Background: Fever of unknown origin (FUO) has been defined as a fever of ≥101°F that persists for 3 weeks or more. It is not readily diagnosed after 1 week of intensive in-hospital testing or after intensive outpatient or inpatient testing. Fevers of unknown origin may be caused by infectious diseases, malignancies, collagen vascular diseases, or a variety of miscellaneous disorders. The relative distribution of causes of FUOs is partly age-related. In the elderly, the preponderance of FUOs is attributable to neoplastic and infectious etiologies, whereas in children, collagen vascular diseases, neoplasms, and viral infectious disease predominate. The diagnostic approach to FUOs depends on a careful analysis of the history, physical findings, and laboratory tests. Most patients with FUOs exhibit localizing findings that should direct the diagnostic workup and limit diagnostic possibilities. The most perplexing causes of FUOs involve those without specific diagnostic tests, e.g., juvenile rheumatoid arthritis (JRA) or adult Still's disease. In a young adult with FUO, if all of the cardinal symptoms are present, JRA may present either a straightforward or an elusive diagnosis, if key findings are absent or if the diagnosis goes unsuspected.
Methods: We present a 19-year-old man with a recurrent FUO. His illness began 3 years before admission and has recurred twice since. In the past, he did not manifest arthralgias, arthritis, or a truncal rash. On admission, he presented with an FUO with hepatosplenomegaly, aseptic meningitis, and pericarditis. An extensive diagnostic workup ruled out lymphoma and leukemia. Moreover, a further extensive workup eliminated infectious causes of FUO appropriate to his clinical presentation, ie, tuberculosis, histoplasmosis, brucellosis, Q fever, typhoid fever, Epstein-Barr virus, infectious mononucleosis, cytomegalovirus, human herpes virus (HHV)-6, babesiosis, ehrlichiosis, viral hepatitis, and Whipple's disease.
Results: The diagnosis of JRA was based on the exclusion of infectious and neoplastic disorders in a young adult with hepatosplenomegaly, aseptic meningitis, pericarditis, and a double quotidian fever. With JRA, tests for rheumatic diseases are negative, as they were in this case. The only laboratory abnormalities in this patient included elevated serum transaminases, a mildly elevated erythrocyte sedimentation rate, and a moderately elevated level of serum ferritin.
Conclusion: Diagnostic fever curves are most helpful in cases where the diagnosis is most elusive, as was the case here. Relatively few disorders are associated with a double quotidian fever, ie, visceral leishmaniasis, mixed malarial infections, right-sided gonococcal acute bacterial endocarditis, and JRA. Because the patient received antipyretics during the first week of admission, fever was not present. After infectious disease consultation during week 2 of hospitalization, antipyretics were discontinued, and a double quotidian fever was present, which provided the key diagnostic clue in this case.
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http://dx.doi.org/10.1016/j.hrtlng.2011.01.002 | DOI Listing |
J Med Ethics
June 2024
Boston College School of Theology and Ministry, Brighton, Massachusetts, USA
The field of medical ethics, such as the discipline of ethics in general, has traditionally focused on moral dilemmas and quandaries at the expense of 'everyday' moral issues. The methodologies, norms and principles of the field reflect this. Although the principle of double effect works well in adjudicating the provision of life-shortening medications to relieve pain, it fails to guide the vast majority of mundane moral decisions that providers make daily.
View Article and Find Full Text PDFEur J Clin Microbiol Infect Dis
January 2014
Department of Laboratory Medicine, Futian Hospital, Guangdong Medical College, Shenzhen, China.
Gonococcal endocarditis is rarely encountered in the post-antibiotic era. This case report describes a case of a previously healthy male who presented with double quotidian fever, chills, cough, and urethral symptoms. The presence of a cardiac mitral valvular vegetation along with positive blood cultures for Neisseria gonorrhoeae were diagnostic for gonococcal endocarditis.
View Article and Find Full Text PDFHeart Lung
July 2012
Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA.
Background: Fever of unknown origin (FUO) has been defined as a fever of ≥101°F that persists for 3 weeks or more. It is not readily diagnosed after 1 week of intensive in-hospital testing or after intensive outpatient or inpatient testing. Fevers of unknown origin may be caused by infectious diseases, malignancies, collagen vascular diseases, or a variety of miscellaneous disorders.
View Article and Find Full Text PDFRheumatol Int
September 2009
Section of Rheumatology, Department of Clinical and Experimental Medicine, University of Ferrara, Ferrara, Italy.
Adult-onset Still disease (AOSD) is a rare condition disease of unknown etiology, characterized by quotidian or double quotidian spiking fever, with an evanescent pink-salmon rash, arthritis and multi-organ involvement. Diagnosis is usually clinical and made after other diseases in the differential diagnosis are excluded. We herein report the case of a patient with a remarkable familial autoimmune background in whom adult Still disease started off with a diffuse intravascular coagulation, probably triggered by a macrophage activation syndrome, followed by an acute interstitial myocarditis, leading to a fatal complete atrioventricular block.
View Article and Find Full Text PDFHeart Lung
June 2006
Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 1150, USA.
Fever of unknown origin (FUO) in adults is a commonly encountered clinical problem. Treatable causes of FUO in the adult should be the primary focus of the diagnostic workup. Neoplasms have replaced infectious diseases as being the most common cause of FUO in adults, and collagen vascular diseases are now relatively rare.
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