FEVER OF UNKNOWN ORIGIN IN THE ICU: A CASE OF "GOUTY SEPSIS"

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gout associated with systemic inflammatory response syndrome is well described but underappreciated in clinical practice. A prospective analysis of cases admitted to the hospital estimate that 4.5% are associated with fever. We present a case of a critically ill patient with persistent fever of unknown origin diagnosed with polyarticular gout two months into his hospitalization. CASE PRESENTATION: A 67-year-old man with a history of gout, atrial fibrillation, and type 2 diabetes was admitted with a left MCA territory stroke and underwent emergent thrombectomy. He had a period of relative neurologic recovery but became encephalopathic necessitating intubation for airway protection. He developed aspiration pneumonia and progressive renal failure requiring dialysis and underwent percutaneous tracheostomy. Over a period of several weeks, he demonstrated recurrent fevers and persistent leukocytosis and received multiple courses of empiric broad spectrum antimicrobials. Serial cultures, evaluation for atypical pathogens, cross-sectional imaging, lumbar puncture, and autoimmune serologies did not identify an etiology, and he was trialed on bromocriptine for presumed central fever. Repeat physical exam elicited multiple swollen and tender joints. Arthrocentesis was performed and notable for monosodium urate crystals. Acute polyarticular gout was diagnosed, and he was started on dexamethasone and later switched over to anakinra (due to uncontrolled hyperglycemia), with resolution of fevers and articular symptoms. After defervescing his neurologic status significantly improved and he was able to successfully liberate from the ventilator. He was ultimately discharged to rehab on hospital day 112. DISCUSSION: Fever is present in up to 70% of ICU patients and when prolonged is associated with increased morbidity and mortality. This case highlights the difficulty of recognizing non-infectious etiologies of fever in the critically ill patient and the potential harms in a missed diagnosis. These include unnecessary antimicrobial exposure, invasive procedures, and prolonged hospital stay. Sedation and encephalopathy often complicate history-taking and diagnosis. Here, careful physical examination led to the diagnosis of an underappreciated manifestation (fever) of a common condition (gout). While the incidence of gout flares in the ICU is unknown, medical stress, dehydration, and diuretics are frequent triggers and common in critically ill patients. Treatment may be challenging as high rates of renal insufficiency can preclude the use of common therapies such as NSAIDs or colchicine, and steroids may potentiate issues with glycemic control. CONCLUSIONS: Polyarticular gout should be routinely considered as a possible cause of fever in the ICU. REFERENCE #1: Schäfer VS. Systemic Inflammatory Polyarticular Gout Syndrome - Description of a Previously Neglected Entity. JSM Arthritis. 2017;2(2): 1024. REFERENCE #2: Circiumaru B, Baldock G, Cohen J. A prospective study of fever in the intensive care unit. Intensive Care Med. 1999. Jul;25(7): 668-73. REFERENCE #3: Raddatz DA, Mahowald ML and Bilka PJ. Acute polyarticular gout. Ann Rheum Dis. 1983;42: 112-117. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Tracey Liu, source=Web Response No relevant relationships by Scott Oh, source=Web Response No relevant relationships by Jared Wilkinson, source=Web Response