Fever Of Unknown Etiology Research Articles

Searching for antibodies against Trichinella spiralis in the sera of patients with fever of unknown cause.

Human cases of trichinellosis are often difficult to identify because the signs and symptoms of the disease, if the infection produces any at all, are non-specific, being similar to those observed in several other infectious diseases. In an investigation of Mexican patients with fever of unknown aetiology, attempts were made to develop a serodiagnostic test for the detection of antibodies specific for Trichinella spiralis. The excretory and secretory products of T. spiralis larvae (from the muscle tissue of experimentally infected rats) were used as the antigens in an enzyme-linked immuno-electrotransfer blot assay. The sera tested came from patients with fever of unknown cause (N=250), patients confirmed to have infectious or parasitic diseases other than trichinellosis (N=134) and 168 apparently healthy subjects. Overall, 4% of the samples from the febrile group, 1.8% of those from the healthy subjects but none of the sera from those with 'other diseases' reacted with the antigens of interest (of 45, 49 and 55 kDa). The results not only confirm that human infection with T. spiralis may be asymptomatic but also indicate that such infection may be mis-diagnosed.

Gastrointestinal infections in the immunocompromised host

Immunocompromised patients, including patients with AIDS, solid organ and bone marrow transplant recipients, patients with leukemia and lymphoma, patients with inherited immune deficiencies, and patients on immunosuppressive therapy for a variety of disorders, are at risk for infections-particularly opportunistic infections, which, by definition, do not infect the healthy host. All systems of the body, including the gastrointestinal tract, are susceptible. The esophagus, stomach, small intestine, and large intestine are sites of infection for viruses, bacteria, fungi, and protozoa. Symptoms can range in severity from fevers of unknown etiology to life-threatening hemorrhage and perforation. This review summarizes recent case reports, clinical studies, and reviews pertaining to pathogens that uniquely cause disease, more frequently cause disease, or cause more severe disease in the immunocompromised host than in the immunocompetent host.

Serological evidence for the continued presence of human rickettsioses in southern India

Rickettsiosis is generally believed to have disappeared from many parts of India. However, the serological testing of 37 residents of southern India who presented with fever of unknown aetiology in 1996–1998 confirmed that spotted fever, epidemic/endemic typhus and scrub typhus continue to occur in southern India. The epidemiology and magnitude of the problem need to be evaluated.

Serological evidence for the continued presence of human rickettsioses in southern India.

Rickettsiosis is generally believed to have disappeared from many parts of India. However, the serological testing of 37 residents of southern India who presented with fever of unknown aetiology in 1996-1998 confirmed that spotted fever, epidemic/endemic typhus and scrub typhus continue to occur in southern India. The epidemiology and magnitude of the problem need to be evaluated.

Opportunistic pulmonary infection after renal transplantation

INFECTIOUS complications in kidney transplant recipients are associated with significant morbidity and mortality. The risk of infection is based on two main factors: recent or past exposure to infectious agents, and the patient’s level of immunosuppression. Bacterial infections usually occur in the first month following transplantation, and technical issues related to the procedure can play an important etiologic role. Most febrile illness that occurs in kidney recipients between 1 and 6 months posttransplantation is caused by cytomegalovirus (CMV) and other opportunistic agents. The regimen and level of immunosuppression are important in the pathogenesis of these infectious complications. Kidney recipients whose grafts have come from cadavers tend to develop more frequent and severe infectious complications than living-donor kidney recipients due to the increased level of immunosuppression that is usually needed in the former group. Also, recipients of cadaveric kidneys who receive induction antilymphocyte globulin (ATG) preparations have higher infection rates than those who do not receive this treatment. Further, research has shown that patients who receive azathioprine as their primary immunosuppressive agent have a higher rate of infection than patients on cyclosporine-based regimens. Beyond 6 months, in patients with well-functioning allografts who are on stable maintenance immunosuppression the pattern of infection is similar to that in the general population. Another significant finding is that transplant recipients often develope infection that simultaneously involves several causal agents. This underlines the importance of considering concomitant infection in patients who do not respond to the initial line of treatment. While the incidence of tuberculosis (TB) after kidney transplantation in highly industrialized countries is low, the figure for developing regions is significantly higher. Mycobacterial disease should be considered in any patient with fever of unknown etiology. Most cases of Mycobacterium tuberculosis infection in kidney transplant recipients are due to reactivation of latent TB lesions. Important risk factors for reactivation include nonwhite race, history of active TB, presence of a marked abnormality on a chest radiograph, exposure to a person with a confirmed case of TB, and skin test positivity. In transplant patients, the clinical presentation of tuberculosis may be atypical, and extrapulmonary and miliary tuberculosis is seen more frequently than in the normal population. With regard to fungal infection, in kidney transplant recipients these most commonly present as prolonged fever that does not respond to antibiotic therapy. These infections are associated with very high mortality. The most common fungal infections reported in first series from developing countries were candidiasis, aspergillosis, and cryptococcosis. Several factors influence the development of symptomatic CMV infection after kidney transplantation, but most important are the CMV serologic statuses of the donor and recipient. Symptomatic CMV infection can be primary, can occur due to reactivation of latent infection, or can arise secondary to superinfection. The most severe form is usually observed when a CMV-seronegative recipient receives a graft from a CMV-seropositive donor. Host cell–mediated immunity and the type and level of immunosuppressive therapy influence the development of symptomatic CMV infections. Polyclonal and monoclonal antilymphocyte antibody treatments have the highest CMVpromoting effect, and represent the most important factor in the development of CMV infections after kidney transplantation. Nocardia is a filamentous gram-negative soil organism that can cause pneumonia. This infection also frequently disseminates to the brain and results in abscess formation. The overall mortality associated with nocardiosis in kidney transplant recipients is 25%, but this figure jumps to 44% in patients who have central nervous system involvement.

Dyssegmental dysplasia Silverman-Handmaker type in a consanguineous Druze Lebanese family: Long term survival and documentation of the natural history

We report on a male infant born with clinical and radiographic evidence of a lethal form of dyssegmental dysplasia not comparable to Silverman-Handmaker type, who had a prolonged survival of more than eight months. He had ocular and central nervous system abnormalities which have not been previously described. His course included significant feeding and respiratory difficulties, severe physical and psychomotor retardation, and recurrent fever of unknown etiology believed to be of central origin. The relatively long survival of this infant enabled us to focus on the natural history of this rare syndrome. The infant was born to first cousin parents of Druze Lebanese origin supporting an autosomal recessive mode of inheritance for the condition. This is the first documentation of dyssegmental dysplasia Silverman-Handmaker type in a family of Druze Lebanese ethnicity.

Percutaneous needle colposuspension to Cooper's ligament for the treatment of stress incontinence in women: a report of 82 cases

We describe a procedure for the treatment of genuine stress urinary incontinence by percutaneous needle colposuspension of the bladder neck to Cooper's ligament. The procedure was performed in 82 patients and was associated with other procedures in 75 cases (91.5%). The mean operative time was 19 min (range 15 to 30). One peroperative hemorrhagic complication (1.2%) was noted. Nine postoperative complications were observed (10.9%) including seven urinary infections, one retropubic hematoma and one fever of unknown etiology. The mean follow-up was 13 months (range 6 to 22). Eight patients had a failure of the technique. All failures were diagnosed during the two first postoperative months. They included five cases of detrusor instability and three of persistent urinary incontinence. No additional failure was noted among the 53 patients having a follow-up greater than 12 months, suggesting a good stability of this new technique of colposuspension with a success rate of 85%.

FEVER IN THE COMPROMISED HOST

Fever in the compromised host remains a significant clinical problem. Multiple potential pathogens, subtle physical findings, and a variety of noninfectious problems that may masquerade as infection contribute to this clinical challenge. A review of host defense defects along with a careful physical examination will begin to narrow the etiologic possibilities for fever. Recognizing that the majority of infections will represent as fevers of unknown etiology, a consistent approach to the patient who responds to empiric antibiotic therapy as well as to the patient who fails to respond should be developed.

Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis

Background Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. Methods and Results One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were conside...

Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis

Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died. Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.

Inflammatory pseudotumor of intra-abdominal lymph nodes manifesting as recurrent fever of unknown origin: A case report

A 27-year-old man presented with a 7-month history of debilitating recurrent fever and weight loss. Extensive clinical evaluation led to the discovery of splenomegaly and retroperitoneal lymphadenopathy. The patient underwent splenectomy as well as liver and lymph node biopsy. Histologic examination of the lymph nodes, but not the liver and spleen, revealed inflammatory pseudotumor of lymph nodes. The patient has remained asymptomatic for more than 3 years following the surgical procedure despite the absence of further intervention. Inflammatory pseudotumor of lymph nodes should be considered in the differential evaluation of prolonged or relapsing fever of unknown etiology.

633 VALUE OF LIVER BIOPSIES IN THE DIAGNOSIS OF OPPORTUNISTIC INFECTION IN CHILDREN WITH AIDS

Liver biopsies were obtained from 9 AIDS patients with fever of unknown etiology and hepatomegaly. All patients had prenatal or early neonatal acquisition of AIDS. All were HBsAg, anti-S and IgM-anti-HAV negative, although several mothers had evidence of hepatitis B infection. The age at time of biopsy was two mo. to six years, with a mean age of two years eight months. M.avium/intercellulare (MAI) was identified histologically in four patients' liver while bone marrow aspirates revealed organisms in only one. Bone marrow culture subsequently confirmed the diagnosis of MAI in all four. Reactive changes in liver varied from the presence of isolated macrophages in sinusoids and portal tracts to aggregates forming ill-defined granulomas devoid of multinucleated cells or lymphocytes. Ziehl-Nielsen stain was necessary to identify organisms in the biopsies showing minimal tissue reaction. Distinction between M. tuberculosis and MAI was based on the abundant MAI within a given cell, their long filamentous shape and PAS affinity. No HBsAg was identified by Orcein staining. Conclusions: Unlike adults with AIDS, these children had no evidence of hepatitis A or B infection. FUO and hepatomegaly in children with AIDS was often associated with atypical mycobacterial infection. Percutaneous liver biopsy is a rapid way to diagnose MAI, but requires use of an acid fast stain as a routine.

Inflammatory bowel disease in children and adolescents

Ulcerative colitis and Crohn's disease are significant childhood illnesses. With their many extraintestinal manifestations, they may masquerade as fever of unknown etiology, arthritis, anorexia nervosa, growth hormone deficiency, collagen-vascular disease, idiopathic growth retardation and even irritable bowel syndrome of childhood. In any child who presents with growth failure and/or chronic abdominal pain with fever or weight loss, the diagnosis of inflammatory bowel disease must be considered. As in any other chronic disease of childhood, long-term management will often challenge the physician emotionally and intellectually. As the etiology is yet unknown and a definitive cure is lacking, proper treatment depends on optimal medical and surgical management and supportive care.

A randomized study of carbenicillin plus cefamandole or tobramycin in the treatment of febrile episodes in cancer patients

Patients were randomly assigned to receive carbenicillin plus tobramycin by continuous infusion (C+T), carbenicillin plus cefamandole by continuous infusion (C+CC) or carbenicillin plus cefamandole by intermittent infusion (C+IC) during 490 febrile episodes. Carbenicillin was administered over 2 hours every 4 hours. The per cent of cures achieved during the 235 documented infections was 65 per cent for C+CC, 57 per cent for C+IC and 54 per cent for C+T. Among those infections caused by single gram-negative bacilli, C+CC produced a higher cure rate than C+IC or C+T (74 per cent versus 59 per cent versus 50 per cent). C+CC was significantly more effective than C+IC among patients with persistent severe neutropenia of < 100 neutrophils/mm 3 (65 per cent versus 21 per cent, p = 0.03). If the infecting organism was sensitive to both antibiotics, the cure rate for C+CC was 94 per cent. The only major toxicity was azotemia which occurred during 12 per cent to 13 per cent of the febrile episodes, regardless of antibiotic regimen. However, it occurred significantly more often during documented infections than during fevers of unknown etiology (20 per cent versus 6 per cent, p < 0.001). C+CC appears to be the most effective of the three regimens for the treatment of infections in patients with persistent severe neutropenia.

Recurrent Attacks of Abdominal Pain and Fever With Familial Segmentation Arrest of Granulocytes

Abstract In a family four sisters have suffered, the oldest two for nearly 20 yr, from recurring attacks of abdominal pain and fever of unknown etiology. Clinical similarity to familial Mediterranean fever is striking. However, they all have a segmentation arrest of granulocytes, which resembles the Pelger-Huet anomaly. It seems that the association is more than a mere coincidence.

Thirty Two Years Male Patient with Adult Still’s Disease

A rare systemic inflammatory disorder is Adult onset Still's disease (AOSD), characterized by diverse clinical and laboratory findings, which is often difficult to diagnose. It is responsible for a significant proportion of cases of acute febrile illness in young adults. Adult Onset Stills Disease (AOSD) usually affects multiple organs, but it is a diagnosis of exclusion. Here we describe a case of a 32-year old patient with fever of unknown etiology, arthralgia, sore throat and skin rash. The final diagnosis of Still's disease was made by clinical and laboratory criteria and exclusion of other causes of similar presentation. Â DOI = 10.3329/jom.v9i1.1428 J MEDICINE 2008; 9 : 58-61

Leukapheresis∗ by Continuous Flow Centrifugation (CFC) in Patients with Chronic Myelocytic Leukemia (CML)

Abstract A closed continuous flow centrifuge (NCI-IBM Blood Cell Separator) was utilized to collect large quantities of leukocytes from donors with chronic myelocytic leukemia. Ninety-eight separate centrifugations of one to six hours duration were performed in 12 patients. Quantities of blood between 2.4-20.3 liters were processed during each centrifugation representing 0.4-3.2 donor blood volumes. An additional five centrifugations were attempted unsuccessfully. Buffy coat cells were collected while plasma and red blood cells were returned to the donor without change in flow or gravitational field. White blood cell yields of up to 75 per cent were obtained while platelet yields were electively varied from 0.1 per cent in donors with thrombocytopenia to 61.0 per cent in donors with thrombocytosis. Red blood cell hemolysis and excessive platelet losses with thrombocytopenia were not observed. One patient developed chills and fever of unknown etiology on two separate occasions, once during and once following CFC Leukocytes collected by this method and transfused into granulocytopenic recipients resulted in granulocyte increments of 2.0 x 103 per mm3 per 1011 granulocytes per m2 of body surface area. The persistence of cells with the Ph1 chromosome in the bone marrow of recipients demonstrated that viable proliferating cells survived the procedure.

A Patient with Ulcerative Colitis

He was truly as white as the sheet he lay under, that skinny old man I had chosen for my patient. His sparse, colorless hair stood out at all angles, his gray-blue eyes were sunken and hollow, and his skin hung loosely on his long bones. He lay twisted in sheets and blankets, his huge calloused feet protruding to rest on the cold, hard metal at the foot of his bed. The size of the intravenous needle looked cruel in comparison to his bony, wasted forearm. His face was haggard and his cheeks gray with several days' growth of beard. A Levin tube looped out of one thin nostril. In ridiculous contrast to his drawn face were his large ears-the only prominent features on his head. I learned more about Harold Crain from the Kardex and chart. He was a retired farmer who had been admitted to a hospital near his home three weeks earlier with a myocardial infarction. The infarct healed without incident, but during that hospitalization he developed vomiting, diarrhea, abdominal distention, and fever of unknown etiology. When these symptoms did not abate with various methods of treatment, he was transferred to our hospital. When he arrived he was described by the doctor as being weak and critically ill; however, cooperative and alert. The only significant finding was a tympanic, distended abdomen. The examining doctor thought that he might have arteriosclerotic heart disease with recent myocardial infarct; lower gastrointestinal bleeding from a polyp, or cancer; or paralytic ileus secondary to electrolyte imbalance.

Hemorrbagic fever in children in Thailand: Report of 69 cases

Summary In Asia, where hemorrhagic fever can be (or is) endemic, it should be considered in the differential diagnosis of cases of thrombocytopenic purpura, measles, bronchopneumonia, typhoid, influenza, “Chinese medicine poisoning”, gastroenteritis, and fevers of unknown etiology. Sixty-nine cases of hemorrhagic fever in children seen at the Bangkok Sanitarium and Hospital during the 1958 Thailand epidemic are reported. Symptoms, physical and laboratory findings, age, sex, and seasonal incidences are discussed, and specific cases representing various manifestations are described.