RESUMO
Fever of unknown origin (FUO) is defined as persistent fevers without an identifiable cause despite extensive medical workup. Emergency physicians caring for patients reporting a persistent, nonspecific, febrile illness should carefully consider potentially serious non-infectious causes of FUO. We present a case of a 35-year-old man who presented to the emergency department (ED) three times over a 10-day period for persistent febrile illness and was ultimately diagnosed with Adult-Onset Still's Disease (AOSD) after a serum ferritin level was found to be over 42,000 µg/L. AOSD, along with macrophage activation syndrome, catastrophic antiphospholipid syndrome, and septic shock comprise the four hyperferritinemic syndromes. These are potentially life-threatening febrile illnesses that characteristically present with elevated ferritin levels. In this article, we highlight the value of a serum ferritin level in the workup of a patient with prolonged febrile illness and its utility in facilitating early diagnosis and prompt treatment of hyperferritinemic syndromes in the ED.
Assuntos
Febre de Causa Desconhecida/fisiopatologia , Hiperferritinemia/sangue , Doença de Still de Início Tardio/diagnóstico , Adulto , Síndrome Antifosfolipídica/sangue , Síndrome Antifosfolipídica/complicações , Serviço Hospitalar de Emergência , Febre de Causa Desconhecida/etiologia , Humanos , Hiperferritinemia/etiologia , Síndrome de Ativação Macrofágica/sangue , Síndrome de Ativação Macrofágica/complicações , Masculino , Choque Séptico/sangue , Choque Séptico/complicações , Doença de Still de Início Tardio/sangue , Doença de Still de Início Tardio/complicações , Doença de Still de Início Tardio/fisiopatologiaRESUMO
Fever of unknown origin (FUO) continues to present a clinical conundrum for even expert practitioners. The syndrome of FUO has over 200 possible etiologies. Burkitt lymphoma (BL) is a highly aggressive B-cell non-Hodgkin lymphoma with only 1,200 US adult cases reported annually. Fever, night sweats, and weight loss, otherwise known as B symptoms, are common early symptoms of BL. Nerve palsy, especially isolated hypoglossal nerve palsy (IHNP), is rarely seen as a presenting sign in any pathological condition. A case report of FUO and IHNP as the presenting manifestations of BL is presented. The rarity of IHNP and its clinical features delayed the recognition of this syndrome and emphasizes the value of a thorough understanding of the physical examination and the association of unusual clinical findings with a readily identifiable clinical syndrome.
Assuntos
Linfoma de Burkitt/complicações , Linfoma de Burkitt/diagnóstico , Linfoma de Burkitt/fisiopatologia , Diagnóstico Diferencial , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Humanos , Doenças do Nervo Hipoglosso/etiologia , Doenças do Nervo Hipoglosso/fisiopatologia , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: This study aimed to elucidate the etiologies and diagnostic errors of early-phase pediatric fever without an obvious cause. METHODS: This single-center, retrospective, descriptive study included 1334 febrile children hospitalized at Beppu Medical Center in Japan between 2014 and 2018. Eligibility criteria were age ≤12 years, axillary temperature ≥38.0°C, and fever duration ≤7 days at admission. Initial diagnoses on the day of admission and final diagnoses at defervescence were divided into initial fever with identified source (FIS) and initial fever without source (FWS) and final FIS and final FWS, respectively. The etiology of initial FWS and diagnostic discordance between initial FIS and final FIS were investigated. RESULTS: Of the 1334 participants, 94 (7.0%) were diagnosed with initial FWS. Among patients with initial FWS, final diagnoses were confirmed in 40 (43%), including Kawasaki disease in 17, urinary tract infection in 5, bacteremia in 4, exanthem subitum in 3, and the others in 11. Among the 1275 patients diagnosed with final FIS, diagnostic discordances between initial and final diagnoses were observed in 131 patients (10%). The multiple logistic regression analysis identified increased serum C-reactive protein value at admission (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.06-1.13), exanthem subitum (OR: 409; 95% CI: 119-1399), and Kawasaki disease (OR: 14.3; 95% CI: 8.7-23.3) as independent risk factors for diagnostic discordance. CONCLUSION: Exanthem subitum and Kawasaki disease may be undiagnosed or misdiagnosed in febrile children with fever duration ≤7 days.
Assuntos
Febre de Causa Desconhecida , Criança , Pré-Escolar , Diagnóstico Diferencial , Exantema Súbito/complicações , Exantema Súbito/diagnóstico , Exantema Súbito/epidemiologia , Feminino , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/epidemiologia , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Humanos , Lactente , Recém-Nascido , Masculino , Síndrome de Linfonodos Mucocutâneos/complicações , Síndrome de Linfonodos Mucocutâneos/diagnóstico , Síndrome de Linfonodos Mucocutâneos/epidemiologia , Faringite/complicações , Faringite/diagnóstico , Faringite/epidemiologia , Pneumonia/complicações , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Estudos RetrospectivosRESUMO
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.
Assuntos
Febre de Causa Desconhecida/fisiopatologia , Arterite de Células Gigantes/diagnóstico por imagem , Arterite de Células Gigantes/fisiopatologia , Granuloma/diagnóstico por imagem , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Doenças Pulmonares Intersticiais/fisiopatologia , Idoso , Povo Asiático , Feminino , Febre de Causa Desconhecida/diagnóstico , Humanos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
INTRODUCTION: A variety of medications may cause drug fever. Drug fevers may persist for days to weeks until diagnosis is considered. The diagnosis of drug fever is confirmed when there is resolution of fever within 3 days after the medication is discontinued. Only rarely do undiagnosed drug fevers persist for over 3 weeks to meet fever of unknown origin (FUO) criteria. FUOs due to drug fever are uncommon, and drug fevers due to immunosuppressive drugs are very rare. CASE REPORT: This is a case of a 58-year-old female renal transplant recipient who presented with FUO that remained undiagnosed for over 8 weeks. DISCUSSION: We believe this is the first reported case of an FUO due to drug fever from sirolimus in a renal transplant recipient.
Assuntos
Febre de Causa Desconhecida , Transplante de Rim , Sirolimo/efeitos adversos , Feminino , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Humanos , Pessoa de Meia-Idade , Sirolimo/uso terapêuticoRESUMO
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.
Assuntos
Febre de Causa Desconhecida/etiologia , Doenças Reumáticas/complicações , Febre de Causa Desconhecida/fisiopatologia , HumanosRESUMO
No disponible
Assuntos
Humanos , Masculino , Adulto , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/etiologia , Trombose Venosa/complicações , Trombose Venosa/diagnóstico , Fluordesoxiglucose F18 , Fluordesoxiglucose F18/metabolismo , Diagnóstico Diferencial , Febre de Causa Desconhecida/fisiopatologia , Febre de Causa Desconhecida , Tomografia por Emissão de Pósitrons/métodos , Tomografia por Emissão de Pósitrons/tendências , Tomografia por Emissão de Pósitrons , Sedimentação Sanguínea/efeitos da radiação , Radiografia Torácica/tendências , Anticoagulantes/uso terapêuticoAssuntos
Humanos , Masculino , Idoso de 80 Anos ou mais , Febre de Causa Desconhecida/complicações , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/etiologia , Silicotuberculose/complicações , Silicotuberculose/tratamento farmacológico , Silicotuberculose , Mycobacterium tuberculosis/isolamento & purificação , Febre de Causa Desconhecida/tratamento farmacológico , Febre de Causa Desconhecida/fisiopatologia , Endocardite/complicações , Repertório de Barthel , Fosfomicina/uso terapêutico , Broncoscopia , Escarro/citologia , Radiografia TorácicaRESUMO
BACKGROUND: Valproate-induced Fanconi syndrome is a rare adverse effect of valproate. Severely disabled patients who require tube feeding are reported to be susceptible to valproate-induced Fanconi syndrome. Although most patients with valproate-induced Fanconi syndrome are asymptomatic and detected incidentally with findings such as hypophosphatemia, hypouricemia, increased urinary ß2-microglobulin, and generalized hyperaminoaciduria, clinical symptoms such as bone fracture, fever, tachypnea, and edema have been reported. PATIENT DESCRIPTION: This 15-year-old, severely disabled, tube-fed, male patient with cytochrome oxidase deficiency had taken valproate for 3 years when he developed fever for 3 weeks. Hypophosphatemia, hypouricemia, hypokalemia, increased urinary ß2-microglobulin, and generalized hyperaminoaciduria, as well as hypocarnitinemia, were found, indicating that he had Fanconi syndrome. Valproate was the most likely cause of Fanconi syndrome in this patient. After discontinuation of valproate, the fever resolved immediately, and the laboratory findings normalized. CONCLUSION: Valproate-induced Fanconi syndrome should be considered when individuals taking valproate develop fever of unknown origin.
Assuntos
Inibidores Enzimáticos/efeitos adversos , Síndrome de Fanconi/induzido quimicamente , Síndrome de Fanconi/fisiopatologia , Febre de Causa Desconhecida/fisiopatologia , Ácido Valproico/efeitos adversos , Adolescente , Deficiência de Citocromo-c Oxidase/tratamento farmacológico , Síndrome de Fanconi/complicações , Humanos , MasculinoRESUMO
No disponible
Assuntos
Humanos , Masculino , Adulto , Doença de Still de Início Tardio/complicações , Doença de Still de Início Tardio , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Febre de Causa Desconhecida , Fluordesoxiglucose F18 , Tomografia por Emissão de Pósitrons/instrumentação , Tomografia por Emissão de Pósitrons/métodos , Tomografia por Emissão de Pósitrons , Fator Reumatoide , Fator Reumatoide/efeitos da radiaçãoAssuntos
Anemia Ferropriva/diagnóstico , Linfo-Histiocitose Hemofagocítica/diagnóstico , Metemoglobinemia/diagnóstico , Choque Séptico/diagnóstico , Anemia Ferropriva/sangue , Anemia Ferropriva/tratamento farmacológico , Diagnóstico Diferencial , Diarreia/etiologia , Diarreia/fisiopatologia , Feminino , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Humanos , Lactente , Infusões Intravenosas , Masculino , Metemoglobinemia/tratamento farmacológico , Azul de Metileno/uso terapêutico , Medição de Risco , Índice de Gravidade de Doença , Choque Séptico/terapiaAssuntos
Artefatos , Axila/fisiopatologia , Temperatura Corporal , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/fisiopatologia , Termografia/métodos , Membrana Timpânica/fisiopatologia , Feminino , Humanos , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is a rare form of primary liver cancer (PLC). It is difficult to make a correct preoperative diagnosis of cHCC-CC because of the lack of special features of the disease. We here present a case of a 68-year-old man who presented with fluctuant fever, chills, and sweating and was eventually diagnosed as cHCC-CC after surgery. The tumor was 6.0 cm in diameter with distinct borders and no satellite lesions or lymph nodes were observed during macroscopic examination of the resection specimen. The fever resolved in the postoperative period till the 28th day after surgery, when the patient developed extensive abdominal metastases and died shortly after. More attention should be paid to the patient with PLC showing abnormal features such as FUO, normal range of tumor markers, atypical imaging, and less cirrhosis. Hepatic resection is the treatment of choice although with short-term outcomes.
Assuntos
Neoplasias Abdominais/secundário , Neoplasias dos Ductos Biliares/patologia , Carcinoma Hepatocelular/secundário , Colangiocarcinoma/secundário , Febre de Causa Desconhecida/fisiopatologia , Neoplasias Hepáticas/patologia , Neoplasias Abdominais/fisiopatologia , Neoplasias Abdominais/cirurgia , Idoso , Neoplasias dos Ductos Biliares/fisiopatologia , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/patologia , Carcinoma Hepatocelular/fisiopatologia , Carcinoma Hepatocelular/cirurgia , Colangiocarcinoma/fisiopatologia , Colangiocarcinoma/cirurgia , Evolução Fatal , Humanos , Neoplasias Hepáticas/fisiopatologia , Neoplasias Hepáticas/cirurgia , MasculinoAssuntos
Crioterapia/métodos , Febre de Causa Desconhecida/etiologia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Melfalan/efeitos adversos , Estomatite/etiologia , Antibacterianos/uso terapêutico , Estudos de Coortes , Feminino , Febre de Causa Desconhecida/tratamento farmacológico , Febre de Causa Desconhecida/fisiopatologia , Seguimentos , Transplante de Células-Tronco Hematopoéticas/métodos , Humanos , Incidência , Mucosa Intestinal/fisiopatologia , Masculino , Melfalan/uso terapêutico , Estudos Prospectivos , Medição de Risco , Índice de Gravidade de Doença , Estomatite/epidemiologia , Transplante Autólogo , Resultado do TratamentoRESUMO
Fever of unknown origin (FUO) in adults is conventionally defined by the occurrence of body temperatures above 38.3 degrees C (101 degrees F) for a period of 3 weeks without any identified etiology after a period of 1-week hospitalization. The issue of FUO in pediatrics is rather hazy and still represents a challenging diagnostic dilemma. Most of the available data are limited to nationwide cohorts of patients of any age. The major difficulty in establishing a diagnosis is that the characteristic features rendering specific disorders clinically recognizable are absent or subtle, hence only a painstaking questioning on family background may elicit the correct investigative path. No diagnostic algorithms are actually available and clinicians must rely on a very careful step-by-step evaluation of the single patient. The need for invasive diagnostic techniques should be closely taken into consideration when laboratory tests or simple imaging procedures fail to discern the origin of FUO. Fevers with no reasonable explanation and no localizing signs often conceal different common diseases in children, which tend to display an unusual or atypical pattern. The principal causes behind FUO in pediatric age remain infections, followed by collagen vascular diseases and neoplastic disorders, although most children with malignancies present other systemic signs or suggestive laboratory abnormalities. The possibility of autoinflammatory syndromes, drug fever, and factitious fever should also be taken into account.
Assuntos
Algoritmos , Regulação da Temperatura Corporal , Procedimentos Clínicos , Febre de Causa Desconhecida/diagnóstico , Adolescente , Fatores Etários , Criança , Pré-Escolar , Doenças do Colágeno/complicações , Doenças do Colágeno/diagnóstico , Doenças Transmissíveis/complicações , Doenças Transmissíveis/diagnóstico , Febre de Causa Desconhecida/classificação , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/fisiopatologia , Febre de Causa Desconhecida/terapia , Humanos , Lactente , Recém-Nascido , Neoplasias/complicações , Neoplasias/diagnóstico , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Fatores de Tempo , Doenças Vasculares/complicações , Doenças Vasculares/diagnósticoRESUMO
Adult-onset Still's disease (AOSD) remains a perplexing, difficult to diagnose clinical entity, with clinical characteristics that are often broad and encountered in numerous other clinical entities. This vague clinical presentation is depicted in the commonly used diagnostic criteria, as the ones by Yamaguchi and Fautrel. The authors sought to investigate how diagnostic criteria apply in a series of 22 new cases of AOSD patients presenting with fever of unknown origin (FUO) and diagnosed at the Internal Medicine Department of Hatzikosta General Hospital of Ioannina, Greece. The aims of the study were: (1) to study the incidence of AOSD and (2) to retrospectively apply different classifications to the data of these patients in search of a more efficient way of diagnosing these patients in the future. The annual incidence of AOSD was estimated at two new cases per 10(5). The clinical manifestations of the patients are discussed, with an emphasis on specific manifestations being considered as criteria by Yamaguchi and Fautrel classifications. Four patients exhibited markedly increased serum D: -dimers, a finding of which the potential pathophysiologic implications are discussed. Serum ferritin levels have additive values, both for diagnostic and cost-reduction purposes in cases presenting as FUO; serum ferritin values are not included in any diagnostic set of criteria at present. The finding of high levels of D-dimers in AOSD needs further studies.
Assuntos
Febre de Causa Desconhecida/diagnóstico , Doença de Still de Início Tardio/diagnóstico , Adolescente , Adulto , Diagnóstico Diferencial , Feminino , Febre de Causa Desconhecida/fisiopatologia , Grécia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doença de Still de Início Tardio/epidemiologia , Doença de Still de Início Tardio/fisiopatologia , Adulto JovemRESUMO
Describimos un caso de fiebre de origen desconocido, en su forma clásica de presentación. Numerosos estudios diagnósticos llevados a cabo mostraron resultados no concluyentes, pero finalmente la tomografía de emisión de protones/tomografía computarizada nos permitió llegar al diagnóstico de rabdomiosarcoma de la región pélvica (AU)
We report a case of fever of unknown origin, in its classical presentation. A wide range of studies were unrevealing, but finally a positron emission tomography/computed tomography allowed us to establish the diagnosis of rhabdomyosarcoma in the pelvic region (AU)
Assuntos
Humanos , Febre de Causa Desconhecida/complicações , Febre de Causa Desconhecida/diagnóstico , Febre de Causa Desconhecida/tratamento farmacológico , Prótons , /instrumentação , /métodos , Rabdomiossarcoma/complicações , Rabdomiossarcoma/diagnóstico , Febre de Causa Desconhecida/fisiopatologia , Febre de Causa Desconhecida , Rabdomiossarcoma/fisiopatologia , RabdomiossarcomaRESUMO
PURPOSE: Febrile seizures (FS) are the most common type of convulsive events in children. FS are suggested to result from a combination of genetic and environmental factors. However, the pathophysiologic mechanisms underlying FS remain unclear. Using an animal model of experimental FS, it was demonstrated that hyperthermia causes respiratory alkalosis with consequent brain alkalosis and seizures. Here we examine the acid-base status of children who were admitted to the hospital for FS. Children who were admitted because of gastroenteritis (GE), a condition known to promote acidosis, were examined to investigate a possible protective effect of acidosis against FS. METHODS: We enrolled 433 age-matched children with similar levels of fever from two groups presented to the emergency department. One group was admitted for FS (n = 213) and the other for GE (n = 220). In the FS group, the etiology of fever was respiratory tract infection (74.2%), otitis media (7%), GE (7%), tonsillitis (4.2%), scarlet fever (2.3%) chickenpox (1.4%), urinary tract infection (1.4%), postvaccination reaction (0.9%), or unidentified (1.4%). In all patients, capillary pH and blood Pco(2) were measured immediately on admission to the hospital. KEY FINDINGS: Respiratory alkalosis was found in children with FS (pH 7.46 ± 0.04, [mean ± standard deviation] Pco(2) 29.5 ± 5.5 mmHg), whereas a metabolic acidosis was seen in all children admitted for GE (pH 7.31 ± 0.03, Pco(2) 37.7 ± 4.3 mmHg; p < 0.001 for both parameters). No FS were observed in the latter group. A subgroup (n = 15; 7%) of the patients with FS had GE and, notably, their blood pH was more alkaline (pH 7.44 ± 0.04) than in the GE-admitted group. During the enrollment period, eight of the patients were admitted on separate occasions because of FS or GE. Consistent with the view that generation of FS requires a genetic susceptibility in addition to acute seizure triggering factors, each of these patients had an alkalotic blood pH when admitted because of FS, whereas they had an acidotic pH (and no FS) when admitted because of GE (pH 7.47 ± 0.05 vs. pH 7.33 ± 0.03, p < 0.005). SIGNIFICANCE: The results show that FS are associated with a systemic respiratory alkalosis, irrespective of the severity of the underlying infection as indicated by the level of fever. The lack of FS in GE patients is attributable to low pH, which also explains the fact that children with a susceptibility to FS do not have seizures when they have GE-induced fever that is associated with acidosis. The present demonstration of a close link between FS and respiratory alkalosis may pave the way for further clinical studies and attempts to design novel therapies for the treatment of FS by controlling the systemic acid-base status.