnormalities. It is postulated that cerebral dysrhythmia can affect the hypothalamic mechanisms of body temperature and regulation of adrenocorticotropic hormone levels.

Possible psychogenic fever of 103.5 degrees F in a patient with borderline personality disorder

The authors describe a 24-year-old woman with borderline personality disorder and prolonged fever of unknown origin. After an extensive search for a fever source, they noted that her temperature responded to pseudoseizures and to phenobarbital.