Fever Of Unknown Origin Research Articles

Unmasking Subacute Thyroiditis in a Young Male with PUO: A Case Report

Pyrexia of unknown origin (PUO) poses a diagnostic challenge, defined as persistent fever exceeding 38.3°C (100°F) without an identified cause after extensive investigation. Subacute thyroiditis (SAT), an uncommon inflammatory condition of the thyroid gland, typically presents with neck pain, thyrotoxic symptoms, and elevated inflammatory markers. However, it rarely manifests as PUO without typical symptoms. We report a case of a 32-year-old Indian male presenting with a 20-day history of persistent fever without localized symptoms, initially treated empirically with antibiotics without improvement. Clinical examination revealed a firm, non-tender goiter, and laboratory investigations showed elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Subsequent thyroid function tests indicated elevated free T4 levels with low TSH, suggestive of thyroiditis, after negative thyroid autoantibodies ruling out Graves' disease. Further investigations including imaging and tests for PUO were negative, prompting an empirical trial of steroid therapy which resulted in rapid clinical improvement. Subsequent thyroid function tests revealed transient hypothyroidism, resolving without intervention. Retrospectively, a diagnosis of subacute thyroiditis was established, highlighting its atypical presentation as PUO. Our case sheds light on the importance of considering uncommon thyroid pathologies in the differential diagnosis of PUO, especially when typical symptoms are absent.

Evaluating Antibiotic De-escalation for Autologous Stem Cell Transplant Patients With Febrile Neutropenia in a Real-World Clinical Setting

Febrile neutropenia (FN) is a complication in approximately 90% of autologous stem cell transplant (SCT) patients. Guidelines support early broad-spectrum antibiotics (BSA) to prevent morbidity and mortality. However, in patients who are clinically stable and deemed to have a fever of unknown origin, the optimal duration of BSA is unknown. Accumulating evidence suggests that de-escalation of BSA in select patients may decrease duration of BSA exposure without compromising clinical outcomes such as infection, recurrent fever, and readmission. With this, a de-escalation protocol was implemented at Vanderbilt University Medical Center (VUMC) to identify autologous SCT patients who may benefit from early de-escalation of BSA. The objectives of this study were to analyze the impact of early empiric antibiotic de-escalation on the duration of BSA as well as its impact on the incidence of recurrent fever and documented infection in autologous SCT patients. This was a single-center, retrospective study evaluating patients older than 18 years of age who underwent autologous SCT and experienced an episode of FN from January 2018 to December 2022 at VUMC (N = 195). The protocol was initiated on January 1, 2020, to de-escalate BSA back to prophylaxis in stable neutropenic patients determined to have a fever of unknown origin. The primary outcome was the number of BSA days within 30 days. Secondary clinical outcomes included recurrent fever, documented infection, readmission, 30-day mortality, and 90-day non-relapsed mortality (NRM). Outcomes were compared across pre- and postprotocol groups with a Wilcoxon rank sum test, Pearson chi-square test, or regression analysis as appropriate. The median BSA duration was 4.7 and 2.7 days in the pre- and postprotocol groups, respectively (P < .001). Recurrent fever (14.2% versus 16.0%, P = .726), documented infection (1.7% versus 6.7%, P = .068), and readmission (13.3% versus 22.7%, P = .091) within 30 days were not significantly different between the two groups. Neither 30-day mortality (0.8% versus 1.3%, P = .736) nor 90-day NRM (0.8% versus 1.3%, P = .736) differed. The implementation of an early de-escalation protocol for autologous SCT patients who develop FN was associated with a reduction in duration of BSA compared to the preprotocol group without a significant difference in readmission, recurrent fevers, and documented infections. This study adds to existing evidence that early de-escalation of BSA in FN patients with a fever of unknown origin who are afebrile and clinically stable is safe and reduces unnecessary antibiotic use.

Patients&amp;rsquo; right to confidentiality and sharing information with colleagues: The dilemma in managing a patient with Munchausen syndrome &amp;ndash; A case report

We report the case of a young woman with a “pyrexia of unknown origin” in the background of a history involving SLE, ocular toxoplasmosis and Ig A nephropathy. The history was narrated by her with precise details but there was no documentary proof of any previous admissions. She had a prolonged hospital stay and repeated hospital admissions for the same illness with extensive investigations including a PET scan. Once evidence for “factitious fever” was overwhelming she got herself discharged from hospital refusing psychiatric help. Close scrutiny revealed that she had got herself admitted to several hospitals in the Western Province subsequently, with the same complaint, with all clinicians investigating her extensively, sometimes including invasive procedures. The ethical dilemma faced by us relating to sharing her clinical details with a wider clinical group is discussed.

Frequency of Leptospira in the Blood of Patients with Fever of Unknown Origin in Sinaloa, Mexico.

Background: Leptospira is a genus of bacteria that causes the zoonotic disease known as leptospirosis, which mainly affects countries with tropical and subtropical climates. Its prevalence may be underestimated because the initial stage of the infection is characterized by presenting a febrile condition that is easily confused with other diseases, such as dengue. This work reports the frequency of leptospirosis in the blood of patients with febrile symptoms of unknown origin. Materials and Methods: A total of 218 peripheral blood samples were analyzed from volunteer participants from Culiacan Sinaloa in June 2019, one half corresponded to patients with undiagnosed febrile symptoms and the other half to asymptomatic volunteers. Data collected included the age and sex of the participants. Leptospira was detected by qPCR using a fragment of the lipL32 gene from the bacteria's genome as a target. Fisher's exact test was used as a statistical method to estimate the relationship between the infection and the data collected. Results: The study group comprised 134 female and 84 male patients ranging from ages 1 to 92 years, averaging 41 years. In this study, Leptospira infection was identified in the blood of 22/218 participating volunteers (10.09%), of which 20/109 (18.34%) presented febrile symptoms, whereas 2/109 (1.83%) were asymptomatic. The most affected participants were women with ages between 27 and 59 years. However, the analysis of the relationship between infection and the variables studied did not show statistical significance. Conclusions: Leptospirosis was detected in blood samples from patients with undiagnosed febrile illness and asymptomatic symptoms in Sinaloa. The lipL32 gene is useful as a target in identifying Leptospira in human blood in the acute phase of the disease.

The Diagnostic Yield of [18F]FDG-PET/CT in a Heterogeneous In-Patient Population with Suspected Infection or Inflammation Is Comparable to Findings in Patients with Classic Fever of Unknown Origin.

Suspected infection or inflammation of unknown origin in in-patients remains challenging. Literature on [18F]FDG-PET/CT is abundant in classic fever of unknown origin (FUO), but evidence is complex and may not always reflect clinical reality. This study explores the application of [18F]FDG-PET/CT in a diverse clinical population of in-patients with suspected infection not defined by stringent FUO-criteria. Retrospective chart review of consecutive in-patients who underwent [18F]FDG-PET/CT in the workup of suspected infection or inflammation from 1 July 2022 to 31 December 2022 was conducted. We evaluated indications, diagnostic yield, and clinical impact of [18F]FDG-PET/CT, and compared the findings of [18F]FDG-PET/CT and stand-alone CT. Univariate logistic regression assessed associations between [18F]FDG-PET/CT outcome and clinical parameters. Receiver operating characteristic curve (ROC) analysis evaluated diagnostic performance. 77 patients met the inclusion criteria. [18F]FDG-PET/CT established a diagnosis in 35% of cases, ruled out focal infection in 26%, and thus was helpful in 61% of patients. It prompted 72 additional examinations resulting in seven incidental diagnoses, including two cancers. Antibiotic treatment was changed in 26% of cases. Regression analysis found white blood cell counts (WBC) associated with true positive outcomes. [18F]FDG-PET/CT was compared to stand-alone CT findings, and was concordant in 69% of cases. Results were comparable to findings in more classic FUO. [18F]FDG-PET/CT was clinically helpful in 61% of cases but also prompted many additional examinations with relatively few clinically important findings. WBC count was a predictor of true positive outcome. CT and [18F]FDG-PET/CT were discordant in 31%, of cases, especially in cases of endocarditis and spondylodiscitis.

Fever of Unknown Origin (FUO) Criteria Influences Diagnostic Outcomes: A Systematic Review and Meta-Analysis

BackgroundCriteria classifying fever of unknown origin (FUO) patients remains subject to discrepancies. A minimal standardized set of investigative tests serves as the foundation for the qualitative criteria, whereas quantitative incorporates the length of evaluation (7 or 3 days). A systematic review of studies would help physicians anticipate the frequency of illness types that could influence management. MethodsProspective studies published in Medline (PubMed), Embase, Scopus, and Web of Science databases from January 1, 1997 to July 31, 2022, were included. A meta-analysis estimated associated pooled proportions between these criteria and diagnostic outcomes adjusted to the International Classification of Diseases, 10th edition (ICD-10) definitions. ResultsFive qualitative studies corresponded to an increase of 15.3% (95% CI: 2.3%-28.3%, P = .021) in undiagnosed FUO proportions compared to eleven quantitative studies. Quantitative studies had 19.7% (95% CI: 6.0%-33.4%, P = .005) more in adjusted infectious disease proportions than qualitative studies. No significant differences in proportions between FUO defining criteria were noted for adjusted noninfectious inflammatory disorders (P = .318), oncology (P = .901), non-inflammatory miscellaneous disorders (P = .321), diagnostic evaluation process, gross national income (GNI), or World Health Organization (WHO) geographic region. ConclusionsUse of either qualitative or quantitative FUO criteria was associated with a statistically significant risk of over- or under-estimating infectious diseases and undiagnosed illnesses when using an ICD-10 adjusted FUO five-category system. Clinicians should anticipate differences depending on which criteria are used. While further research is warranted, qualitative criteria provide the best framework for study comparisons.

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

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. 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. 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. 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.

An uncommon diagnosis of a young female with fever of unknown origin (FUO): Idiopathic Hemophagocytic Lymphohistiocytosis (HLH)

Background. Hemophagocytic Lymphohistiocytosis (HLH), characterized by the uncontrolled activation of immune cells leading to a hyperinflammatory state, is seldom considered in the initial differential diagnosis of FUO. The rarity of idiopathic HLH, especially in young individuals without an identifiable trigger, emerges as an uncommon and particularly challenging diagnosis. This case report presents a compelling narrative of a young female grappling with the complexities of FUO, ultimately revealing the rare and life-threatening entity of idiopathic HLH. Case report. A 25 year old female was referred to our hospital in view of persistent high grade fever since 3 months. Patient has no other complaints. Vitals stable. General and systemic examination normal. Lab investigations showed a total leukocyte count 18000 cell/μL, hemoglobin 9.2 g/dL, and platelets 68000 cells/μL. Other blood investigations showed erythrocyte sedimentation rate (ESR) 88 mm/h, C-reactive protein 21 mg/L, ferritin 670 ng/mL, triglyceride 281 mg/dL, and fibrinogen 1.2g/L. She also had transaminitis with AST 80, ALT 92 and ALP 1442. The entire infectious diseases panel was done which came negative for all, including viral serologies and hepatitis markers. Procalcitonin level was normal and no other relevant investigations came positive. Autoimmune panel analysis also came negative. Blood cultures came negative in two different samples. Also, there is no evidence of vegetation in echocardiography. Coming to the invasive investigations, bone marrow biopsy and aspiration were done to arrive at a diagnosis and it showed hemophagocytosis. Endoscopy and colonoscopy were done, which came normal. CT thorax and abdomen also showed no significant abnormalities, ruling out the probability of missing any gross malignancies. After all this extensive work up and according to Hscore, which is used to estimate an individual’s risk of having reactive hemophagocytic syndrome, this patient was diagnosed with HLH. According to the current HLH guidelines, initial treatment for the disease consists of etoposide, corticosteroids (dexamethasone), or cyclosporine given for 8 weeks. The patient was started on the same above treatment regimen, but only with corticosteroids for a period of 8 weeks, after a consultation with the hematologist. No recurrence is seen in her 6-months of follow-up. The regimen was well tolerated by the patient. Studies also have shown that therapeutic plasma exchange also has a role in HLH treatment, which can be tried in familial and relapsing cases. Conclusion. In our case, this young female was diagnosed to have idiopathic HLH, after ruling out all the familial and secondary causes of HLH including infections, malignancy and autoimmune diseases. The patient was also started on treatment early after the bone marrow and other relevant investigations according to HScore suggested the diagnosis of HLH and the patient improved accordingly. Hence, apart from clearly knowing the etiology or clinical manifestations, HLH is associated with a high mortality rate if appropriate treatment not given. Generally, the underlying etiology determines the prognosis of the disease. But, it is not a good idea to delay the treatment in order to find the cause and type of HLH, because the exhaustive work up might lead to unacceptable delays in improvement and prognosis of the patient. The diagnostic work up and treatment should be done simultaneously in the patient, which has been done in our case and it lead to a good outcome. Though HLH is a fatal and dangerous disease and also highly challenging to make a diagnosis due its uncommon and largely variable clinical presentation, smart work up and early initiation of treatment will lead to better prognostic outcomes.

Intravascular large B-cell lymphoma (IVLBCL): subtle presentation and challenging diagnosis; a case report

Intravascular large B-cell lymphoma (IVLBCL) is a rare, clinically aggressive lymphoma defined by the proliferation of atypical lymphoma cells in the lumen of all sized blood vessels, particularly capillaries. The reasons for this unusual neoplastic cell proliferation are still only partially understood. IVLBCL is considered stage IV lymphoma and manifests with a variety of nonspecific signs and symptoms. Patients with IVLBCL usually do not present with lymphadenopathy. The tumor cells invade the blood vessels of multiple organs such as the central nervous system, skin, lungs, kidneys, and bone marrow. Common presenting symptoms are based on the organ affected and include mental status changes and fever of unknown origin. Although immunochemotherapy has significantly improved the often-poor prognosis of this kind of lymphoma, a large percentage of patients’ relapse. We present a 63-year-old man who had been diagnosed with large B cell lymphoma in the bone marrow in March 2021 and was in remission state after completing six cycles of chemotherapy. There was no abnormal FDG uptake on a post-chemotherapy PET/CT scan. Patient presented to the emergency room (ER) two months later with fever and dyspnea. The entire workup was completed and showed pancytopenia and elevated ESR. While chest CT scan did not show lymphadenopathy or lesions, PET/CT scans revealed a widespread increase in FDG uptake in both the lungs and spleen. Lung biopsy revealed large, atypical cells within alveolar septae and vessels. Immunohistochemical stains demonstrated that these cells were positive for CD20 and PAX-5 and had high proliferation rate based on Ki67. IVLBCL has a low incidence rate with non-specific clinical presentation. The diagnosis can be easily missed in both clinical, radiological and the corresponding histopathological findings. Radiological finding and CT scan are not sensitive enough and may miss the lesion. Even though the PET/CT scan is more sensitive, the definitive diagnosis of IVLBCL relies mainly on histopathology and immunohistochemistry, at which point awareness of this entity by the pathologist is most necessary.

Recommendations for Updating Fever and Inflammation of Unknown Origin From a Modified Delphi Consensus Panel.

Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are syndromes commonly used as medical diagnoses. Since the existing literature has a mixture of diagnostic approaches, developing consensus-based recommendations would be helpful for clinicians, researchers, and patients. A modified Delphi process was performed from October 2022 to July 2023, involving 4 rounds of online surveys and 2 live video conferences. The panel comprised international experts recruited based on peer-reviewed published publications and studies. Among 50 invited experts, 26 (52.0%) agreed to participate. Twenty-three panelists completed round 1 of the survey, 21 completed rounds 2 and 3, 20 completed round 4, and 7 participated in round 5 live video discussions. Of the participants, 18 (78.3%) were academic-based clinicians and researchers, 5 (21.7%) practiced in a community-based hospital, and 6 (26.1%) were female. Consensus was reached on 5 themes: (1) incorporating epidemiologic factors, such as geographic location and travel history; (2) updated criteria for classifying FUO or IUO; (3) initial evaluation approaches; (4) a classification system for diagnoses; and (5) recommendations for judicious limitation of empiric therapies. Experts strongly disagreed with using 2-deoxy-2-[18F] fluoro-D-glucose positron emission tomography/computed tomography as part of the diagnostic criteria for FUO. There were mixed opinions about the importance of the temperature measurement site, the 3-week minimum illness criterion, the need for a standard definition of relapsing fevers, and the use of similar evaluation strategies for FUO and IUO. These Delphi-generated consensus-based recommendations offer potential improvements compared with earlier definitions and a guide for clinical practice and future research.

Distribution of the causes of fever of unknown origin in China, 2013-2022.

Fever of unknown origin (FUO) has long been a cause for concern among clinicians, and its spectrum has evolved with progress in medicine. This study aimed to investigate the distribution of causes of FUO in China between 2013 and 2022 to facilitate the clinical understanding of the etiology of FUO. Case series of FUO in China published between 2013 and 2022 were retrieved from PubMed, Wanfang Data, and CNKI databases and retrospectively analyzed. The rates of different causes of FUO were calculated, and these data were compared with previously published distributions of causes of FUO in China. The causes of FUO with the highest rates from the 51 identified case series (n = 19,874) were infectious, autoimmune, and neoplastic diseases (59.6%, 14.3%, and 7.9%, respectively). A comparison of a subset (43 case series subdivided by disease category, n = 16,278) with previously reported data revealed an increased rate of FUO attributed to infectious diseases in the past decade, with a significantly higher rate attributed to bloodstream infections (10.0% vs. 4.8%) and a significantly lower rate attributed to tuberculosis (9.3% vs. 28.4%), compared with the rates from the previous period. In contrast, the rates of FUO attributed to both autoimmune and neoplastic diseases decreased, with significantly decreased rates attributed to adult-onset Still's disease among autoimmune diseases (4.6% vs. 8.5%) and lung cancer among neoplastic diseases (0.6% vs. 1.6%). Despite an overall increase in the rate attributed to infectious diseases, that attributed to tuberculosis has decreased. The rates attributed to both autoimmune and neoplastic diseases have also decreased.

Casirivimab-imdevimab monoclonal antibody treatment for an immunocompromised patient with persistent SARS-CoV-2 infection: a case report

BackgroundPersistent acute SARS-CoV- 2 infection is characterised by the persistence of symptoms of a COVID-19 illness and a persistently positive SARS-CoV-2 RT PCR result. It is often seen in immunocompromised individuals. Currently, there are no approved treatment regimens or guidelines for management.MethodsOur patient is a middle-aged male who had received chemotherapy prior to the onset of his SARS- CoV-2 infection and subsequently was diagnosed with a persistent and acute SARS- CoV-2 infection after presenting to us with a pyrexia of unknown origin. He was treated on an off-label basis following informed consent with casirivimab-imdevimab monoclonal antibody therapy, comprising two IgG1 neutralising human monoclonal antibodies at a dose of 600 mg each.ResultsOur patient had significant clinical improvement on treatment with the monoclonal antibody therapy and it was well tolerated without any adverse effects. He is currently doing well during follow up.ConclusionsCasirivimab-imdevimab monoclonal antibody therapy could be beneficial for people with persistent acute SARS-CoV-2 infection. Therapy is warranted on a case-to-case basis. This highlights the need to identify immunocompromised individuals who are at risk of developing persistent acute SARS-CoV-2 infection to enable their prompt treatment.

Brucella Prostatitis: A Rare Manifestation of Fever of Unknown Origin, Detected by FDG PET/CT.

FDG PET/CT is a well-documented imaging investigation to evaluate fever of unknown origin (FUO). Brucellosis is one of the causes of FUO, which can be missed as it requires a longer incubation period for growth on culture media. Rarely, it can involve the prostate. Here, we present a case of FUO with initial negative blood and urine cultures and no localizing signs or symptoms. 18F-FDG PET/CT revealed hypermetabolism in the prostate and seminal vesicles. A repeat blood and urine culture showed the growth of Brucella species after 5 days of incubation, and the patient responded to Brucella-directed antibiotic therapy.

Spider bite presenting as fever, macrophage activation syndrome and a skin ulcer

Introduction: Fever of unknown origin (FUO) refers to a condition of prolonged increased body temperature, without identified causes. The most common cause of FUO worldwide are infections; arthropod bites (loxoscelism) should be considered in view of the spread of the fiddleback spider. Loxoscelism can present in a cutaneous form (a necrotic cutaneous ulcer) or in a systemic form with fever, haemolytic anaemia, rhabdomyolysis and, rarely, macrophage activation syndrome (MAS). For this suspicion, it is important to have actually seen the spider. Case description: A 71-year-old man was admitted to our department because of intermittent fever, arthralgia and a necrotic skin lesion on his right forearm that appeared after gardening. Laboratory tests were negative for infectious diseases, and several courses of antibiotics were administered empirically without clinical benefit. Whole-body computed tomography showed multiple colliquative lymphadenomegalies, the largest one in the right axilla, presumably of reactive significance. A shave biopsy of the necrotic lesion was performed: culture tests were negative and histological examination showed non-specific necrotic material, so a second skin and lymph node biopsy was performed. The patient developed MAS for which he received corticosteroid therapy with clinical/laboratory benefit. Cutaneous and systemic loxoscelism complicated by MAS was diagnosed. Subsequently, the second biopsy revealed morphological and immunophenotypic findings consistent with primary cutaneous anaplastic large cell lymphoma (PC-ALCL). Conclusions: Skin lesions and lymphadenomegalies of unknown origin should always be biopsied. It is very common to get indeterminate results, but this does not justify not repeating the procedure to avoid misdiagnosis.

Primary adrenal insufficiency developed 22 years after the diagnosis of light and heavy chain deposition disease: a case report.

Monoclonal immunoglobulin deposition diseases (MIDDs), including light and heavy chain deposition disease (LHCDD), are rare and heterogeneous disorders associated with underlying B-cell clonal disorders. Adrenal involvement is a potential extrarenal manifestation of MIDDs; however, limited data are available regarding its prevalence and clinical presentation. Herein, the present report describes, for the first time, a case of primary adrenal insufficiency that developed twenty-two years after a diagnosis of LHCDD had been made. A 69year-old woman with a 10year history of hemodialysis suddenly became bedridden after falling down stairs in the absence of focal neurological deficits. Subsequently, she experienced appetite loss, nausea, vomiting, a fever of unknown origin, and unexplained hypotension. Several months later, primary adrenal insufficiency and normal pressure hydrocephalus were diagnosed and successfully managed. The long-term clinical prognosis of MIDDs has not been fully elucidated despite recent advances in the management of the disorders. This report may contribute to improving our understanding of the disease course.

Role of 18 F-FDG PET/CT for providing a targeted approach for etiology of PUO.

This study aimed to evaluate the potential role of 18F-fluorodeoxyglucose PET/computed tomography (18F-FDG PET/CT) in providing a targeted approach for diagnosing the etiology of Pyrexia of Unknown Origin (PUO). A total of 573 PUO patients were included in this ambispective study, with a mean age of 39.40 ± 4.6 years. Patients underwent FDG PET/CT scans using dedicated hybrid scanners. PET/CT data were interpreted by experienced nuclear medicine physicians. The study analyzed the guidance provided by FDG PET/CT for appropriate biopsy sites and assessed concordance between PET/CT findings and histopathological examination. Out of the 573 patients, a final diagnosis was reached for 219 patients, including malignancy, infectious causes, noninfectious inflammatory causes (NIID), and precancerous conditions. FDG PET/CT played a crucial role in guiding clinicians to appropriate biopsy sites, contributing to a higher diagnostic yield. Concordance between PET/CT findings and histopathological examination emphasized the noninvasive diagnostic potential of PET/CT in identifying underlying causes of PUO. Overall, FDG PET/CT contributed to guiding the appropriate site of biopsy or concordance of the first differential diagnosis with the final diagnosis in 50.05% of cases. This study highlights the valuable role of FDG PET/CT in providing a targeted approach for diagnosing PUO, showcasing its potential in guiding clinicians towards appropriate biopsy sites and improving the diagnostic yield. The findings underscore the importance of integrating FDG PET/CT into the diagnostic pathway for PUO, ultimately enhancing patient management and outcomes. Further prospective studies are necessary to validate these results and refine the integration of FDG PET/CT in the diagnosis of PUO.

SEROPREVALENCE AND CLINICAL FEATURES OF SCRUB TYPHUS AMONG FEBRILE PATIENTS IN A TERTIARY CARE HOSPITAL

Objective: Rickettsial infections is the most neglected and underdiagnosed tropical diseases in developing countries. The most common rickettsial disease, which is caused by the obligate intracellular gram-negative bacteria Orientia tsutsugamushi, is Scrub Typhus. Scrub typhus can prove to an important diagnosis in pyrexia of unknown origin (PUO) patients and is transmitted by a species of trombiculid mites (“chiggers”). Aim of this study is to find seroprevalence and clinical features of scrub typhus among febrile patients from a tertiary care hospital in North India. Methods: This study was undertaken for a period of 1 y. All the patients attending the outpatient department or admitted indoors suspected of PUO were included in the study. Serum samples of suspected cases were tested for IgM Scrub typhus. Results: During the study period, a total of 755 cases were tested for scrub typhus, out of which 223 were positive so, the seroprevlance of Scrub typhus is 29.5%. Out of 223 positive patients, 105 (47%) were males and 118 (53%) were females. Maximum no. of patients was from age group 21 to 40 y of age and maximum number of cases is in autumn season. Most common clinical feature is fever, followed by myalgia, headache, ocular pain, dyspnoea, cough and eschar, respectively. Conclusion: Scrub typhus is an emerging tropical rickettsial disease in the Indian subcontinent. The present study highlights the importance of screening of PUO cases for Scrub typhus as timely institution of simple empirical treatment can prove to be lifesaving in such cases.

A prospective study on Rickettsia infections in Central India

Rickettsial infections are under-reported in India. The actual disease burden has been underestimated as non-specific serological tests are mostly used to diagnose these infections. The aim of this study was the detection of Rickettsia infections in clinical specimens by Real-time Polymerase Chain Reaction.A study was established to analyse blood samples taken from pyrexia of unknown origin (PUO) or undifferentiated fever cases. A total of 69 such patients, were referred/walked-in to our diagnostic centre, Indore, India between October 2021 and May 2023. The blood samples were collected in EDTA lavender (purple) top tube.Of the tested samples, 14 patients (20.3%) were positive for Rickettsia infection.Gender wise distribution revealed higher incidence (57%) of Rickettsial infections in male patients. Children were majorly infected (50% of cases); multiple infection was also noted in them, though severity was not high. Severe clinical manifestation including hospitalization was also noted in some patients. Few reports are available from India on molecular diagnosis of Rickettsia infection. Early-stage molecular diagnosis will help to stave off and prevent serious complications.

Tocilizumab in the treatment of hyperferritinemic syndrome and capillary leak syndrome secondary to rheumatoid arthritis: Case report and literature review.

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease, which is mainly characterized by joint swelling, pressure pain and joint destruction. Some patients may suffer from a variety of serious complications, which require prompt diagnosis and treatment. Otherwise, the patient condition may deteriorate rapidly, leading to premature death. We reported a case of RA combined with hyperferritinemic syndrome and capillary leak syndrome (CLS) that was successfully treated with tocilizumab (TCZ), with the aim of improving diagnostic ideas for clinicians and consequently improving the diagnosis and treatment of the hyperferritinemic syndrome and CLS. A 55-year-old female patient was admitted to the Department of Infectious Diseases of our hospital due to "recurrent fever for more than 1 month and aggravation for 3 days." The patient was diagnosed with fever of unknown origin (lung infection?) and received anti-infective therapy with large encirclement of anti-bacterial, antifungal and empirical anti-tuberculosis successively during hospitalization in the Department of Infectious Diseases. Yet her condition continues to progress. The patient was eventually diagnosed with RA combined with hyperferritinemic syndrome and CLS. Then she received glucocorticoids (GC) (160 mg qd) combined with intravenous immunoglobulin (IVIG, 20 g/d, for 3 days). We considered that the patient also had an overwhelming proinflammatory cytokine storm, so she received a strong anti-inflammatory treatment with TCZ (400 mg qm). The patient symptoms and follow-up chest CT showed significant improvement following treatment. TCZ has good efficacy in the treatment of RA combined with hyperferritinemic syndrome and CLS and is expected to be a promising treatment.

Asymptomatic subacute thyroiditis presenting as bilateral thyroid nodules and pyrexia of unknown origin

Asymptomatic subacute thyroiditis presenting as bilateral thyroid nodules and pyrexia of unknown origin