Thyroid tuberculosis diagnosed as papillary thyroid carcinoma with fever of unknown origin.

Thyroid tuberculosis is a rare disease, very few cases have been reported. It is difficult to diagnose because of no typical characteristics. We report on a patient who underwent surgery for suspected thyroid carcinoma, but who was then diagnosed with thyroid tuberculosis. The patient was a woman in her 70s. She had been diagnosed with chronic renal failure and had been on peritoneal dialysis. She complained of fever and a painful left anterior neck swelling. Computed tomography showed thyroid tumor with cervical lymph node swelling, ultrasound-guided fine needle aspiration cytology was suspected for papillary thyroid carcinoma. We performed surgery to confirm the diagnosis and determine treatment. Procedures for thyroid carcinoma were followed, including left lobectomy of the thyroid gland, central lymph node dissection and right cervical lymph node resection. Pathological examination found no malignant findings in the thyroid tissue but did find a granulation layer even in the right cervical lymph node. Tuberculosis-specific IFN-γ assay was positive, we diagnosed thyroid and cervical lymph node tuberculosis. Postoperatively, the neck pain and fever improved, she was treated as an outpatient with antituberculosis drugs therapy. Thyroid tuberculosis must be considered in patients with immunocompromised, such as this patient, who was on peritoneal dialysis.

Burkholderia multivorans septicemia in a pediatric liver transplant patient.

"Cepacia syndrome", caused by Burkholderia cepacia complex and often associated with cystic fibrosis, carries a high mortality rate. It is rare for Burkholderia multivorans, a species within the B. cepacia complex, to cause cepacia syndrome even among patients with cystic fibrosis. This is the first reported fatal case of cepacia syndrome caused by B. multivorans occurring in a pediatric liver transplant recipient who does not have cystic fibrosis. We describe the unique characteristics of this pathogen among the non-cystic fibrosis population and the importance of early recognition and treatment.

Identification of occult active infection using PET-CT in a combined liver-kidney transplant candidate.

This case describes a patient being considered for combined liver-kidney transplantation for Caroli's disease with a failed renal transplant. A chronic septic focus could not be located with standard imaging techniques, such as ultrasonography and computed tomography. This case report highlights the observation that a retained non-functioning transplant can be the cause of fever of unknown origin and PET-CT can be useful in diagnosing these challenging cases.

Polyclonal, newly derived T cells with low expression of inhibitory molecule PD-1 in tonsils define the phenotype of lymphocytes in children with Periodic Fever, Aphtous Stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome.

PURPOSE: PFAPA syndrome is a benign, recurrent inflammatory disease of childhood. Tonsillectomy is one of the therapeutic options with a yet unexplained biological mechanism. We tested whether specific lymphocyte subsets recruited from blood to human tonsils participate in PFAPA pathogenesis. METHODS: Paired tonsils/peripheral blood (PB) samples were investigated (a) from children with PFAPA that successfully resolved after tonsillectomy (n=10) (b) from children with obstructive sleep apnoea syndrome as controls (n=10). The lymphocyte profiles were analysed using 8-colour flow cytometry, immunoglobulin (IGH) and T-cell receptor (TCR) gene rearrangements via PCR and next generation sequencing; a TREC/KREC analysis was performed using qPCR. RESULTS: The PFAPA tonsils in the asymptomatic phase had a lower percentage of B-lymphocytes than controls; T-lymphocyte counts were significantly higher in PB. The percentages of cytotoxic CD8pos T-lymphocytes were approximately 2-fold higher in PFAPA tonsils; the transitional B cells and naïve stages of both the CD4pos and CD8pos T-lymphocytes with a low expression of PD-1 molecule and high numbers of TREC were also increased. With the exception of elevated plasmablasts, no other differences were significant in PB. The expression levels of CXCL10, CXCL9 and CCL19 genes were significantly higher in PFAPA tonsils. The IGH/TCR pattern showed no clonal/oligoclonal expansion. DNA from the Epstein-Barr virus, Human Herpervirus-6 or adenovirus was detected in 7 of 10 PFAPA tonsils but also in 7 of 9 controls. CONCLUSIONS: Our findings suggest that the uninhibited, polyclonal response of newly derived lymphocytes participate in the pathogenesis of PFAPA. Because most of the observed changes were restricted to tonsils and were not present in PB, they partly explain the therapeutic success of tonsillectomy in PFAPA syndrome.

Enterocutaneous fistula 3 years after resection of an advanced gallbladder carcinoma.

A 71-year-old woman presented to the emergency department with abdominal pain and fever. Her surgical history was significant for gallbladder adenocarcinoma for which she had undergone extensive resection 32 months previously. At that time she underwent cholecystectomy, wedge resection of the liver, pancreatoduodenectomy, right nephrectomy and right hemicolectomy for a locally advanced gallbladder adenocarcinoma. Examination revealed a tender, warm, upper midline abdominal wall mass. A CT scan with oral contrast revealed a fistulous tract extending from the gastrojejunostomy (GJ) into an abscess cavity in the adjacent anterior abdominal wall. She underwent open wound drainage with debridement, and was started on parenteral nutrition and intravenous antibiotics. The patient then underwent surgical repair excision of the fistula and refashioning of the GJ 1 month later. Histological examination of the specimen revealed well-healed suture lines, and no evidence of tumour recurrence.

Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study.

OBJECTIVE: To evaluate whether adenotonsillectomy leads to complete resolution in children with PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome. STUDY DESIGN: Thirty-nine children with PFAPA syndrome were randomized to either adenotonsillectomy (surgery group; n = 19) or expectant management (control group; n = 20). All patients were then invited prospectively to record all PFAPA episodes, and were evaluated clinically every 3 months for 18 months after randomization. RESULTS: The proportion of patients experiencing complete resolution was 63% in the surgery group and 5% in the control group (P < .001). The mean (+/- standard deviation) number of episodes recorded during the study period was 0.7 +/- 1.2 in the surgery group and 8.1 +/- 3.9 in the control group (P < .001). The episodes were less severe in the surgery group. CONCLUSIONS: Adenotonsillectomy is an effective treatment strategy for children with PFAPA syndrome.

A misplaced surgical towel - a rare cause of fever of unknown origin.

Retained surgical towels, usually called gossypiboma, are rare, but can cause important morbidity and mortality. Usually they are discovered during the first few days after surgery, but may remain undetected for many years. Bowel obstruction, perforation, pseudotumor or peritonitis are most often the clinical presentation, but in some cases only constitutional symptoms prevail. Diagnosis can be difficult, mostly because of low clinical suspicion. We report a case of a woman who presented with fever and weight loss three and half years after an abdominal surgery. After an extensive workup, a gossypiboma was finally discovered and removed, leading to a complete cure.

Large left atrial myxoma presented as fever of unknown origin: a challenging diagnosis and a review of the literature.

Myxoma is the most common type of primary tumors of the heart in adults. The majority of patients with myxomas may experience symptoms due to central or peripheral embolism or intracardiac obstruction, while in some cases, they may be completely asymptomatic. Rarely, patients develop unusual symptoms that complicate the diagnostic evaluation. Herein, we describe the case of a 70-year-old patient with a long-lasting low-grade fever due to a large left atrial myxoma revealed during a transthoracic echocardiography.

[Clinical significant of splenectomy for fever of unknown origin with splenomegaly].

OBJECTIVE: To investigate the feasibility, safety, success rate of diagnosis and possible risk factors of splenectomy for fever of unknown origin (FUO) with splenomegaly. METHODS: The clinical data of 54 patients of FUO with splenomegaly who underwent splenectomy in Peking Union Medical College Hospital in the past 20 years were reviewed retrospectively. The diagnosis was not clear even after an extensive clinical evaluation before surgery. The pathologic findings, morbidity, mortality and possible risk factors were analyzed. RESULTS: Pathological diagnosis was made in 39 of the 54 patients (72.2%), including 29 cases of non-Hodgkin's lymphoma (NHL), 4 cases of spleen tuberculosis, 3 cases of Hodgkin's lymphoma, 1 case of Castleman's disease, and 2 cases of hemophagocytic syndrome. Among the 15 cases for whom pathological examination failed to make an confirmed diagnosis were diagnosed as with NHL in 4 cases, Still's diseases in 4 cases, hypersplenism in 2 cases, and lymphoproliferative disease in 2 cases during the follow-up. Operation complications occurred in 25.9% of the patients and 16.7% (9/54) of the patients died within one month after surgery. The mortality of the patients with dropsy of serous cavity was 46.2%, significantly higher than that of the patients without dropsy of serous cavity (7.5%). The mortality of the patients with a spleen heavier than 1500 g was 50.0%, significantly higher than that of the patients with a spleen lighter than 1500 g (11.8%). Complication of dropsy of serous cavity and splenomegaly were relatively independent death influencing factors (RR = 31.7 and 13.4 respectively, and P = 0.004 and 0.021 respectively). There was no significant differences in the mortality rates of the patients with or without jaundice, pancytopenia, elevated SGPT, elevated LDH or duration of the disease (all P > 0.1). CONCLUSION: Splenectomy is an effective way for the diagnosis of FUO with splenomegaly. Patients with dropsy of serous cavity or a spleen heavier than 1500 g have higher mortality rates.

[An unknown cause of prolonged fever: apropos of 6 cases of chronic aortic dissection]. / Une cause méconnue de fièvre prolongée: à propos de six cas de dissection aortique chronique.

PURPOSE: Aortic arch dissection may be sometimes misdiagnosed due to the lack of mild to moderate chest pain. Definite diagnosis is often made while dissection has already occurred more than 15 days ago, being thereafter considered as chronic. Aortic dissection may then present as a prolonged febrile illness with fever and/or inflammation as main symptoms, with little or no pain. METHODS: We retrospectively reviewed cases of chronic aortic dissections seen in a department of internal medicine and a department of neurology between 1975 and 1992. RESULTS: We report six cases of patients presenting with aortic dissection and describe their outcome and treatments after the diagnosis was made based on either thoracic computerized tomography or trans-esophageal echocardiography evidence. Four patients had surgical aortic arch repair while one patient was treated with beta-blockers. CONCLUSION: Chronic aortic dissection has rarely been reported to cause fever or increased sedimentation rate. Treatment has to be discussed between medical and surgical teams involved in the therapeutical management of these unusual patients.

Computed tomography of the abdomen in evaluation of patients with fever of unknown origin.

Applying Petersdorf's classic criteria for fever of unknown origin (FUO), 75 of 6,654 CT scans were reviewed to evaluate the diagnostic effectiveness of abdominal CT. Twenty-three (29%) of these 78 scans had positive CT findings and 8 (10%) had positive but nonspecific findings. Abdominal exploration or biopsy was carried out in 20 of these 31 patients. In addition, 10 cases with negative CT results were explored. In no case was any gross anatomic abnormality found in these negative cases.