Abstract
BackgroundFever of unknown origin is often a diagnostic dilemma for clinicians due to its extremely broad differential. One of the rarer categories of disease causing fever of unknown origin is malignancies; of these, soft tissue sarcoma is one of the least common. Soft tissue sarcomas make up < 1% of all adult malignancies and often do not present with any systemic manifestations or neoplastic fevers.Case presentationA 73-year-old Caucasian woman presented with a 2-week history of fever and profound fatigue. The only other symptom she endorsed was a transient history of left knee pain, initially thought to be unrelated. There was no clear cause on initial examination and routine investigations, but her C-reactive protein was significantly elevated at 207 mg/L. Blood cultures and a urine culture were drawn. She was admitted to hospital for further investigation and placed on empiric antibiotics. Her blood cultures were negative, but she had one further fever in hospital. Computed tomography scans did not yield a cause of her fever. No vegetations were seen on echocardiography. Antibiotics were stopped as she did not seem to have an acute infectious cause of her fever. No new symptoms developed. She felt well enough to proceed with out-patient follow up and was discharged after 8 days in hospital. At 1-month post-discharge: no resolution of symptoms, but she endorsed a recurrence of her left knee pain. Ultrasound and magnetic resonance imaging revealed a 4.5 × 6.8 × 11.6 cm soft tissue mass, identified as a sarcoma on biopsy. She subsequently underwent a distal femur resection. Final staging was pT2bN0M0. She underwent adjuvant radiation therapy, but was found to have developed metastatic disease.ConclusionThis case revealed an atypical presentation of a rare soft tissue sarcoma as the cause of the illness. The etiology behind a fever of unknown origin can be difficult to elucidate, making the approach to investigation particularly important. Repeated history-taking and serial physical examinations can be crucial in guiding investigations and ultimately arriving at a diagnosis. In addition, we believe this case highlights the adage that no seemingly innocuous symptom should be left out when working up a condition with such an extensive and complex differential.
Highlights
ConclusionThis case revealed an atypical presentation of a rare soft tissue sarcoma as the cause of the illness
The case described is of a patient with non-specific constitutional symptoms, an initial history of transient left knee pain, and the development of a Fever of unknown origin (FUO)
90% of cases of sarcoma are defined as soft tissue sarcomas (STSs): developing in the muscles, deep tissues, blood vessels, nerves, fat, and joints, while the rest are classified as malignant bone tumors [2]
Summary
Determining an etiology in a patient with FUO can be challenging due to the breadth of possibilities. It is challenging, but FUO often represents an atypical presentation of a disease. This case provides such an example and aims to highlight the extensive workup required. It supports the adage that a full detailed history and examination is often a necessity when evaluating FUO; repeated history and examinations may be needed, with no symptom being viewed as irrelevant. An investigatory approach is outlined in this case report and aims to provide clinicians a foundation from which to work from in the workup of similar cases
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