Respiratory Muscle Training and Its Impact on Balance and Gait in Patients with Severe COPD.

Background and Objectives: Improving extrapulmonary symptoms in COPD through respiratory muscle training can help alleviate the burden of respiratory symptoms, reduce fatigue, and improve exercise capacity in patients with COPD. This, in turn, can enhance physical activity, balance, and gait, ultimately improving the overall quality of life for individuals with COPD. This study aimed to investigate the effects of respiratory muscle training on balance and gait in patients with moderate to severe COPD. Materials and Methods: We included 65 patients with moderate to severe COPD randomly assigned to either the pulmonary rehabilitation protocol group (PR) or the pulmonary rehabilitation and inspiratory muscle training group (PR + IMT) for three weeks. Patients performed a spirometry, maximal inspiratory and expiratory pressure (MIP/MEP), 6 min walking test (6MWT), activities-specific balance confidence (ABC) scale questionnaire, Berg Balance Scale (BBS), timed up and go test (TUG), and single-leg stance test (SLS). Results: Rehabilitation had a notable impact on MIP in Group 2 (PR + IMT), with a highly significant difference between pre- and post-rehabilitation distributions (p < 0.0001). At the same time, Group 1 (PR-only) showed no significant changes (p = 0.27). In Group 1 (Control), pre- and post-rehabilitation comparisons reveal slight non-significant changes for SLS EO (p = 0.16), ABC (p = 0.07), TUG (p = 0.06), and BBS (p = 0.13). In contrast, in Group 2 (Cases), there are significant improvements in all variables after rehabilitation compared to the pre-rehabilitation values: SLS EO (p < 0.0001), ABC (p < 0.0001), TUG (p < 0.0001), and BBS (p < 0.0001). Conclusions: Our research demonstrated that respiratory muscle training significantly positively impacts balance and gait performance among patients with moderate to severe COPD compared to a control group.

A Narrative Review of Self-Reported Scales to Evaluate Depression and Anxiety Symptoms in Adult Obstructive Sleep Apnea Patients.

Background and Objectives: Obstructive sleep apnea (OSA) is a prevalent chronic condition that has been associated with mental disorders like depression and anxiety. This study intends to provide a practical overview of the most relevant self-reported and self-rating scales that assess depression and anxiety in OSA patients. Materials and Methods: A search for articles was performed using PubMed, Google Scholar, and Semantic Scholar using a combination of words for obstructive sleep apnea, depression, anxiety, and scales. The tools were ordered by type (screening and rating) and arranged chronologically according to the year of publication. Results: Three scales were identified for assessing depression, which were the Center for Epidemiologic Studies Depression Scale (CES-D), the Hospital Anxiety and Depression Scale (HADS-D), and the Patient Health Questionnaire-9 (PHQ-9). For rating depression, two scales were discussed: the Zung Self-Rating Depression Scale (SDS) and the Beck Depression Inventory (BDI), which has three versions (the BDI, the BDI-II, and the Fast Screen (BDI-FS)). For assessing anxiety, the Generalized Anxiety Disorder-7 (GAD-7) scale was identified. Two scales were reviewed for rating anxiety: the State-Trait Anxiety Inventory (STAI) and the Beck Anxiety Inventory (BAI). Each scale is accompanied by a brief description of its practicality and psychometric qualities and an analysis of its strengths and limitations. Conclusions: The findings of this review will contribute to the understanding of the importance of assessing mental health comorbidities in the context of OSA, ultimately guiding clinical practice and future research in this area.

A Systematic Review of Telemedicine-Driven Pulmonary Rehabilitation after the Acute Phase of COVID-19.

The acute phase of COVID-19 often leaves patients with persistent pulmonary deficits. Pulmonary Rehabilitation (PR) has been recommended as an essential part of post-acute COVID-19 management. In light of the global pandemic, telerehabilitation has been increasingly employed to deliver PR. This systematic review aimed to evaluate the effectiveness of telemedicine-driven PR in patients recovering from the acute phase of COVID-19, assessing variations in telerehabilitation practices and identifying the degree of change in mental health, physical health, quality of life, and lung function. A systematic search was conducted across PubMed, Web of Science, Cochrane, and Scopus up until April 2023. Studies focusing on telerehabilitation in PR for post-acute COVID-19 patients with outcomes including pulmonary function, exercise capacity, and quality of life were included after careful assessment of this study's protocol. The selection process involved careful scrutiny of abstracts and full texts, and the quality assessment was performed using the National Heart, Lung, and Blood Institute (NHLBI) tool. Seven studies, published between 2021 and 2022, involving a total of 412 patients, were included. The evaluated telerehabilitation programs stretched between 4 and 10 weeks, involving a mobile app or video connection with the patient, integrating a mix of aerobic and resistance training, breathing exercises, functional activities, and muscle strengthening. Findings revealed that telemedicine-driven PR significantly improved physical health, measured by the step test score (73 vs. 71), 6MWD (30.2 vs. 17.1) and BPAQ, mental health evaluated by SF-12 (6.15 vs. 4.17) and PHQ-4, quality of life measured by the SF-12 (7.81 vs. 3.84), SGRQ (31.5 vs. 16.9), and CAT scores, and some parameters of pulmonary function in post-acute COVID-19 patients (mMRC, STST, and MVV). This review substantiates the potential of telemedicine-driven PR to improve various health outcomes in post-acute COVID-19 patients. The findings underscore the importance of integrating telerehabilitation into the management of post-acute COVID-19 and call for further exploration of its long-term effects, cost-effectiveness, and best practices.

Large Lung Consolidation: A Rare Presentation of Pulmonary Sarcoidosis.

Sarcoidosis is a complex inflammatory disease of uncertain origin, characterized by non-necrotizing epithelioid cell granulomas (NNEGs) affecting multiple organ systems. Although many different clinical and pathological phenotypes can be present, with different organs involved, the lung is the most common site described. In this case report, we (a) present and discuss the broad differential diagnosis of a patient presenting with a solitary lung mass with clinical and imaging features of lung cancer that ultimately was confirmed with a rare manifestation of stage II pulmonary sarcoidosis, and (b) analyze and compare similar cases from the literature.

Evaluating Virtual and Inpatient Pulmonary Rehabilitation Programs for Patients with COPD.

Chronic obstructive pulmonary disease (COPD) is an increasingly frequent disorder that is likely to become the third leading cause of morbidity worldwide. It significantly degrades the quality of life of patients affected and poses a significant financial burden to the healthcare systems providing treatment and rehabilitation. Consequently, our study's purpose was to compare conventional inpatient pulmonary rehabilitation (PR) with virtual (online) PR using a mobile phone application. During a three-month period, two groups of patients followed the research protocol by participating in a pulmonary rehabilitation program administered and supervised by a physical therapist five times per week. A number of respiratory variables were examined before and after the test. At the end of the study period, a total of 72 patients completed the rehabilitation in the inpatient group, respectively 58 in the online group. It was observed that post-test comparison between patients undergoing the traditional and online rehabilitation methods did not show any significant differences. However, the calculated mean differences between pre-test and post-test results were significantly higher in favor of the virtual method. The most significant variations were encountered in maximal inspiratory pressure (MIP) (6.6% vs. 8.5%, p-value < 0.001), 6-min walking test (6MWT) (6.7% vs. 9.4%, p-value < 0.001), and COPD assessment test (CAT) values (4.8 vs. 6.2, p-value < 0.001), respectively. However, the maximal expiratory pressure (MEP) variation was significantly higher in patients undergoing the traditional rehabilitation method, from an average of 4.1% to 3.2% (p-value < 0.001). In this preliminary study, the online pulmonary rehabilitation program proved non-inferiority to the traditional method, with significantly better results in several measurements. Additional studies using larger cohorts of patients and longer exposure to the online rehabilitation program are required to validate these findings.

Self-reported sleep disturbance and mild cognitive impairment in COPD patients with severe airflow limitation.

INTRODUCTION: COPD has multiple extrapulmonary manifestations and the latest studies have focused on cognitive dysfunction effects on sleep quality. The purpose of this study is to assess if there is a relationship between sleep quality and cognitive decline in COPD patients with severe airflow limitation. METHODS: We performed an observational study to determine if there is a link between cognitive function and sleep quality. The included patients were divided into two groups: a group with COPD patients and control group. We evaluated lung volumes, cognitive function, sleep quality and disease impact on the quality of life. RESULTS: Most of the COPD patients presented mild cognitive impairment (MCI) (95.7%), compared with only 24.1% in the control group (Pearson chi-square χ2 (1) = 42.560, p < 0.001). We observed that all the COPD patients were poor sleepers, while only 13.8% of the control patients presented a poor sleep (Pearson chi-square χ2 (1) = 60.379, p < 0.001). We observed that poor sleep was significantly associated with MCI (OR = 9.200; 95% CI = 3.656-23.153; p < 0.001). At the same time, when considering only the COPD patients with moderate disease impact, poor sleep was also a risk factor for MCI (OR = 1.210; 95% CI = 1.016-1.440; p < 0.001). CONCLUSION: COPD patients with severe airflow limitation report a high prevalence of poor sleep quality and cognitive function. We observed a significant association between cognitive function and sleep quality.

The diagnostic utility of the "Thwaites' system" and "lancet consensus scoring system" in tuberculous vs. non-tuberculous subacute and chronic meningitis: multicenter analysis of 395 adult patients.

BACKGROUND: Tuberculous meningitis (TBM) represents a diagnostic and management challenge to clinicians. The "Thwaites' system" and "Lancet consensus scoring system" are utilized to differentiate TBM from bacterial meningitis but their utility in subacute and chronic meningitis where TBM is an important consideration is unknown. METHODS: A multicenter retrospective study of adults with subacute and chronic meningitis, defined by symptoms greater than 5 days and less than 30 days for subacute meningitis (SAM) and greater than 30 days for chronic meningitis (CM). The "Thwaites' system" and "Lancet consensus scoring system" scores and the diagnostic accuracy by sensitivity, specificity, and area under the curve of receiver operating curve (AUC-ROC) were calculated. The "Thwaites' system" and "Lancet consensus scoring system" suggest a high probability of TBM with scores ≤4, and with scores of ≥12, respectively. RESULTS: A total of 395 patients were identified; 313 (79.2%) had subacute and 82 (20.8%) with chronic meningitis. Patients with chronic meningitis were more likely caused by tuberculosis and had higher rates of HIV infection (P < 0.001). A total of 162 patients with TBM and 233 patients with non-TBM had unknown (140, 60.1%), fungal (41, 17.6%), viral (29, 12.4%), miscellaneous (16, 6.7%), and bacterial (7, 3.0%) etiologies. TMB patients were older and presented with lower Glasgow coma scores, lower CSF glucose and higher CSF protein (P < 0.001). Both criteria were able to distinguish TBM from bacterial meningitis; only the Lancet score was able to differentiate TBM from fungal, viral, and unknown etiologies even though significant overlap occurred between the etiologies (P < .001). Both criteria showed poor diagnostic accuracy to distinguish TBM from non-TBM etiologies (AUC-ROC was <. 5), but Lancet consensus scoring system was fair in diagnosing TBM (AUC-ROC was .738), sensitivity of 50%, and specificity of 89.3%. CONCLUSION: Both criteria can be helpful in distinguishing TBM from bacterial meningitis, but only the Lancet consensus scoring system can help differentiate TBM from meningitis caused by fungal, viral and unknown etiologies even though significant overlap occurs and the overall diagnostic accuracy of both criteria were either poor or fair.

Hydrocephalus and vasculitis delay therapeutic responses in tuberculous meninigitis: Results of Haydarpasa-III study.

AIMS: There is no report on the factors affecting the resolution of symptoms related to meningitis during treatment of tuberculous meningitis (TBM). Thus, we examined the factors associated with early therapeutic responses. MATERIALS AND METHODS: This multicenter study included 507 patients with microbiologically confirmed TBM. However, 94 patients eligible for the analysis were included in this study from 24 centers. Six out of 94 patients died and the statistical analysis was performed with 88 survivors. Early and late responder groups were compared in the statistical analysis. P < 0.05 were considered to show a significant difference. RESULTS: In the multivariate analysis, the presence of vasculitis (P = 0.029, OR = 10.491 [95% CI, 1.27-86.83]) was found to be significantly associated with a delayed fever response whereas hydrocephalus was associated with altered mental status for >9 days duration (P = 0.005, OR = 5.740 [95% CI, 1.68-19.57]). According to linear regression analysis, fever was significantly persisting (>7 days) in the presence of vasculitis (17.5 vs. 7, P< 0.001) and hydrocephalus (11 vs. 7, P = 0.029). Hydrocephalus was significantly associated with persisting headache (21 vs. 12, P = 0.025), delayed recovery of consciousness (19.5 vs. 7, P = 0.001), and a delay in complete recovery (21 vs. 14, P = 0.007) in the linear regression analysis. Following institution of treatment, the complaints seemed to disappear in up to 2 weeks among TBM survivors. CONCLUSIONS: In the absence of hydrocephalus or vasculitis, one week of anti-tuberculosis treatment seems to be adequate for the resolution of TBM symptoms. Hydrocephalus and vasculitis delay the resolution of TBM symptoms in response to antimycobacterial treatment.

Chronic obstructive pulmonary disease phenotypes and balance impairment.

BACKGROUND/OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in airflow limitation and respiratory distress, also having many nonrespiratory manifestations that affect both function and mobility. Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with COPD. Our objective was to investigate balance performance in two groups of COPD patients with different body compositions and to observe which of these groups are more likely to experience falls in the future. METHODS: We included 27 stable COPD patients and 17 healthy individuals who performed a series of balance tests. The COPD patients were divided in two groups: emphysematous and bronchitic. Patients completed the activities balance confidence scale and the COPD assessment test questionnaire and afterward performed the Berg Balance Scale, timed up and go, single leg stance and 6-minute walking distance test. We analyzed the differences in the balance tests between the studied groups. RESULTS: Bronchitic COPD was associated with a decreased value when compared to emphysematous COPD for the following variables: single leg stance (8.7 vs 15.6; P<0.001) and activities balance confidence (53.2 vs 74.2; P=0.001). Bronchitic COPD patients had a significantly higher value of timed up and go test compared to patients with emphysematous COPD (14.7 vs 12.8; P=0.001). CONCLUSION: Patients with COPD have a higher balance impairment than their healthy peers. Moreover, we observed that the bronchitic COPD phenotype is more likely to experience falls compared to the emphysematous phenotype.

Clostridium difficile in western Romania: unfavourable outcome predictors in a hospital for infectious diseases.

BACKGROUND: The recent emergence of Clostridium difficile infections has included this condition among top nosocomial infections, due to its incidence, complications and important fatality, as well as to significant economic costs. METHODS: A prospective surveillance study of Clostridium difficile enterocolitis cases was performed in "Victor Babes" Infectious Diseases Hospital in Timisoara (Romania) between 01.01.2013 - 30.06.2014, to estimate the incidence and to investigate the risk factors for unfavourable outcome and relapse. Dichotomous variables were compared by the chi-square test or Fisher exact test and the Mann-Whitney U test was used for continuous variables. Risk factors for unfavourable outcome/recurrence were investigated by logistic regression. RESULTS: 210 patients who experienced 219 episodes of infection with Clostridium difficile were identified, which gives an incidence per hospital of 20.57/15.70 to 1,000 discharged patients in 2013/2014 or 17.73/14.04 to 10,000 patient-days. In 162 patients (77.14%) the evolution was favourable while in 48 (22.86%) the outcome was unfavourable. In 42 patients (20.00%) recurrence of symptoms was identified. The multivariate analysis by logistic regression identified the ATLAS score (OR = 4.97, 95% CI = 2.12 to 11.66, p <0.001), age (OR = 1.12, 95% CI = 1.00 to 1.25, p = 0.046), and the number of antibiotics after episode onset (OR = 2.692, 95% CI = 1.01 to 7.17, p = 0.047) as predictors of an unfavourable evolution, while the number of hospitalization days (OR = 1.10, 95% CI = 1.03 to 1.16, p = 0.0015) was associated with recurrence of symptoms. CONCLUSIONS: The high incidence identified in our study is explained by the endemic character of these infections in some hospitals in Timisoara, released in late 2012, and the fact that "Victor Babes" Hospital is the only one in our area that provides treatment in all suspected or confirmed cases of this condition requiring hospitalization. The study identified the ATLAS score, age, and the number of antibiotics after episode onset as predictors of unfavourable evolution, while the number of days of hospitalization was associated with the recurrence of symptoms.

Balance impairment in patients with COPD.

BACKGROUND/PURPOSE: Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in progressive airflow limitation and respiratory distress. Physiopathological features of COPD suggest that people who suffer from this disease have many risk factors for falls that have been identified in older individuals. The aim of the study was to compare and quantify functional balance between COPD patients and healthy subjects; to investigate the risk of falls in acute stages of the disease and to identify risk factors that could lead to falls. METHODS: We studied 46 patients with moderate-severe COPD (29 stable and 17 in acute exacerbation--AECOPD) and 17 healthy subjects (control group) having similar demographic data. We analyzed the difference in Berg Balance Scale (BBS), Single Leg Stance (SLS) and Timed Up and Go test (TUG) between these three groups and the correlation of these scores with a number of incriminatory factors. RESULTS: The presence of COPD was associated with significant worsening of balance tests: BBS (55 control, vs. 53 COPD, vs. 44 AECOPD points p<0.001), TUG (8.6 control vs. 12.3 COPD vs. 15.9 AECOPD seconds. p<0.001), SLS (31.1 control vs. 17.7 COPD vs. 7.2 AECOPD seconds p<0.001) which may be associated with an increased risk of falls. Anxiety and depression were significantly associated with decreased balance test scores; anxiety (2 control vs. 6 COPD vs. 9 AECOPD points p<0.001) depression (2 control vs. 7 COPD vs. 12 AECOPD points p<0.001). CONCLUSIONS: According to our results COPD patients in moderate-severe stages and especially those in exacerbation have a high risk of falls.

Hamsi scoring in the prediction of unfavorable outcomes from tuberculous meningitis: results of Haydarpasa-II study.

Predicting unfavorable outcome is of paramount importance in clinical decision making. Accordingly, we designed this multinational study, which provided the largest case series of tuberculous meningitis (TBM). 43 centers from 14 countries (Albania, Croatia, Denmark, Egypt, France, Hungary, Iraq, Italy, Macedonia, Romania, Serbia, Slovenia, Syria, Turkey) submitted data of microbiologically confirmed TBM patients hospitalized between 2000 and 2012. Unfavorable outcome was defined as survival with significant sequela or death. In developing our index, binary logistic regression models were constructed via 200 replicates of database by bootstrap resampling methodology. The final model was built according to the selection frequencies of variables. The severity scale included variables with arbitrary scores proportional to predictive powers of terms in the final model. The final model was internally validated by bootstrap resampling. A total of 507 patients' data were submitted among which 165 had unfavorable outcome. Eighty-six patients died while 119 had different neurological sequelae in 79 (16%) patients. The full model included 13 variables. Age, nausea, vomiting, altered consciousness, hydrocephalus, vasculitis, immunosuppression, diabetes mellitus and neurological deficit remained in the final model. Scores 1-3 were assigned to the variables in the severity scale, which included scores of 1-6. The distribution of mortality for the scores 1-6 was 3.4, 8.2, 20.6, 31, 30 and 40.1%, respectively. Altered consciousness, diabetes mellitus, immunosuppression, neurological deficits, hydrocephalus, and vasculitis predicted the unfavorable outcome in the scoring and the cumulative score provided a linear estimation of prognosis.

Cognitive impairment in chronic obstructive pulmonary disease.

BACKGROUND/PURPOSE: Chronic obstructive pulmonary disease (COPD), especially in severe forms, is commonly associated with multiple cognitive problems. Montreal Cognitive Assessment test (MoCA) is used to detect cognitive impairment evaluating several areas: visuospatial, memory, attention and fluency. Our study aim was to evaluate the impact of stable COPD and exacerbation (AECOPD) phases on cognitive status using MoCA questionnaire. METHODS: We enrolled 39 patients (pts), smokers with COPD group D (30 stable and 9 in AECOPD) and 13 healthy subjects (control group), having similar level of education and no significant differences regarding the anthropometric measurements. We analyzed the differences in MoCA score between these three groups and also the correlation between this score and inflammatory markers. RESULTS: Patients with AECOPD had a significant (p<0.001) decreased MoCA score (14.6±3.4) compared to stable COPD (20.2±2.4) and controls (24.2±5.8). The differences between groups were more accentuated for the language abstraction and attention (p<0.001) and delayed recall and orientation (p<0.001) sub-topics. No significant variance of score was observed between groups regarding visuospatial and naming score (p = 0.095). The MoCA score was significantly correlated with forced expiratory volume (r = 0.28) and reverse correlated with C-reactive protein (CRP) (r = -0.57), fibrinogen (r = -0.58), erythrocyte sedimentation rate (ESR) (r = -0.55) and with the partial pressure of CO2 (r = -0.47). CONCLUSIONS: According to this study, COPD significantly decreases the cognitive status in advanced and acute stages of the disease.

[Mycobacterial mediastinal adenopathy]. / Adenopatie tuberculoasa mediastinala--dificultati de diagnostic.

Tuberculosis is a frequent cause of prolonged fever. Mediastinal lymph node enlargement is an uncommon feature of intrathoracic tuberculosis in adults. The authors present the case of a 64 year old man who developed prolonged fever and was admitted to Clinical Hospital of Infectious Diseases and Pneumophtisiology Dr. Victor Babes Timisoara during 06.04-15.04.2009. Diagnosis of mediastinal lymph node tuberculosis was established only after axillary thoracotomy and biopsy of tumoral mass, although the first results obtained after mediastinoscopy were negative. Dynamics of biological features, diagnostic pitfalls, differential diagnosis difficulties and peculiar aspects of evolution are presented. Mediastinal tuberculous adenopathy, without associated pulmonary involvement is a rare form of presentation among adults, generally evolving with sustained fever. Diagnosis of mediastinal tuberculosis is difficult due to non-specific clinical aspects and lack of characteristic radiographic features and so invasive diagnostic procedures gain importance (mediastinoscopy and biopsy).

[AIDS patient with pneumocystosis and pulmonary alveolar proteinosis]. / Pacient cu SIDA asociata cu pneumocistoza si proteinoza alveolara.

Pulmonary alveolar proteinosis can be associated with various microorganisms and Pneumocystis jirovecii is one of them, especially in AIDS patients. Authors present the case of a 30-year-old man treated with corticosteroids for idiopathic pulmonary fibrosis, having restrictive ventilatory disfunction and bilateral perihilar interstitial infiltrates, ground-glass opacity on CT of the lungs. Rapid extension ofpulmonary a bnormalities (over a month) to peripheral reticular lesions and presence of fever were considered as Hamman-Rich syndrome. He was admitted to Clinical Hospital of Infectious Diseases and Pneumophtisiology Dr.V.Babes from Timisoara during 5-13 XII 2008 for prolonged fever, night sweats, weight loss, progressive dyspnea, marked hypoxemia, tachycardia. Diagnosis of AIDS was quickly established on two positive ELISA tests, T helper cell count (CD4 = 3 cells/mm3, CD8 = 480 cells/mm3, CD4/CD8 = 0.01) and viral load (200,000 copies/ml). Treatment was started with trimethoprim-sulfamethoxazole, fluconazole, corticosteroids but the patient died. Postmortem pathological examination showed pulmonary alveolar proteinosis and showed P. jirovecii. Pulmonary changes caused by HIV can mimic idiopathic pulmonary fibrosis and HIV may become the new "great imitator". Although the number of subjects infected with HIV is increasing, failure to recognize this immunodeficiency state is still encountered. HIV infection must be kept in mind in the differential diagnosis of each case of prolonged fever.

[Considerations in prolonged febrile illness]. / Consideratii privind sindromul febril prelungit.

Since the earliest days of systematic thermometry prolonged fever illness has fascinated and generated many frustrations to clinicians and laboratory physicians. The authors present peculiarities of 57 patients with prolonged fever illness that were admitted to 2nd Clinic of Infectious Diseases from "Dr.V.Babes" Clinical Hospital of Infectious Diseases and Pneumo-phtisiology Timisoara between June 2006 and June 2008. We submit data about signs and symptoms associated with fever of unknown origin, dynamics of fever, different etiologies of prolonged fevers, underlying favourable host-associated conditions (immune deficiencies, comorbidities), importance of laboratory investigations and imaging studies in establishing etiologic diagnosis, duration of hospitalization, management of patients. 5% of cases of prolonged fever remained without etiologic diagnosis. Prolonged fever by its frequency, potential severity, multitude of etiologies that are involved, remains a diagnostic challenge and many times it imposes collaboration between different specialists. In our study percentage of infectious cause (73%) is much higher than in developed countries where prolonged fever of infectious origin represents only 27-33% of all cases, just a little above neoplasms. Today the percentage of cases without etiology is smaller because we have better access to more sophisticated diagnostic tools.