History Of Persistent Fever Research Articles

Ovarian carcinosarcoma with lung metastasis characterized by persistent fever: A case report and literature review.

Ovarian carcinosarcoma (OCS) is a rare malignant tumor prone to distant metastasis. Primary manifestations include pelvic and/or abdominal pain, bloating, and compression. Nevertheless, it is uncommon for OCS to present primarily with persistent fever. This is the first reported case of OCS with lung metastasis characterized by persistent fever. A 61-year-old female patient complaining of abdominal pain and fever was admitted to our hospital. Computed tomography showed an irregular, slightly low-density mass on the left side of the uterus and multiple solid nodules in both lungs. She underwent cytoreductive surgery for pathologically confirmed stage IVB OCS. She was administered chemotherapy after cytoreductive surgery. Given the patient's history of persistent fever and progressively enlarged pulmonary nodules, a pulmonary abscess was considered as a possible diagnosis. Following antibiotic therapy, the patient's high body temperature did not decrease; however, following nonsteroidal anti-inflammatory drug therapy, it quickly decreased. These symptoms were eventually considered the consequence of neoplastic fever caused by lung metastases. Owing to the rapid progression of the disease, the patient ultimately died. This study suggests that, for patients with pelvic and/or abdominal pain, bloating, and pelvic masses, especially those with suspicious lesions in other organs accompanied by fever of unknown origin, a diagnosis of cancer or sarcoma with metastasis should be considered after ruling out infectious fever.

Ecthyma Gangrenosum in Three Unrelated Patients with Combined Immunodeficiency

Background: Ecthyma Gangrenosum (EG) is a necrotizing vasculitis characterized by cutaneous manifestation ranging from a nodule or papule to necrotic ulceration with surrounding erythema, especially with black eschar or central crust. The most common pathogen that causes EG is Pseudomonas aeruginosa (PA). PA is an opportunistic pathogen with predominance incidence among patients with primary immunodeficiency with hypo or agammaglobulinemic, malignancies, and acquired immune deficiency. Case Presentation: In this case study, we present three unrelated patients (three male toddlers, mean age: 0.75 years) with the primary manifestation of EG, who underwent immunological assessment and were diagnosed with combined immunodeficiency. All patients were alive although EG has a high mortality rate, the prognosis depends on the host and the degree of immunosuppression. A history of Persistent fever followed by skin lesions was common in our cases. Surprisingly, the initial immunological assessment reported different cellular and humoral immune deficiencies with the overall diagnosis of combined immunodeficiency based on the ESID criteria. For patients suspected of EG, early diagnosis and administration of appropriate systemic antibiotic therapy can considerably reduce morbidity and potential mortality. Conclusions: This case report illustrates the importance of immunodeficiency evaluation in patients with a skin lesion and considers pseudomonas aeruginosa culture for initiating appropriate antipseudomonal antibiotic therapy. Although recent studies show high EG-related mortality with predisposing factors, hopefully, due to appropriate intravenous antibiotics and immunoglobulin therapy, all patients remained alive.

Life threatening macrophage activation syndrome as the initial presentation of systemic lupus erythematosus: A case report and review of the literature

BackgroundMacrophage activation syndrome (MAS) is characterized by activation of hemophagocytic cells and is a very rare initial manifestation of systemic lupus erythematosus (SLE). Aim of the workTo describe the features of a challenging case of SLE initially presented with MAS. Case reportA previously healthy 20-year-old female was referred to the Rheumatology clinic with a 25-days’ history of persistent fever, general fatigue, and significant weight loss. Clinical examination revealed a high-grade fever (41 °C), significant hair loss and general malaise. Laboratory investigations revealed leucopenia (1.5 × 109/L), neutropenia (0.7 × 109/L), lymphopenia (0.6 × 109/L), normocytic normochromic anemia (9 g/dL), thrombocytopenia (95 × 109/L), elevated liver enzymes, hyperbilirubinemia (2.6 mg/dl); hypertriglyceridemia (306 mg/dL), hyperferritinemia (16000 ng/mL), elevated D-Dimer (4.7 mg/L), elevated lactate dehydrogenase (1379 U/L) and direct and indirect Coombs' tests were positive. Erythrocyte sedimentation rate was 28 mm/1st h. Immunological screening was positive for antinuclear antibody (ANA) and anti-double stranded deoxyribonucleic acid (anti-dsDNA). Serum C3 and C4 complement factors were low and C reactive protein was negative. Soluble CD25 was elevated (9800 pg/ml). Bone marrow biopsy showed hypocellular bone marrow with normal megakaryocytes and erythroid series with evidence of hemophagocytosis. A diagnosis of SLE initially presented with MAS was made. The patient received intravenous methylprednisolone for 5 consecutive days followed by prednisolone and cyclosporine A and intravenous immunoglobulin. The condition deteriorated with progressive coagulopathy, thrombocytopenia and hyperferritinemia. Subsequently, the conscious level of the patient deteriorated, multiorgan failure developed and the patient died. ConclusionMAS is a serious condition that may be the first presentation of SLE.

MIS-C frenzy: The importance of considering a broad differential diagnosis

We report a case of a 3 year-old boy with possible typhoid fever with recent travel to a typhoid endemic area who was primarily managed as a case of multisystem inflammatory syndrome in children (MIS-C). The patient was initially treated for tonsillitis after a 3 day history of persistent fever, sore throat, and constipation. The patient presented later when he deteriorated. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) viral RNA was not detected but the antibodies were positive. The patient went on to develop mucosal, cardiac, and gastrointestinal manifestations and was subsequently treated with immunoglobulins and corticosteroids for MIS-C. Despite the rarity of MIS-C as a complication of COVID-19 infection, the endemic typhoid fever which is relatively more common was not ruled out. The patient additionally received antibiotics for a total of 5 weeks given his unremitting fever. Even during the COVID-19 pandemic, healthcare professionals should carry out timely testing to exclude more probable differential diagnoses, with area-specific common diseases given due diligence.

Case Study: Pneumococcal Prosthetic Valve Endocarditis with Mitral Annular Abscess Fistulised in the Left Atrium: An Uncommon Germ with Dramatic End

Background: Streptococcus pneumoniae is an infrequent cause of infectious endocarditis. Several case series have underscored the aggressive course of Streptocoque Pneumiae with acute clinical presentation, rapid valvular destruction, and high mortality despite appropriate antibiotic therapy. Case summary: We present a 74-year-old woman with previous aortic and mitral valve replacement 12 years ago, presented with a 5 days history of persistent fever and a red, hot, and swollen right knee. Atrial fibrillation was demonstrated on a 12-lead electrocardiogram. The initial echocardiography did not show any sign of endocarditis but in front of the clinical symptomatology the patient was put under probabilistic antibiotic therapy. in the meantime blood culture grew Streptocoque Pneumiae and then the antibiotic treatment was adapted. The sudden deterioration of the patient brought us back to control the heart by a transthoracic echocardiography, which revealed a mitral annular abscess fistulizing to the left atrium. the patient expired 30 days after admission from presumed severe sepsis and cardiogenic choc. Conclusion: Pneumococcal endocarditis in prosthetic valve is associated with very high mortality, especially when complicated by paravalvular abscess and other comorbidities. This case highlights the need for a carefull considered approach for fast and efficient care.

Detection of selected arboviral infections in patients with history of persistent fever in Pakistan

Surveillance is a valuable tool for understanding prevailing and previously undiagnosed infections in a geographic area. We examined 480 archived serum samples from patients with history of persistent fever (>40°C, 60–72h) who were referred to hospitals in Rawalpindi/Islamabad, Lahore, and Faisalabad districts for dengue antibody detection in 2014-15. Each sample was processed for detection of antigens and seroconversion, using real-time polymerase chain reaction and enzyme linked immunosorbent assay, respectively, against dengue haemorrhagic fever (DHF) virus serotypes 1–4, West Nile virus fever (WNVF), Crimean-Congo haemorrhagic fever (CCHF), and Chikungunya virus (CGV). The presence of antigens and antibodies to at least one of the studied viral haemorrhagic fevers (VHFs) was detected in 465 (96.8%, 95% CI: 94.9–98.1) and 442 samples (92.1%, 95% CI: 89.3–94.2), respectively. No sera were found positive to CCHF. There was a significant association between gender and positivity to at least one of the VHFs (χ2=8.12, df=1, p<0.005). Except for DHF serotype 2 and 3 (ττ=0.41), Goodman and Kruskal's Tau statistic revealed no significant association for occurrence of different viruses within the studied population (ττ=0–0.06). Cosinor analysis confirmed significant seasonality, with a higher number of cases of persistent fever in August through November, peaking in October. The study suggests circulation of multiple arthropod-borne viral infections and, in addition to DHF, ascertain the needs for screening patients for CGV and WNVF too. It also demonstrates the necessity of well-integrated disease surveillance in several geographic regions and at-risk populations in Pakistan to develop appropriate disease and vector control strategies.

Kikuchi Disease with Generalized Lymph Node, Spleen and Subcutaneous Involvement Detected by Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

Kikuchi-Fujimoto disease, known as Kikuchi disease, is a rare benign and self-limiting disorder that typically affects the regional cervical lymph nodes. Generalized lymphadenopathy and extranodal involvement are rare. We report a rare case of a 19-year-old female with a history of persistent fever, nausea, and debilitating malaise. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) revealed multiple hypermetabolic generalized lymph nodes in the cervical, mediastinum, axillary, abdomen and pelvic regions with diffuse spleen, diffuse thyroid gland, and focal parotid involvement, bilaterally. In addition, subcutaneous lesions were noted in the left upper paraspinal and occipital regions. An excisional lymph node biopsy guided by 18F-FDG PET/CT revealed the patient’s diagnosis as Kikuchi syndrome.

Miliary tuberculosis disease complicated by Pott's abscess in an infant: Seven year follow-up.

A 20-month-old boy presented with 1-year history of persistent fever, cough, and progressive abdominal distention. Abdominal ultrasonography showed hepatomegaly and multiple calcifications in the liver and spleen. Thoracic computed tomography showed multiple mediastinal lymph nodes and consolidation in both lungs. Additionally, there was a 2-cm thick retroperitoneal soft tissue mass destroying the T7-8 and L1-L2 vertebral bodies. The patient was preliminarily diagnosed with miliary tuberculosis (TB) and Pott's disease, and began administering anti-TB treatment consisting of isoniazid, rifampin, ethambutol, and pyrazinamide. Acid-resistant bacilli analysis and mycobacterial culture of the biopsy specimen of Pott's abscess were positive. Mycobacterial culture and PCR of gastric aspirate were also positive. The patient's condition progressively improved with anti-TB treatment and he received 12 months of antiTB therapy. At the end of the treatment all of the patient's symptoms were relieved and he was well except for kyphosis. Miliary TB complicated by Pott's abscess is a very rare presentation of childhood TB. The presented case shows that when Pott's abscess is diagnosed and surgically corrected without delay, patients can recover without squeal.

Drug induced aseptic meningitis: A diagnostic challenge

Drug-induced aseptic meningitis (DIAM) is a rare but important and often challenging diagnosis for the physician. Intake of antimicrobials, steroids, analgesics amongst others has been implicated. Signs and symptoms generally develop within 24-48 hours of drug ingestion. The patient often exhibits the classic symptoms of meningitis.Aim: Two cases of drug induced meningitis are presented with review of literature.Case reports:Case I: A 13 year old male with a three days history of persistent fever, vomiting, abdominal pain and poor appetite. He also had generalized throbbing headache and neck pain of a day’s duration. He had been on Bactrim® for urinary tract infection (UTI) three days prior to the onset of the present symptoms. On examination, he had altered mental status (confused), neck stiffness and a positive Kerning’s and Brudzinski's signs. Muscle tone and deep tendon reflexes were normal with no cranial nerve deficits. Other systems examinations were unremarkable.Case II: 15 year old male with no significant past medical history presented with a day’s history of altered mental status, headache with no fever. He had been on selfmedication with over the counter Ibuprofen tablets for intractable headache three days prior to presentation. Examination showed equivocal neck stiffness clouded by profound altered mental status. They were both initially managed for meningitis. Cerebrospinal fluid work-up for both cases ruled out infectious etiologies. Possible drug induced meningitis was then considered.Conclusion: Drug-induced aseptic meningitis is rare but should be considered in the differential diagnosis of patients presenting with acute or recurrent symptoms and signs of meningitis, especially after infectious causes have been ruled out.

Granulomatosis with polyangiitis (Wegener’s) presenting as the right ventricular masses: A case report and review of the literature.

Granulomatosis with polyangiitis (Wegener's) is a systemic necrotizing vasculitis. Cardiac involvement in Wegener's has rarely been reported. In this study the echocardiographic findings of granulomatosis with polyangiitis (GPA) in a patient is described. The case was a 45 years old man admitted to the hospital with a 3 months history of persistent fever and sinusitis. Mild left and right ventricular enlargements as well as three small masses in the right ventricular cavity were identified in echocardiography. One mass was attached to the tricuspid valve and the other two masses were attached to the right septum. Pulmonary artery hypertension (45mmHg) was also reported. The masses responded dramatically to plasma exchanges in combination with steroid therapy, followed by oral cyclophosphamid and low-dose steroid therapy. In the kidney biopsy, 8 out of 11 golomeruli contained fibrous crescents along with sclerotic lesions. Spleen has 140 mm diameter with multiple echo-free lesions and coarse parenchyma in abdominal ultrasound. Serum C-ANCA=671, P-ANCA=1.7 (normal= up to 15U/mL). The diagnosis of granulomatosis with polyangiitis (Wegener's) was established. Presence of three small masses in right ventricular cavity and pulmonary artery hypertension in association with the spleen lesions were an uncommon presentation of GPA. GPA should be considered in the differential diagnosis of any nonspecific illnesses with cardiac involvement.

Case 1: Persistent fever in a toddler

A previously well 20-month-old girl, with a two-week history of persistent fever and neutropenia, was transferred from a secondary care hospital for investigation to rule out a possible diagnosis of leukemia. There was no history of infectious contacts or viral prodrome. The patient previously visited the family physician and emergency room on days 3, 7 and 12 of the fever, and was diagnosed with acute otitis media. She was treated with clarithromycin until day 7, when she was switched to amoxicillin due to continued fever. The medical history revealed a fully immunized, healthy child of Asian descent who, at nine months of age, developed a maculopapular rash following seven days of treatment with amoxicillin and ibuprofen for acute otitis media. A physical examination revealed an irritable child with a fever of 40°C, a new-onset generalized erythematous maculopapular rash and a palpable spleen, but no lymphadenopathy. The remainder of the examination was unremarkable. Specifically, there were no findings of nonpurulent conjunctivitis, oral-mucosal changes, cervical lymphadenopathy, palmar or plantar changes, cardiac murmur or arthritis. The initial workup revealed pancytopenia (absolute neutrophil count 0.2×109/L, hemoglobin 70 g/L, platelets 119×109/L), hypoalbuminemia, an elevated erythrocyte sedimentation rate (ESR), an elevated C-reactive protein (CRP) level, a positive Epstein-Barr virus (EBV) polymerase chain reaction (12,100 copies detected) and splenomegaly on abdominal ultrasound. Bone marrow biopsy and hemoglobin electrophoresis findings were normal. Other negative test results for infections included urine, blood and stool cultures, and serology for cytomegalovirus, varicella, hepatitis A, B and C, and HIV I and II. Because of a possible penicillin allergy, she was empirically treated with vancomycin and meropenem, which were discontinued following negative blood and urine cultures. She was also transfused with packed red blood cells and albumin because of low hemoglobin and albumin levels. The patient improved clinically and was discharged on day 21 of fever onset. She was febrile but clinically stable. The diagnosis was believed to be EBV infection and a subsequent hypersensitivity vasculitis reaction to penicillin. The toddler initially improved, then worsened with new-onset jaundice, irritability and hepatomegaly. She returned five days later with the following laboratory findings: pancytopenia (absolute neutrophil count 0.4×109/L, hemoglobin 76 g/L, platelets 24×109/L), hypertriglyceridemia (12.4 mmol/L), hypofibrinogenemia (1.56 g/L), hyperferritinemia (1230 μg/L), hyperbilirubinemia (68.7 μmol/L), transaminitis (alanine aminotransferase 313 U/L, aspartate aminotransferase 1507 U/L), coagulopathy (international normalized ratio 1.2, partial thromboplastin time 67 s) and a lactate dehydrogenase level of 5364 U/L. Her CRP level increased from 42 mg/L to 56 mg/L but her ESR decreased from 62 mm/h to 16 mm/h. A diagnosis was made based on the clinical findings and laboratory test results.

Case 2: Where have all the white cells gone?

A 23-month-old girl with a significant history for preseptal cellulitis at three months of age and pneumonia at 14 months of age presented to the emergency department (ED) with chief complaints of fever, tachypnea and cough. She was initially seen in the ED five days before admission with a five-day history of persistent fever, despite recent use of antibiotics (cephalexin, then azithromycin) for acute otitis media and pharyngitis, which were diagnosed by her family physician. At the initial ED visit, she was diagnosed with right middle lobe pneumonia and sent home on oral clindamycin. Additional laboratory test results showed an erythrocyte sedimentation rate of 70 mm/h, and a white blood cell count of 10.2×109/L, with an absolute neutrophil count of 0.51×109/L. Epstein-Barr virus titres, and blood and urine cultures were also sent and remained negative. The patient returned to the ED with persistent daily fevers (10 days total) with a maximum temperature of 38.8°C, and new-onset tachypnea and cough. Her parents denied grunting, retractions, cyanosis, vomiting, diarrhea or lethargy. Her immunizations were up to date. There was no recent travel and no known sick contacts. During the second presentation to the ED, the patient’s vital signs were a temperature of 38.8°C, heart rate of 186 beats/min, respiratory rate of 30 breaths/min, blood pressure of 141/82 mmHg and an oxygen saturation of 100% on room air. She was non-toxic in appearance and had decreased breath sounds at the right base, but an otherwise unremarkable examination. Her tachycardia resolved with administration of intravenous fluids, and her blood pressure subsequently normalized to 97/74 mmHg. A complete blood count during this second ED visit revealed a white blood cell count of 10.2×109/L with 0% neutrophils, 0% bands, 47% lymphocytes, 38% monocytes, 13% eosinophils, 0% basophils and 2% myelocytes. Her erythrocyte sedimentation rate was 65 mm/h. A chest x-ray showed minimal improvement of her pneumonia. Given her neutropenia and the lack of clinical improvement on outpatient antibiotic therapy, the patient was admitted to the hospital for further management. On admission, the patient was placed on intravenous cefotaxime. However, she remained persistently febrile, so antibiotic coverage was broadened to vancomycin and meropenem. Laboratory investigations including blood and fungal cultures, a viral respiratory panel, quantitative immunoglobulins, disseminated intravascular coagulation panel, lactate dehydrogenase, ferritin and uric acid were all unremarkable. A purified protein derivative test was negative. An abdominal ultrasound to evaluate for intra-abdominal abscess was normal. She had multiple repeat complete blood counts, which demonstrated persistent neutropenia. On her fifth day of hospitalization, the patient was able to undergo a procedure that revealed the diagnosis.

Bilateral Tuboovarian Abscess Due to Salmonella paratyphi A

Local abscess formation may occur as a complication of any Salmonella infection by either hematogenous or lymphatic spread but a tuboovarian site of Salmonella infection is rare. Mostly, predisposing factors such as ovarian abnormalities like dermoid cyst, endometrioma, cystadenoma, or simple cyst are present where hematogenously disseminated Salmonella tend to localize. A case of bilateral tuboovarian abscess due to Salmonella paratyphi A is being reported in a 36-year-old woman having multicystic ovaries to highlight the unusual presentation of this organism. In countries like India, where Salmonella infections are endemic, differential diagnosis of Salmonella should always be kept in mind by the clinicians while dealing with the tuboovarian abscesses because there is a possibility of Salmonella infection at aberrant sites, especially in patients with history of persistent fever or gastroenteritis or any preexisting abnormality that makes the tissue or organ vulnerable.