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Pyrexia of unknown origin (PUO) is one of the most challenging medical problems. Endocrine causes of PUO are rare. Fever is common in a few endocrine disorders (e.g., thyroid storm, adrenal crisis and pheochromocytoma). However, PUO as the sole presenting feature is very rare with only a few reported cases in the literature. We present the case of a middle-aged male who came to us with PUO, weight loss and loss of appetite. The unusual symptomatology like loss of appetite, altered bowel habits made diagnosis difficult. This case highlights the importance of considering thyroid disorder in the differential diagnosis of PUO. Abnormal thyroid function may be an early clue for diagnosis.
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We report a case of pyrexia of unknown origin (PUO) in a 19-year-old male, who was admitted with a history of pyrexia for 2 weeks. The diagnosis remained uncertain despite multiple investigations and the patient subsequently had various clinical manifestations similar to those seen in coronavirus disease 2019 (COVID-19). Since it was initially presumed to be pyrexia due to viral origin or enteric fever, patient was started on empirical treatment. The diagnosis of COVID-19 was confirmed by corroborating various biochemical markers that had a greater association with COVID-19. Patient was discharged after 21 days with empirical antibiotics, anticoagulants and other supportive medications. He required no further hospital admissions and has been on regular follow-up.
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It is very rare to have a lymphomatous involvement of ovary. Malignant lymphoma of ovary is a well-known late manifestation of disseminated nodal disease. Primary ovarian lymphoma with ovarian mass as an initial manifestation is a rare entity and may have varied presentations which can cause confusion to the physician and cause delay in diagnosis. Study presents a case of non-Hodgkin’s lymphoma where the initial presentation was fever with weight loss, and was evaluated as pyrexia of unknown origin. When no other cause of fever was identified PET-CT was done showing metabolically active uterine mass with no lymphadenopathy. Exploratory laparotomy was planned followed by hysterectomy with bilateral salpingo ophorectomy with omentectomy. Ovarian malignancy was detected intraoperatively, which was diagnosed as diffuse large B cell lymphoma, NHL double expresser phenotype on histopathology and IHC. Patient was started on chemotherapy and is doing fine.
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Mevalonate kinase deficiency (MKD) is a rare autosomalrecessive autoinflammatory disease caused by mutations inMVK. We report two siblings with MKD, presenting withrecurrent febrile illnesses, detected to have compoundheterozygous variants in MVK. MKD mimics common pediatricconditions and should be considered as a differential diagnosis.
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Petersdorf and Beeson defined pyrexia of unknown origin (PUO) as a complaint with temperature surpassing 38.30 C, developing over a period of at least three weeks, with no possible opinion reached after one week of inpatient investigation. In the present study, an attempt has been made to find out the causes of PUO based on bone marrow morphology. The range of diseases causing PUO not only seems to be determined by geographical factors, but time also plays a vital role. Bone marrow examination plays an important role in early diagnosis of core cause for PUO and is the best tool for picking haematological and non-haematological disorders in any age group.METHODSAll patients presenting with classical PUO coming to Government Medical College, Jammu, fulfilling the criteria of Petersdorf RG et al whether inpatient or outpatient over a period of two years were included in this cross-sectional study.RESULTSOut of 76 patients, 48 were males and 28 were females. Age of patients varied from 12 years to 70 years. Majority of patients were in the age group of 30-44 years comprising of 45% of total cases. Anaemia was seen in nearly 50% of cases of PUO. Most common diagnosis was neoplastic changes, seen in 20% of patients, 16% cases show megaloblastic changes, iron deficiency was seen 10 % cases, reactive myeloid hyperplasia was seen in 18% cases, haemophagocytosis in 6% cases, 5% cases showed hypocellular marrow. Among infections, malaria was the commonest constituting 5.2% cases. Out of total of 15 cases of neoplastic changes in bone marrow, majority of them were acute myeloid leukaemia seen in 40% cases.CONCLUSIONSBone marrow examination is an important investigation of PUO in arriving at an etiological diagnosis. The most frequent causes of pyrexia of unknown origin observed in children were acute lymphoblastic leukaemia, megaloblastic anaemia and haemophagocytosis, whereas in adults, the main causes were malignancies, megaloblastic anaemia and reactive myeloid hyperplasia. This study sheds light on the current spectrum of diseases causing pyrexia of unknown origin in this region.
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Adult onset still’s disease is a rare systemic inflammatory disorder of unknown aetiology, characterized by clinical triad (high spiking fever, evanescent rash and arthritis) and biological triad with lack of serological markers as a true gold standard makes diagnosis difficulty. Here is a case of 32year old male presented with high grade fever for 2 months, joint pains and swelling for 1month rash for 3 days. O/E: pallor and B/L tender, swollen ankle and knee joints, and P/A: splenomegaly. Investigations showed-Hb%. 8 gms, neutrophilic leucocytosis with thrombocytosis, ESR:72 mm/1h, CRP elevated. ASO-titre, RA factor and Anti CCP antibodies are negative. Adult onset still’s disease is a heterogenous and rare systemic inflammatory disorder of unknown aetiology with lack of serological diagnostic modalities.
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Brucellosis is a significant bacterial zoonotic disease with a high seroprevalence in low-to-middle-income countries where there is a significant contact of humans with animals. This prospective study was conducted to observe the seroprevalence of brucellosis in 75 symptomatic patients with pyrexia of unknown origin (PUO) and 75 high-risk individuals (10 veterinarians, 15 milkmen and 50 healthy contacts of symptomatic patients) with possible exposure to brucellosis. Serum samples collected from these patients and individuals were subjected to rose Bengal test (RBT) and ELISA for the detection of IgM and IgG antibodies. RBT was positive in 50 samples (40 PUO and 10 high risk), of which 25 (33.3%) PUO cases had detectable IgM antibodies, whereas IgG antibodies were detected in 20 patients. None of samples from high-risk individuals was reactive for IgM/IgG antibodies by ELISA. The overall seroprevalence in this study was 16.7% (33.3% in PUO patients). Being a predominantly livestock rearing area, brucellosis is a significant health-care problem in this part of India with this entity being linked to 33% of PUO cases.
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Wuchereria bancrofti is the most common parasite causing lymphatic filariasis. Microfilariae are demonstrated in the peripheral blood, body fluids, fine needle aspirates and in onchial ushings but it is an uncommon finding in the bone marrow. We report a case of a 45-year old male who presented with pyrexia of unknown origin and on peripheral blood and bone marrow examination found to have pancytopaenia with megaloblastoid changes in the bone marrow and W. bancrofti microfilariae.
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Background: Scrub typhus is lesser known cause of fever of unknown origin in India. Even if there have been reports documenting the prevalence of scrub typhus in different parts of India, it is still an unknown entity, and clinicians usually do not consider it as differential diagnosis. The present study was performed to document the prevalence of scrub typhus among febrile patients in western part of Uttar Pradesh and to assess the clinical profile of infected patients on the one hand and knowledge, attitude, and practices among clinicians on the other. Materials and Methods: A total of 357 adult patients with fever of more than 5-day duration were recruited. All patients underwent complete physical examination, and detailed clinical history was elicited as per predesigned pro forma. After primary screening to rule out malaria, enteric fever, and leptospirosis infection, secondary screening for scrub typhus was done by rapid screen test and IgM ELISA. Results: Scrub typhus infection was positive in 91 (25.5%) cases. The most common symptoms among the patients were fever (100%), pain in abdomen (79.1%), pedal edema 56 (61.5%), rash 44 (48.3%), headache 44 (48.3%), vomiting 42 (46.1%), constipation 33 (36.2%), cough 28 (30.7%), and lymphadenopathy 20 (21.9%). The median values of interleukin-8, interferon-gamma, and tumor necrosis factor-alpha in healthy controls were 15.54 pg/ml, 7.77 pg/ml, and 54.1 pg/ml, respectively, while the median values of these cytokines in scrub typhus-positive patients were 21.04 pg/ml, 8.74 pg/ml, and 73.8 pg/ml, respectively. Conclusion: Our results highlight that scrub typhus infection is an important cause of pyrexia of unknown origin, and active surveillance is necessary to assess the exact magnitude and distribution of the disease.
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Background & objectives: Bartonella henselae causes infections which closely resemble febrile illness and chronic diseases such as tuberculosis and haematological malignancies. There are not many studies on Bartonella infections from India. The present study was undertaken to diagnose B. henselae infection in diverse clinical conditions in a tertiary care hospital in north India. Methods: A total of 145 patients including those with fever and lymphadenopathy, infective endocarditis and neuroretinitis were enrolled in the study. Whole blood, serum and lymph node aspirate and valvular vegetations if available, were obtained. Samples were plated on chocolate agar and brain-heart infusion agar containing five per cent fresh rabbit blood and were incubated at 35°C for at least four weeks in five per cent CO2with high humidity. Immunofluorescent antibody assay (IFA) was done for the detection of IgM antibodies in the serum using a commercial kit. Whole blood was used to perform polymerase chain reaction (PCR) for the citrate synthase gene (gltA). Results: IFA was positive in 11 of 140 (7.85%) patients and PCR was positive in 3 of 140 (2.14%) patients. Culture was negative in all the cases. A higher incidence of Bartonella infection was seen in patients with fever and lymphadenopathy (n=30), seven of whom were children. In ophthalmological conditions, four cases were IFA positive. Interpretation & conclusions: The present study shows that the threat of Bartonella infection is a reality in India. It is also an important treatable cause of fever and lymphadenopathy in children. Serology and PCR are useful tests for its diagnosis. Clinicians should consider Bartonella infection in the differential diagnosis of febrile illnesses and chronic diseases.
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This descriptive study evaluated 49 children with fever lasting formore than 7 days at a tertiary hospital in urban Mumbai. Etiologicdiagnosis could be established in 88% of the cases. Infectionswere the causein 34 (79%)patients, 6 (14%) were diagnosed ascollagen vascular diseases, and 3 (7%) had other cause
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Background: Human trypansomiasis due to infection by animal trypanosomes is rarelyreported from India. Case characteristics: We describe clinical presentation of a 2-month-old boyfrom a rat infested house in rural Gujarat who was diagnosed to be havinginfectionwith the rodent parasite Trypanosoma lewisi. Observation: The fever and parasitemiaresolved on treatment with liposomal amphotericin B, Ceftriaxone and Amikacin, and therewas no recurrence of parasitemia over a 2 month follow-up. Message: The case highlightsthe need for increased awareness and heightened surveillance for this rare zoonoticinfection
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@#Introduction: Imaging modality has become increasingly important in hospital setting especially in cases of unknown site of infection/pyrexia of unknown origin (PUO) and osteomyelitis (OM). In recent years, nuclear imaging has been used and is known to deliver prompt and precise diagnoses of numerous infectious diseases. The purpose of the study is to detect and localise the site of infection using Tc99m-besilesomab and to assess the added contributions of single photon emission computed tomography/computed tomography (SPECT/CT) over planar scan in patients with PUO and OM. Methods: Tc99m-besilesomab with SPECT/CT were prospectively performed in 23 patients (eight males, 15 females) with suspected infection. True findings were diagnosed by both cold and hot spot in the scan with reference to positive blood or tissue cultures, or other additional imaging. Results: Tc99m-besilesomab managed to detect presence of infection with high sensitivity of 87.5% and specificity of 71.4%. Interobserver variability agreement that was obtained between the presence of infection and the ability of Tc99m-besilesomab imaging to detect it was significant (p<0.05), Kappa=0.7. SPECT/CT has increased the detection sensitivity by 6.3% and specificity by 28.6%. Out of 23 patients, 15 had true positive, seven had true negative and only one patient had false negative study. SPECT/CT has changed the management in one patient which was missed by planar imaging. Conclusions: Indeed, SPECT/CT has further increased the detection sensitivity and specificity, provides extra information of the anatomical location and the extent of involvement of the disease as compared to planar imaging alone.
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OsteomielitisRESUMEN
@#Giant cell arteritis (GCA) has a Caucasian preponderance and mainly affects persons older than 50 years old. We report on 2 elderly patients of Asian origin who presented with pyrexia of unknown origin to highlight the rare occurrence of GCA in Asians without classical symptoms. Due to its wide spectrum of manifestations and ethnic differences in epidemiology, the disease can pose a diagnostic challenge to unwary clinicians, resulting in serious sequelae; thus a high index of suspicion is needed for prompt diagnosis and treatment. Temporal artery biopsy should be performed when GCA is suspected.
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Background: Scrub typhus and leptospirosis are bacterial zoonotic disease causing high morbidity and mortality. The seasonal outbreak of pyrexia is common in Arunachal Pradesh (AP); many times the disease remains undiagnosed. Objective: An outbreak of pyrexia of unknown origin (PUO) occurred in Longding district of Arunachal Pradesh in 2013, with 108 deaths, which was investigated to elucidate the cause of illness. Methodology: Blood samples from the affected region with acute pyrexia were collected, and screened for the malaria parasite, scrub typhus IgM and leptospira IgM. Results: Scrub typhus IgM was reactive in 97% (30/31), and 25% (8/31) cases were co-infected with leptospira. Incidentally, scrub typhus reactive (67%) and leptospira co-infection (62.7%) were higher in females. Record of previous 3 years (2011–2013) from Longding, Community Health Centre showed an increase in indoor pyrexia cases by 2-fold or more during October and November. Conclusion: The present study is the first report of co-infection of scrub typhus with leptospirosis from Northeast India. Medical officers in this region should take scrub typhus and leptospirosis in their differential diagnosis of patients with PUO for early diagnosis and effective treatment.
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Objective: Fever of unknown origin (FUO) is a challenging problem among people living with HIV (PLHIV). With increasing access to Anti-retroviral treatment (ART), the spectrum of causes of FUO has evolved in the developed world. This study evaluated the etiology of FUO among PLHIV in the era of ART in India. Methodology: This prospective study was conducted at a tertiary-care institution in New Delhi, India. Sixty four PLHIV with a diagnosis of FUO were assessed by detailed clinical evaluation and immunological assessment. Specific investigations to identify the etiology of fever: microbiological and radiological investigations, bone marrow and histopathological examination of biopsies were performed. A simple diagnostic algorithm for FUO was developed based on the findings. Results: Sixty five episodes of FUO were studied. Seventy percent of subjects were men, 76% were <40 years of age, and 39% were receiving ART. The mean CD4 count was 156.57±178.43 cells/mm3 (5 to 1144 cells /mm3) and 23% patients had CD4 counts <50 cells/mm3. The mean duration of fever was 11.26±8.54 weeks. Infections were the most common cause for FUO, with Tuberculosis the most common (61.54%), particularly disseminated tuberculosis (41.54%). Cryptococcal meningitis (7.69%), bacterial pneumonia (4.62%), pyogenic abscesses (4.62%), Pneumocystis jirovecii pneumonia (PCP) (3.08%), visceral leishmaniasis (3.08%) were other infections observed. Non-infectious etiologies including lymphoma (4.62%) and progressive multifocal leucoencephalopathy (PMLE) (3.08%) were also seen. The etiology remained undiagnosed in 6.15% episodes. Importantly, two or more concurrent etiologies of fever were seen in 60% of patients. Conclusion: Infections especially Tuberculosis remain the most common cause of FUO in PLHIV even in the era of ART in developing countries like India. Multiple concurrent infections and a rising trend to non-infectious causes are being observed. A simple diagnostic algorithm will help diagnose majority of FUO even at the peripheral centers.
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Vitamin B12 deficiency is an uncommon cause of fever. Here we describe a case of a 16- year-old male who presented with pyrexia of unknown origin from one and half month subsequently on investigation patient diagnosed to nutritional megaloblastic anemia secondary to severe vitamin B12 deficiency after exclusion of other infective, neoplastic or inflammatory causes. Megaloblastic anemia (vitamin B12, folate deficiency) is a reversible cause of pyrexia that should be considered in any patient who presents with pyrexia from long time and pancytopenia.
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Scrub typhus is an acute febrile illness that is known to be endemic in the South East Asian countries and the Western Pacific region. We here report an outbreak in the tiny Himalayan state of Sikkim. Patients with pyrexia of unknown origin were evaluated. They were screened by Weil-Felix test and the rapid immunochromatographic method. Samples that were positive by either Weil-Felix agglutination test or by rapid immunochromatography were confirmed by IgM enzyme-linked immunosorbent assay (ELISA). A total 204 samples were screened. Sixty-three patients were confirmed positive among which 42 were male and 21 were female. Effective management and early administration of antibiotics will help prevent the complications and mortality associated with scrub typhus.
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Objective: To evaluate the serological profile of leptospirosis by microscopic agglutination test (MAT) and dark field microscopy (DFM) and to determine the serovar prevalence rate among patients with pyrexia of unknown origin. Materials and Methods: A total of 3830 blood samples were received from different hospitals and laboratories in and around Chennai. They were screened for leptospirosis by MAT and direct observation of live Leptospira by DFM. Results: A total of 748 (19.5%) Leptospira positive cases were identified; among these, 36.76% were Leptospira australis, 30% were Leptospira canicola, 14.57% were Leptospira autumnalis, 12% were Leptospira icterohaemorrhagiae, 4.68% were Leptospira patoc and 1.87% were Leptospira grippotyposa. Patients were in the age group of 1-86 years, with a median age of 43.5 years. 50% positive cases were in the age group of 10-35 years. Majority of the Leptospira infected cases were males (62.98%) than females (37.02%). Conclusion: Leptospirosis occurs in Chennai throughout the year although the number and positivity of cases increased during the monsoon season.
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Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Pruebas de Aglutinación , Niño , Preescolar , Femenino , Humanos , India/epidemiología , Lactante , Leptospira/aislamiento & purificación , Leptospirosis/diagnóstico , Leptospirosis/epidemiología , Masculino , Microscopía , Persona de Mediana Edad , Prevalencia , Adulto JovenRESUMEN
Over the past decade, there has been an increasing evidence of false-positive FDG uptake in several infectious diseases and aseptic inflammatory processes. With the widespread application of FDG-PET imaging in oncology, the interpreting physicians have come across these conditions frequently leading to false-positive diagnosis. Such conditions can coexist with metastatic lesions in patients with cancer, and hence, early and accurate diagnosis or exclusion of infection and inflammation is of utmost importance for the optimal management of these patients. Also, this powerful imaging modality can play an invaluable role for the appropriate management of these complicated benign conditions. The present communication on this non-oncological application of FDG is intended as an educative primer for practicing oncologists on this very important aspect of PET-CT imaging with an ultimate aim for bettering patient management.