Fever of unknown origin: A 12-year case series in Colombia.

BACKGROUND: Fever of unknown origin (FUO) is a diagnostic challenge with highly heterogeneous causes. Its etiology can change according to the studied regions, and the chance of reaching a diagnosis depends on available resources. The aim of this study is to describe the clinical characteristics, etiology and the usefulness of diagnostic aids in cases of FUO managed over 12 years in a Colombian reference center. METHODOLOGY: Single-institution retrospective case series. All cases of FUO between 2006 and 2017 were identified with the help of an electronic medical record search software. Cases of adults with fever for more than three weeks who remained undiagnosed after three days of hospitalization are described. RESULTS: Of 1,009 cases evaluated, 112 cases met the inclusion criteria (median age 43 years, 66% men). The etiologies identified were infectious (31.2%), inflammatory (20.5%), neoplastic (14.3%), and miscellaneous (2.7%) diseases. 31.2% remained without etiological diagnosis. The most frequent conditions were tuberculosis (17%), Hodgkin's lymphoma (7.1%), systemic lupus erythematosus (6.3%), disseminated histoplasmosis, and adult Still's disease. Contrast tomography and biopsies were the studies that most frequently supported or confirmed the final diagnosis. CONCLUSIONS: This series of contemporary Latin American cases suggests that the categories of FUO etiologies are similar to those reported in studies from developed countries, with tuberculosis being the most frequent cause in our setting. Our results highlight the importance of tomography-guided invasive studies in the diagnostic approach to FUO.

Dengue en paciente de 32 días de vida. Reporte de un caso poco habitual / Dengue fever in a 32-day-old patient. A rare case report

El dengue es una enfermedad viral transmitida por la picadura del mosquito Aedes aegypti. El comportamiento del dengue en Argentina es epidémico; la mayoría de los casos se observan en los meses de mayor temperatura. Hasta la semana epidemiológica (SE) 20/2023, se registraron en Argentina 106 672 casos; se vieron afectadas 18 de las 24 provincias que conforman el país. Dentro de los principales grupos de riesgo, se incluyen los menores de 2 años. Reconocer los signos, síntomas e identificar los factores de riesgo es fundamental para el manejo de casos con mayor riesgo de gravedad. Presentamos el caso de una paciente de 32 días de vida que se internó por síndrome febril sin foco, con diagnósticos diferenciales de meningitis viral y sepsis, evolucionó con leucocitosis, plaquetopenia, hipoalbuminemia, asociado a exantema y edemas. Se llegó al diagnóstico de dengue por la clínica, epidemiologia e IgM positiva.

Dengue fever is a viral disease transmitted by the Aedes aegypti mosquitoes. In Argentina, dengue fever is an epidemic disease; most cases are reported during the hot months.Until epidemiological week (EW) 20/2023, 106 672 cases were reported across 18 of the 24 provinces of Argentina. Children younger than 2 years are among the main groups at risk. Recognizing signs and symptoms and identifying risk factors is fundamental for the management of cases at a higher risk of severity. Here we describe the case of a 32-day-old female patient who was hospitalized due to febrile syndrome without a source, who had a differential diagnosis of viral meningitis and sepsis and progressed to leukocytosis, thrombocytopenia, hypoalbuminemia in association with rash and edema. The diagnosis of dengue fever was established based on clinical, epidemiological, and positive IgM data.

Fiebre de origen desconocido como forma de presentación de la enfermedad de Still del adulto / Fever of unknown origin as a form of presentation of an adult-onset Still's disease

Introducción: La enfermedad de Still del adulto es una enfermedad reumática, inflamatoria, sistémica y crónica cuya prevalencia en la población caucásica se estima en 1 caso por cada 100 000 adultos Objetivo: Presentar un paciente adulto joven, con una fiebre de origen desconocido como forma de presentación de la enfermedad de Still del adulto. Caso clínico: Paciente de 29 años de edad con antecedente de fiebre reumática, con un ingreso hospitalario anterior; que presentó un cuadro febril no infeccioso, de 50 días de duración, al cual no se le determinó la causa. Un año después reapareció la fiebre, de similares características, asociada a poliartralgia, hepatoesplenomegalia, anemia, hiperferritinemia, neutrofilia, factor reumatoideo negativo y se constató un cuadro de pericarditis durante el ingreso. Se realizó el diagnóstico de enfermedad de Still del adulto, por exclusión. Se inició tratamiento con esteroides, desapareció la fiebre en las primeras 24 horas y el paciente tuvo una evolución favorable. Conclusiones: La enfermedad de Still del adulto puede presentarse como una fiebre de origen desconocido y se diagnostica por exclusión, ya que no existen manifestaciones clínicas ni pruebas de laboratorio, patognomónicas. La hiperferritinemia es útil para la sospecha diagnóstica(AU)

Introduction: Adult Still's disease is a rheumatic, inflammatory, systemic and chronic disease whose prevalence in the Caucasian population is estimated at 1 case per 100,000 adults. Objective: To present a young adult patient with a fever of unknown origin as the presentation of adult Still's disease. Clinical case: 29-year-old patient with a history of rheumatic fever, with a previous hospital admission; who presented a non-infectious febrile illness lasting 50 days, for which the cause was not determined. A year later, the fever reappeared, with similar characteristics, associated with polyarthralgia, hepatosplenomegaly, anemia, hyperferritinemia, neutrophilia, negative rheumatoid factor, and pericarditis was noted during admission. The diagnosis of adult Still's disease was made by exclusion. Treatment with steroids was started, the fever disappeared in the first 24 hours and the patient had a favorable evolution. Conclusions: Adult Still's disease can present as a fever of unknown origin and is diagnosed by exclusion, since there are no pathognomonic clinical manifestations or laboratory tests. Hyperferritinemia is useful for diagnostic suspicion(AU)

Dengue fever in a 32-day-old patient. A rare case report. / Dengue en paciente de 32 días de vida. Reporte de un caso poco habitual.

Dengue fever is a viral disease transmitted by the Aedes aegypti mosquitoes. In Argentina, dengue fever is an epidemic disease; most cases are reported during the hot months. Until epidemiological week (EW) 20/2023, 106 672 cases were reported across 18 of the 24 provinces of Argentina. Children younger than 2 years are among the main groups at risk. Recognizing signs and symptoms and identifying risk factors is fundamental for the management of cases at a higher risk of severity. Here we describe the case of a 32-day-old female patient who was hospitalized due to febrile syndrome without a source, who had a differential diagnosis of viral meningitis and sepsis and progressed to leukocytosis, thrombocytopenia, hypoalbuminemia in association with rash and edema. The diagnosis of dengue fever was established based on clinical, epidemiological, and positive IgM data.

El dengue es una enfermedad viral transmitida por la picadura del mosquito Aedes aegypti. El comportamiento del dengue en Argentina es epidémico; la mayoría de los casos se observan en los meses de mayor temperatura. Hasta la semana epidemiológica (SE) 20/2023, se registraron en Argentina 106 672 casos; se vieron afectadas 18 de las 24 provincias que conforman el país. Dentro de los principales grupos de riesgo, se incluyen los menores de 2 años. Reconocer los signos, síntomas e identificar los factores de riesgo es fundamental para el manejo de casos con mayor riesgo de gravedad. Presentamos el caso de una paciente de 32 días de vida que se internó por síndrome febril sin foco, con diagnósticos diferenciales de meningitis viral y sepsis, evolucionó con leucocitosis, plaquetopenia, hipoalbuminemia, asociado a exantema y edemas. Se llegó al diagnóstico de dengue por la clínica, epidemiologia e IgM positiva.

Mononucleosis infecciosa en paciente con fiebre prolongada

La mononucleosis infecciosa es una enfermedad infectocontagiosa causada por el virus de Epstein-Barr, que afecta principalmente a personas jóvenes, se caracteriza por presencia de fiebre, faringitis y linfadenopatía, generalmente autolimitada, de 1-2 semanas de evolución. Se presenta el caso de un paciente masculino de 22 años con historia de 1 mes de evolución de fiebre y cefalea al que posteriormente se añade odinofagia, adenopatía cervical posterior y exantema generalizado. En analítica laboratorial se constata leucocitosis con neutrofilia. Entre sus estudios complementarios retorna IgM para virus de Epstein-Barr positivo.

Infectious mononucleosis is an infectious disease caused by the Epstein-Barr virus, which mainly affects young people. It is characterized by the presence of fever, pharyngitis and lymphadenopathy, generally self-limited, lasting 1-2 weeks. The case of a 22-year-old male patient with a 1-month history of fever and headache is presented to which odynophagia, posterior cervical lymphadenopathy, and generalized rash are later added. Laboratory analysis revealed leukocytosis with neutrophilia. Among his complementary studies, IgM for Epstein-Barr virus was positive.

Estado reaccional de enfermedad de Hansen como causa de fiebre de origen desconocido

Los fenómenos reaccionales de la lepra son complicaciones inflamatorias que a menudo se presentan como verdaderas emergencias médicas durante el curso del tratamiento o incluso después de culminarlo. A menudo, los síntomas sistémicos como la fiebre pueden aparecer antes que las manifestaciones cutáneas y desconcertar al médico. Se realiza la presentación del caso de un paciente masculino, 39 años, sano, que acude con cuadro de 2 meses de evolución de fiebre, pérdida de peso, con posterior aparición de manchas rojas en todo el cuerpo. Se realizaron biopsia de piel y baciloscopia, con los cuales se pudieron llegar al diagnóstico de lepra.

The reactional phenomena of leprosy are inflammatory complications that often present as true medical emergencies during treatment or even after completion. Often, systemic symptoms such as fever can appear before skin manifestations and baffle the doctor. The case presented is a 39-year male patient, healthy, who consult with a 2-month history of fever, and weight loss, with subsequent appearance of red spots all over the body. A skin biopsy and smear microscopy were performed, with which leprosy was diagnosed.

Granulomatous hepatitis, deciphering an elusive spectrum: a clinical case-based approach

Granulomatous hepatitis is a well-defined histopathologic entity characterized by aggregates of modified macrophages (epithelioid in appearance) and other inflammatory cells that accumulate after persistent exposure to antigens. It induces a cellular immune response mediated by the release of various cytokines (including interferon-gamma [INF-γ], tumor necrosis factor-alpha [TNF-α], and interleukin 12 [IL-12]) that stimulate mononuclear cell fusion, culminating in the formation of multinucleated giant cells with a surrounding border of lymphocytes and fibroblasts. It represents between 2% and 15% of all pathological liver studies, usually during an infiltrative or cholestatic biochemical pattern. A practical approach is proposed based on a challenging clinical case of a patient with a fever of unknown origin in an intermediate incidence area for tuberculosis, such as Colombia.

La hepatitis granulomatosa es una entidad histopatológica bien definida que se caracteriza por la presencia de agregados de macrófagos modificados (de aspecto epitelioide) y otras células inflamatorias que se acumulan luego de la exposición persistente a antígenos, lo que induce una respuesta inmunitaria celular mediada por la liberación de varias citocinas (entre las que se destacan el interferón gamma [INF-γ], el factor de necrosis tumoral alfa [TNF-α] y la interleucina 12 [IL-12]) que estimulan la fusión de células mononucleares para culminar en la formación de células gigantes multinucleadas con un borde circundante de linfocitos y fibroblastos. Representa entre el 2 % y el 15 % de todos los estudios anatomopatológicos de hígado, en el curso por lo general de un patrón bioquímico de tipo infiltrativo o colestásico. Se propone un enfoque práctico a partir de un caso clínico retador de un paciente con fiebre de origen desconocido en una zona de incidencia intermedia para tuberculosis, como lo es Colombia.

Unusual presentation of antisynthetase syndrome: a case series and review of the literature.

BACKGROUND: Antisynthetase syndrome is an inflammatory myopathy that is characterized by the presence of anti-aminoacyl-tRNA synthetase antibodies. Only 30% of those who suffer from the disease can be identified. We present three Hispanic cases of antisynthetase syndrome with unusual clinical pictures were extended myositis panel results enable disease diagnosis and treatment. CASE PRESENTATION: A 57-year-old Hispanic/Latino female with an erythematous scaly plaque, unresolved fever and non-immune haemolytic anaemia in whom inpatient work-up for fever of unknown origin was positive for anti-PL12 positive myositis extended panel. A 72-year-old Hispanic/Latino male with amyopathic weakness syndrome and mechanic hands in whom impatient work-up was relevant for proximal muscle uptake and anti-PM75 and AntiPL-12 myositis extended panel. And a 67-year-old Hispanic/Latino male with progressive interstitial lung disease and unresolved fever ended in myositis extended panel positive for antiPL-7. After systemic immunosuppressor treatment, patients had favourable clinical and paraclinical responses during outpatient follow-up. CONCLUSIONS: The high variability of the antisynthetase syndrome in these cases demonstrates the importance of identification through an expanded panel and highlights the probability that this is a variable disease and that we need to include emerging molecular tests to promote the timely treatment of patients.

Acute Chagas disease Diagnostic experience through an outbreak / Enfermedad de Chagas aguda Experiencia diagnóstica a través de un brote

Abstract Chagas disease is a public health problem in Latin America, with a tendency to globalize due to migration phenomena. The acute phase of the disease tends to be indolent, but a low percentage of patients have an ominous course, especially when the route of transmission is oral, presenting as a prolonged febrile syndrome in the form of an epidemic outbreak. Early detection of the disease will probably avoid morbid outcomes and, in some cases, death. In this case report we summarize a diagnostic approach by describing the index case in an epidemic outbreak. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2727).

Resumen La enfermedad de Chagas constituye un problema de salud pública en Latinoamérica con tendencia a la globalización, debido a los fenómenos de migración. La fase aguda de la enfermedad suele ser indolente, pero un bajo porcentaje de pacientes tienen un curso ominoso, especialmente cuando la ruta de transmisión es oral, presentándose como un síndrome febril prolongado en forma de brote epidémico. La detección temprana de la enfermedad probablemente evite desenlaces de morbilidad y en algunos casos la muerte. En este reporte de caso resumimos un enfoque diagnóstico a través de la descripción del caso índice de un brote epidémico. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2727).

Enfermedad de castleman multicéntrica y tuberculosis diseminada en paciente HIV positivo / Multicentric Castleman disease and tuberculosis in HIV positive patient

Resumen Presentamos el caso de un hombre de 40 años, HIV positivo con regular adherencia al tratamiento, que consultó por episodios febriles intermitentes de dos años de evolución, agregando en los últimos dos meses dolor abdominal difuso progresivo y adenomegalias ge neralizadas indoloras. En el laboratorio presentó panci topenia, coagulopatía, hipoalbuminemia y reactantes de fase aguda aumentados. La tomografía computarizada (TC) de tórax, abdomen y pelvis únicamente evidenció hepato-esplenomegalia y adenomegalias generalizadas. Se realizaron múltiples exámenes microbiológicos, in cluyendo cultivos para Mycobacterium sp. de distintas muestras, todos con resultados negativos, a excepción de la RT-PCR para VHH-8. Se tomó biopsia escisional de ganglio iliaco izquierdo con hallazgos compatibles con enfermedad de Castleman. A pesar de reiniciar terapia antirretroviral, la sintomatología progresó, iniciando tratamiento con corticoides y ganciclovir. Luego de una semana, desarrolló falla mulitorgánica y anasarca, que contraindicaron los fármacos iniciados. Se realizó nueva TC de tórax que mostró infiltrados con patrón en árbol en brote en lóbulo superior derecho asociado a derra me pleural bilateral, y a nivel abdominal, progresión de hepato-esplenomegalia y ascitis. Pasó a unidad de cui dados intensivos 48 horas después por falla hepática ful minante. El paciente falleció en pocas horas. Se recibió postmortem el cultivo del aspirado traqueal positivo para Mycobacterium tuberculosis y la punción-biopsia hepática con granulomas no necrotizantes. Nuestro objetivo es remarcar la importancia de pesquisar tuberculosis activa en nuestro país frente a la sospecha de enfermedad de Castleman antes de iniciar tratamiento, y resaltar que la TBC también puede presentarse como complicación infecciosa elevando la morbimortalidad.

Abstract We present the case of a 40-year-old man, HIV posi tive with regular adherence to treatment, who consulted for intermittent febrile episodes during a two-years period, progressive diffuse abdominal pain and painless generalized lymphadenopathy in the last two months. Laboratory analysis showed pancytopenia, altered co agulation tests, hypoalbuminemia, and increased acute phase reactants. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepato-splenomegaly and generalized lymphadenopathy. Multiple microbiological tests were performed, including cultures for Mycobacte rium sp. from different samples, with negative results, except for the RT-PCR for HHV-8. An excisional biopsy of the left iliac lymph node was taken with findings compatible with Castleman's disease. Despite restarting antiretroviral therapy, the symptoms progressed, starting treatment with steroids and ganciclovir. After a week, he developed multiple organ failure and anasarca, which contraindicated the drugs previously started. A new CT of the chest showed infiltrates with a tree-in-bud pattern in the right upper lobe with bilateral pleural effusion, and at the abdominal level, progression of hepatospleno megaly and ascites. He was transferred to the intensive care unit 48 hours later due to fulminant hepatic fail ure. The patient died within a few hours. Postmortem recieved culture results of the tracheal aspirate were positive for tuberculosis (TB) and the histopathology of the liver biopsy showed non-necrotizing granulomas. Our objective is to highlight the importance of screening for active TB, in our country, when Castleman's disease is suspected, before starting treatment, and to stand out that TB can also present as an infectious complication, increasing morbidity and mortality.

[Multicentric Castleman disease and tuberculosis in HIV positive patient]. / Enfermedad de Castleman multicéntrica y tuberculosis diseminada en paciente HIV positivo.

We present the case of a 40-year-old man, HIV positive with regular adherence to treatment, who consulted for intermittent febrile episodes during a two-years period, progressive diffuse abdominal pain and painless generalized lymphadenopathy in the last two months. Laboratory analysis showed pancytopenia, altered coagulation tests, hypoalbuminemia, and increased acute phase reactants. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepato-splenomegaly and generalized lymphadenopathy. Multiple microbiological tests were performed, including cultures for Mycobacterium sp. from different samples, with negative results, except for the RT-PCR for HHV-8. An excisional biopsy of the left iliac lymph node was taken with findings compatible with Castleman's disease. Despite restarting antiretroviral therapy, the symptoms progressed, starting treatment with steroids and ganciclovir. After a week, he developed multiple organ failure and anasarca, which contraindicated the drugs previously started. A new CT of the chest showed infiltrates with a tree-in-bud pattern in the right upper lobe with bilateral pleural effusion, and at the abdominal level, progression of hepatosplenomegaly and ascites. He was transferred to the intensive care unit 48 hours later due to fulminant hepatic failure. The patient died within a few hours. Postmortem recieved culture results of the tracheal aspirate were positive for tuberculosis (TB) and the histopathology of the liver biopsy showed non-necrotizing granulomas. Our objective is to highlight the importance of screening for active TB, in our country, when Castleman's disease is suspected, before starting treatment, and to stand out that TB can also present as an infectious complication, increasing morbidity and mortality.

Presentamos el caso de un hombre de 40 años, HIV positivo con regular adherencia al tratamiento, que consultó por episodios febriles intermitentes de dos años de evolución, agregando en los últimos dos meses dolor abdominal difuso progresivo y adenomegalias generalizadas indoloras. En el laboratorio presentó pancitopenia, coagulopatía, hipoalbuminemia y reactantes de fase aguda aumentados. La tomografía computarizada (TC) de tórax, abdomen y pelvis únicamente evidenció hepato-esplenomegalia y adenomegalias generalizadas. Se realizaron múltiples exámenes microbiológicos, incluyendo cultivos para Mycobacterium sp. de distintas muestras, todos con resultados negativos, a excepción de la RT-PCR para VHH-8. Se tomó biopsia escisional de ganglio iliaco izquierdo con hallazgos compatibles con enfermedad de Castleman. A pesar de reiniciar terapia antirretroviral, la sintomatología progresó, iniciando tratamiento con corticoides y ganciclovir. Luego de una semana, desarrolló falla mulitorgánica y anasarca, que contraindicaron los fármacos iniciados. Se realizó nueva TC de tórax que mostró infiltrados con patrón en árbol en brote en lóbulo superior derecho asociado a derrame pleural bilateral, y a nivel abdominal, progresión de hepato-esplenomegalia y ascitis. Pasó a unidad de cuidados intensivos 48 horas después por falla hepática fulminante. El paciente falleció en pocas horas. Se recibió postmortem el cultivo del aspirado traqueal positivo para Mycobacterium tuberculosis y la punción-biopsia hepática con granulomas no necrotizantes. Nuestro objetivo es remarcar la importancia de pesquisar tuberculosis activa en nuestro país frente a la sospecha de enfermedad de Castleman antes de iniciar tratamiento, y resaltar que la TBC también puede presentarse como complicación infecciosa elevando la morbimortalidad.

Fiebre de origen desconocido como forma de presentación de fiebre chikungunya en varón joven

La fiebre chikungunya es una enfermedad viral descrita por primera vez en 1952. Actualmente se informan brotes esporádicos de fiebre chikungunya a nivel país (abril 2022). Presentamos el caso de un varón joven con fiebre chikungunya en fase subaguda la cual se presentó al ingreso hospitalario como fiebre de origen desconocido.

Chikungunya fever is a viral disease first described in 1952. Sporadic outbreaks of chikungunya fever are currently reported nationwide (April 2022). We present the case of a young man with chikungunya fever in the subacute phase which presented at hospital admission as fever of unknown origin.

Lactantes febriles menores de tres meses sin foco aparente: ¿es necesario cambiar la estrategia de evaluación?: probamos el step by step / Febrile infants of under three months of age without apparent focus: is it necessary to change the assessment strategy?: we tested the step-by-step approach / Lactentes febris com menos de três meses de idade e sem foco aparente: é necessário alterar a estratégia de avaliação?: tentamos o "passo a passo"

Introducción: la fiebre es un motivo muy frecuente de consulta y hasta en un 20% de los pacientes no se encuentra la causa. En el ámbito de la emergentología pediátrica clásicamente ha existido interés en homogeneizar la forma de evaluar los lactantes febriles menores de tres meses. Contar con un protocolo que permita detectar precozmente el niño que cursa una infección bacteriana invasiva (IBI) sin realizar conductas desproporcionadas es todo un desafío. Objetivo: evaluar y comparar la capacidad para identificar IBI en la pauta actual de fiebre sin foco (FSF) como en la estrategia step by step, en lactantes con FSF valorados en el DEP-CHPR. Material y métodos: estudio observacional, descriptivo, retrospectivo y de pruebas diagnósticas. Criterios de inclusión: lactantes menores de 90 días de vida que consultaron en 2017 y 2018 en DEP-CHPR con diagnóstico de FSF. Resultados: se incluyeron 261 lactantes evaluados con la pauta de FSF actual, en ellos se aplicó la estrategia step by step. El rango de edad fue de 84 días (4-88 días) con una media de 41 días. Sexo masculino 148 niños (56,7%). Se registraron 37 infecciones bacterianas (14,2%) de las cuales 3 fueron IBI (1,1%) y 34 fueron no-IBI (13,1%). La sensibilidad para step by step fue de 0,94% y de 0,89 para la pauta actual, con un VPN de 0,98 para ambas estrategias. Discusión: los lactantes menores de 3 meses son más susceptibles por características fisiológicas a infecciones bacterianas invasivas y cuanto más pequeño aumenta aún más la frecuencia. El step by step discrimina a menores de 1 mes en menores de 21 días y otro grupo de más de 21 días. Nuestra pauta no hace esta discriminación y realiza por igual laboratorio en sangre, orina y líquido cefalorraquídeo; realizando en ocasiones estudios cruentos no necesarios. Conclusiones: ambas estrategias aplicadas en esta población resultaron altamente sensibles para identificar infección bacteriana con un VPN elevado. La aplicación de step by step presenta como beneficio adicional evitar con seguridad la punción lumbar en recién nacidos entre los 21 y 28 días.

Introduction: fever is a very frequent reason for consultation and in up to 20% of patients the cause has not been found. In the field of pediatric emergentology, there has been a traditional interest in homogenizing the way of assessing febrile infants under three months of age. Having a protocol that enables early detection of children with IBIs without engaging in disproportionate procedures is a challenge. Objective: to evaluate and compare the ability to identify IBIs in the present FSF regimen as in the Step-by-Step strategy, in infants with FSF assessed at the Pereira Rossell Pediatric Hospital Center. Material and methods: observational, descriptive, retrospective study and diagnostic tests. Inclusion criteria: Infants under 90 days of age who consulted in 2017 and 2018 at the DEP-CHPR with a diagnosis of FSF. Results: 261 infants diagnosed with FSF regimen were included and they all received a Step-by-Step approach. The age range was 84 days (4 - 88) days with a mean of 41 days. Males 148 children (56.7%). There were 37 bacterial infections (14.2%), of which 3 were IBI (1.1%) and 34 were Non-IBI (13.1%). The sensitivity for the Step-by-Step approach was 0.94% and 0.89 for the current regimen, with a NPV of 0.98 for both strategies. Discussion: infants younger than 3 months-old are more susceptible due to physiological characteristics to invasive bacterial infections, and the younger they are, the higher the frequency. The Step-by-Step Approach splits children of under 1 month of age into those under or over 21 days of age. Our guideline does not make this discrimination and performs the same blood, urine and cerebrospinal fluid laboratory tests sometimes carrying out blood tests is not necessary. Conclusions: both approaches used in this population were highly sensitive to the identification of bacterial infections with a high NPV. The application of the "Step-by-Step" approach has the additional benefit of avoiding lumbar puncture to newborns of between 21 and 28 days of age.

Introdução: a febre é um motivo muito comum de consulta e em até 20% dos pacientes a causa não é encontrada. No campo da emergência pediátrica, tradicionalmente tem havido interesse em homogeneizar a forma de avaliação de lactentes febris menores de três meses de idade. Ter um protocolo que permita a detecção precoce de uma criança com IBI sem realizar procedimentos desproporcionais é um desafio. Objetivo: avaliar e comparar a capacidade de identificação de IBI na atual Diretriz da FSF e na estratégia Passo a Passo, em lactentes com FSF avaliados no DEP-CHPR. Material e métodos: estudo observacional, descritivo, retrospectivo e de testes diagnósticos. Critérios de inclusão: Lactentes com menos de 90 dias de idade que consultaram em 2017 e 2018 no Hospital Pediátrico Pereira Rossell do Uruguai com diagnóstico de FSF. Resultados: Foram incluídos 261 lactentes avaliados com a atual diretriz da FSF, nos quais foi aplicada a estratégia Passo a Passo. A faixa etária foi de 84 dias (4 - 88) dias com média de 41 dias. Sexo masculino 148 crianças (56,7%). Foram registradas 37 infecções bacterianas (14,2%), sendo 3 IBI (1,1%) e 34 Não IBI (13,1%). A sensibilidade para Passo a Passo foi de 0,94% e 0,89 para o esquema atual, com VPN de 0,98 para ambas estratégias. Discussão: crianças menores de 3 meses de idade são mais suscetíveis a infecções bacterianas invasivas devido às características fisiológicas e quanto menores, mais frequentes. O Passo a Passo separa crianças menores de 1 mês em dois grupos: menores de 21 dias e acima de 21 dias. Nossa diretriz não faz essa discriminação e realiza exames laboratoriais de sangue, urina e líquido cefalorraquidiano da mesma forma; às vezes realizando estudos de sangue que não são necessários. Conclusões: ambas as estratégias aplicadas nesta população foram altamente sensíveis para identificar infecção bacteriana com alto VPN. A aplicação do "Passo a Passo" apresenta como benefício adicional evitar a punção lombar em recém-nascidos entre 21 e 28 dias.

Fiebre de origen desconocido como presentación de carcinoma de cérvix / Fever of unknown origin as presentation of carcinoma of the cervix

El carcinoma de cérvix constituye una causa rara de fiebre de origen desconocido (FOD). Se presenta el caso de una paciente femenina de 42 años de edad con fiebre de 80 días de evolución. Había estado ingresada en dos hospitales sin que se llegase a diagnosticar su causa. Se le habían administrado múltiples regímenes antibióticos sin lograrse remisión de la hipertermia. Fue remitida al hospital Hermanos Ameijeiras para continuar estudios en el protocolo de atención a pacientes con ese tipo de afección. Tenía anemia ferropénica y refería hipermenorrea. Al examen físico se encontró engrosamiento del cuello uterino al tacto vaginal y se visualizó una tumoración del mismo al examen con espéculo. La biopsia mostró un carcinoma y recibió tratamiento con radioterapia y quimioterapia con lo cual desapareció la fiebre. Se concluye que esta neoplasia puede presentarse a forma de fiebre prolongada producida directamente por el tumor primario, por lo que debe mantenerse un índice de sospecha en pacientes con FOD. Resulta importante tener en cuenta la asociación de fiebre y sangramiento vaginal como posible forma de presentación. Puede constituir una pista diagnóstica relevante para no perder tiempo. Este caso resalta la importancia de realizar un examen físico completo y exhaustivo a todos los pacientes(AU)

Carcinoma of the cervix is a rare cause of fever of unknown origin. We present the case of a 42-year-old female patient with fever of 80 days of evolution. She had been admitted to two hospitals without a diagnosis of the cause. She had been administered multiple antibiotic regimens without achieving remission of hyperthermia. She was referred to the "Hermanos Ameijeirasˮ Hospital to continue studies under the protocol for the care of patients with this type of condition. She had iron deficiency anemia and reported hypermenorrhea. Physical examination showed thickening of the cervix on vaginal examination and a tumor was visualized on speculum examination. The biopsy showed a carcinoma and she was treated with radiotherapy and chemotherapy, with which the fever disappeared. It is concluded that this neoplasm can present as a prolonged fever directly produced by the primary tumor, so an index of suspicion should be maintained in patients with fever of unknown origin. It is important to take into account the association of fever and vaginal bleeding as a possible form of presentation. It may constitute a relevant diagnostic clue to avoid wasting time. This case highlights the importance of performing a complete and thorough physical examination in all patients(AU)

Neutropenic fever of unknown origin and disseminated granulomatous disease in a patient with acute lymphoblastic leukemia.

An 18-year-old male was admitted for his second induction chemotherapy treatment for an acute lymphoblastic leukaemia with cyclophosphamide, cytarabine, and mercaptopurine. He presented with high fever, abdominal pain, non-bloody diarrhoea, portal hypertension and leukopenia. Stool sample analysis, blood cultures and extensive work-up were negative. The only microbiologic evidence was the presence of cytomegalovirus DNA detected by PCR. A profound hypogammaglobulinemia was documented. Pathology material reported non-caseating granulomas in liver, bone marrow, duodenum and colon with negative cytomegalovirus immunostaining. What is your diagnosis?

Un varón de 18 años se internó para recibir el segundo ciclo de inducción por una leucemia linfoblástica aguda con ciclofosfamida, citarabina y mercaptopurina. Desarrolló fiebre alta, dolor abdominal, diarrea no sanguinolenta, hipertensión portal y leucopenia. El análisis de materia fecal, cultivos de sangre y una evaluación exhaustiva fueron negativas. La única evidencia microbiológica fue la detección de ADN de citomegalovirus en sangre por PCR. También se documentó una hipogamaglobulinemia profunda. El material de patología reportó granulomas no caseificantes en hígado, médula ósea, duodeno y colon con inmunohistoquímica negativa para citomegalovirus. ¿Cuál es su diagnóstico?

Fever of Unknown Origin, Wasting Syndrome and Bone Marrow Involvement: A Leprosy Case Report.

Mycobacterium leprae, the etiologic agent of leprosy, is an acid-fast-staining and slow-growing bacilli that infect macrophages and Schwann cells individually or through forming globi. The clinical presentation of leprosy is broad and depends on the host immune response. We report a case of a 42-year-old Brazilian man presenting with fever of unknown origin (FUO), anemia, wasting syndrome, and neuropathy. The diagnosis of lepromatous leprosy was made after an extensive investigation revealed the presence of M. leprae in the bone marrow. Bone marrow involvement in leprosy is rare and some authors believe the presence of M. leprae in the bone marrow can act as a reservoir of the disease facilitating future relapses. It is important to investigate bone marrow involvement in leprosy, especially when the patient presents with cytopenias and positive epidemiologic history.

Two-year history of lymphadenopathy and fever caused by Bartonella henselae in a child

ABSTRACT We report the case of a 6-year-old boy that presented with enlarged lymph nodes on his neck. He complained of tiredness and discouragement, which worsened during feverish periods. There were no relevant laboratory test abnormalities and serological tests were not reactive. Bartonella henselae DNA was detected by species-specific nested polymerase chain reaction. After treatment, the patient progressed with no fever or lymphadenopathy. Bartonellosis is a group of infectious diseases caused by bacteria of the genus Bartonella. This case report is a useful reminder to clinicians that long-term fever of unknown origin can be related to B. henselae infection, even if the specific serology is not reactive.

[Hepato-splenic involvement, an unusual finding secondary to cat-scratch disease: a clinical case]. / Compromiso hepatoesplénico, un hallazgo inusual secundario a enfermedad por arañazo de gato: a propósito de un caso.

The infection by Bartonela henselae (BH), the cause of cat scratch disease, it could be asymptomatic or produce local and multisystem illness. The objective of this case report is to document that the hepato-splenic involvement is unusual in BH infection, and the treatment is discussed and individualized in each patient. This case is about an eleven-year girl who presented with findings in abdominal tomography and ultrasound of hepato-splenic abscesses, with later positive serology for BH. In this way, a bibliographic review is carried out to show the low prevalence and incidence of hepato-splenic involvement where the anamnesis and the physical examination are essential to make an early diagnosis and treatment.

La infección por Bartonella henselae (BH) que causa la enfermedad por arañazo de gato puede cursar de manera asintomática, así como presentar manifestaciones locales y sistémicas. El objetivo de este caso es documentar que el compromiso hepatoesplénico es poco habitual en este tipo de infección y el tratamiento, que debe ser personalizado, aún genera controversia. Se presenta un caso de una paciente de 11 años con fiebre de origen de desconocido con hallazgos en tomografía y ecografía abdominal de abscesos hepatoesplénicos, y confirmación de infección por BH a través de métodos serológicos. Se realiza una revisión bibliográfica donde se evidencia la baja frecuencia de compromiso hepatoesplénico. De esta manera, la anamnesis y el examen físico son fundamentales para realizar un rápido diagnóstico y tratamiento.

Compromiso hepatoesplénico, un hallazgo inusual secundario a enfermedad por arañazo de gato: a propósito de un caso / Hepato-splenic involvement, an unusual finding secondary to cat-scratch disease: a clinical case

La infección por Bartonella henselae (BH) que causa la enfermedad por arañazo de gato puede cursar de manera asintomática, así como presentar manifestaciones locales y sistémicas. El objetivo de este caso es documentar que el compromiso hepatoesplénico es poco habitual en este tipo de infección y el tratamiento, que debe ser personalizado, aún genera controversia. Se presenta un caso de una paciente de 11 años con fiebre de origen de desconocido con hallazgos en tomografía y ecografía abdominal de abscesos hepatoesplénicos, y confirmación de infección por BH a través de métodos serológicos. Se realiza una revisión bibliográfica donde se evidencia la baja frecuencia de compromiso hepatoesplénico. De esta manera, la anamnesis y el examen físico son fundamentales para realizar un rápido diagnóstico y tratamiento

The infection by Bartonela henselae (BH), the cause of cat scratch disease, it could be asymptomatic or produce local and multisystem illness. The objective of this case report is to document that the hepato-splenic involvement is unusual in BH infection, and the treatment is discussed and individualized in each patient. This case is about an eleven-year girl who presented with findings in abdominal tomography and ultrasound of hepato-splenic abscesses, with later positive serology for BH. In this way, a bibliographic review is carried out to show the low prevalence and incidence of hepato-splenic involvement where the anamnesis and the physical examination are essential to make an early diagnosis and treatment.

A Case Report of Brucellosis and the Differential Diagnosis of Lymphoma and Tuberculosis

ABSTRACT In this paper, we present a male patient from Xinjiang with fever of unknown origin and significant weight loss for more than 1 month. He was admitted to hospital with negative Rose Bengal test (RBT) and decreased leucocyte count. Ultrasound revealed splenomegaly and abdominal computed tomography, which showed multiple hypodense splenic nodules. The patient was suspected of lymphoma or tuberculosis. Pathological biopsy suggested brucellosis infection following splenectomy. Anti-Brucella treatment was effective and his temperature gradually returned to normal. During the follow-up, the patient's RBT result turned to positive and he was instructed to continue the anti-Brucella drug regimen. His temperature, weight, white blood cell count, other laboratory examinations, and imaging findings all returned to normal during the 6-month follow-up after the treatment.