Recent Fever Research Articles

Index of Suspicion * Case 1: Voiding Difficulty in a 10-year-old * Case 2: Seizure-like Activity Precipitated by Loud Noise in a 2-year-old * Case 3: Purplish-brown, Shiny Upper Extremity Lesion and Stiff Hand in a 9-year-old

A 10-year-old boy presents with severe abdominal pain and urinary urgency. He denies any dysuria, hematuria, frequency, meatal spotting, penile discharge, or incontinence. He has had no recent viral infections or fevers and he denies any history of perineal trauma. He has no significant medical or surgical past medical history. Three days earlier, he was seen at a local hospital with a 3-day history of increasing difficulty with voiding, including straining to void and incomplete bladder emptying. A bladder scan revealed a full bladder after he voided. Therefore, an 8-French catheter was placed and he was told to return in 3 days for a voiding trial. He failed the voiding trial, and personnel at the local hospital were unable to replace the catheter. He was referred to our institution for further management. Physical examination reveals normal Sexual Maturity Rating stage 1 genitalia and a palpable bladder. He does not have any sacral dimples. Efforts to pass a 5-French feeding tube through the urethra also fail. Additional history and an imaging procedure lead to the diagnosis. The neurology consultant examines a 2-year-old boy in the outpatient clinic for “passing-out seizures.” His mother indicates that, in response to loud sounds, her otherwise healthy child experiences episodes of generalized, nonrhythmic, tonic muscle contractions characterized by “stiffness and back-arching,” collapse, and apnea. The episodes last 30 to 45 seconds, and in a typical day, the boy experiences three to four events. No other family members experience similar bouts. Findings on ECG, echocardiography, and 23-hour cardiac monitoring are unremarkable. Physical examination reveals an alert toddler who interacts appropriately with his mother and has no obvious signs of sensory or motor deficit. To evaluate the events, the child is admitted to the epilepsy monitoring unit. Examination of the electroencephalogram (EEG) reveals normal background rhythm. During the …

An Enlarging Solitary Mass in an Asymptomatic Patient

i PRESENTATION What is the differential diagnosis to consider in an asymptomatic, elderly patient presenting with an enlarging, solitary, right-sided paratracheal mass over 2 years? The patient in question was a 70-year-old woman, an Ohio resident since childhood, who had been admitted to our hospital 2 years previously because of a urinary tract infection associated with high-grade fever and hypotension. She had denied any recent respiratory symptoms, fever, or weight loss but reported a history of mild dyspnea on exertion over the previous few months. An echocardiogram performed at the time estimated her right-ventricular systolic pressure at 50 mm Hg. A computerized tomography (CT) scan of the chest done to evaluate the possibility of a pulmonary parenchymal abnormality demonstrated a 29.2 27.8-mm right-sided paratracheal mass (Figure 1). The patient was discharged and scheduled for outpatient fiber optic bronchoscopy, but she never had the procedure and was lost to follow-up.

Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected children and infants in northern Tanzania.

To describe the contribution of paediatric HIV and of HIV co-infections to admissions to a hospital in Moshi, Tanzania, using contemporary laboratory methods. During 1 year, we enrolled consecutively admitted patients aged ≥2 months and <13 years with current or recent fever. All patients underwent standardized clinical history taking, a physical examination and HIV antibody testing; standard aerobic blood cultures and malaria film were also done, and hospital outcome was recorded. Early infant HIV diagnosis by HIV-1 RNA PCR was performed on those aged <18 months. HIV-infected patients also received serum cryptococcal antigen testing and had their CD4-positive T-lymphocyte count and percent determined. A total of 467 patients were enrolled whose median age was 2 years (range 2 months-13 years); Of those patients, 57.2% were female and 12.2% were HIV-infected. Admission clinical diagnosis of HIV disease was made in 10.7% and of malaria in 60.4%. Of blood cultures, 5.8% grew pathogens; of these 25.9% were Salmonella enterica (including 6 Salmonella Typhi) and 22.2%Streptococcus pneumoniae. Plasmodium falciparum was identified on blood film of 1.3%. HIV infection was associated with S. pneumoniae (odds ratio 25.7, 95% CI 2.8, 234.0) bloodstream infection (BSI), but there was no evidence of an association with Escherichia coli or P. falciparum; Salmonella Typhi BSI occurred only among HIV-uninfected participants. The sensitivity and specificity of an admission clinical diagnosis of malaria were 100% and 40.3%; and for an admission diagnosis of bloodstream infection, they were 9.1% and 86.4%, respectively. Streptococcus pneumoniae is a leading cause of bloodstream infection among paediatric admissions in Tanzania and is closely associated with HIV infection. Malaria was over-diagnosed clinically, whereas invasive bacterial disease was underestimated. HIV and HIV co-infections contribute to a substantial proportion of paediatric febrile admissions, underscoring the value of routine HIV testing.

Visual Diagnosis: Bilateral Posterior Swelling of the Knees in a 12-year-old Boy

1. Moshe Shapira, MD* 2. Daniela Militianu, MD† 3. Miriam Butnariu, MD§ 1. *Maccabi Health Services, Nave-Sha'anan Clinic, Haifa, Israel. 2. †The Department of Medical Imaging, MRI Unit, Rambam Health Care Campus, Technion Rappaport Faculty of Medicine and Research Institute, Haifa, Israel. 3. §The Pediatric Orthopedic Unit, The Bnai-Zion Medical Center, Technion Rappaport Faculty of Medicine and Research Institute, Haifa, Israel. A 12-year-old boy presents with a 2-month history of mild bilateral posterior knee discomfort and fullness, especially on the left side. The swelling does not restrict walking or weight bearing. There is no history of recent fever, rash, anorexia, weight loss, bleeding disorder, or any other joint pain or swelling. The only finding of note on his past medical history is a fall 19 months ago that did not cause a sprain or fracture to the lower limbs. Physical examination shows a well-appearing boy whose vital signs are normal for age. Inspection and palpation of the posteromedial aspect of both knees reveals bilateral swelling, with the left side larger than the right (Fig. 1). However, there is no evidence of knee joint effusion or limited range of motion, lower extremity erythema, warmth, or edema. The remainder of the physical examination findings are within normal parameters. A complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, and blood chemistry panel and urinalysis yield normal results. Ultrasonography of the posterior knees confirms the suspected clinical diagnosis. Figure 1. Bilateral swelling of the posterior aspect of the knees, with the left side larger than the right. Ultrasonography of the posterior aspect of the knees revealed fluid-filled formations measuring 5.3×1.6 cm on the left and 2.35×1.34 cm on the right (Fig. 2), confirming the clinical diagnosis of bilateral popliteal cysts. Figure 2. Ultrasonography demonstrating the right popliteal cyst. A popliteal synovial cyst is a fluid-filled mass in the popliteal fossa resulting from extrusion of joint fluid into the gastrocnemius-semimembranosus bursa through a weak portion of the posteromedial capsule of the knee between the medial head of gastrocnemius …

Left Atrial Undifferentiated Pleomorphic Sarcoma Causing Mitral Valve Obstruction

A 61-year-old Latino woman with no past medical history presented to the emergency department with 2 weeks of gradual onset of dyspnea on exertion, cough, and palpitations. She denied any recent illnesses, fevers, or unintentional weight loss. She was not taking any medications or using tobacco, alcohol, or illicit drugs. On physical examination, she had a temperature of 100.6°F, a heart rate of 122 bpm, respiratory rate of 25 breaths per minute, blood pressure of 155/92 mm Hg, and oxygen saturation of 92% on bilevel positive airway pressure. Her physical examination was notable for jugular venous distension, a loud S1 and normal S2, a grade 2/6 middiastolic murmur heard loudest at the apex, crackles throughout her posterior lung fields, and trace bilateral lower-extremity edema. Her ECG showed sinus rhythm with no significant ST-T abnormalities (Figure 1). A portable chest radiograph showed mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions (Figure 2). Computed tomography of the chest with intravenous contrast was done to evaluate for pulmonary embolism; it revealed a mass with lobulated margins within the left atrium (Figure 3) protruding into the left ventricular cavity and infiltrating the left atrial wall. Figure 1. Twelve-lead ECG demonstrating normal sinus rhythm with no significant ST-T segment abnormalities. Figure 2. Portable chest radiograph showing mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions. Figure 3. A …

Identification of Cases by Non-Microscopic Rapid Diagnostic Test in Suspected Malaria Infection in Community Setting

Background: Malaria presents a diagnostic challenge in most tropical countries. Malaria is diagnosed pre-dominantly by using clinical criteria, with microscopy as gold standard for detecting parasitemia. Recently, rapid diagnostic tests (RDTs) have been developed for situations in which reliable microscopy may not be available. Objective: To identify the cases of malaria by non-microscopic Care Start malaria Pf/Pv combo RDT in suspected malaria infection in community setting. Subjects and Methods: This descriptive observa-tional study was conducted from October to December 2010 in Ehsas Field Hospital, Kot Addu, District Muzaffargarh. Data was collected from Medical and Paediatric outpatient departments of field hospital. Patients of age 5 - 75 years were included in the study. Malaria was clinically suspected in patients with recent fever, chills and/or anemia and was confirmed by Care Start malaria Pf/Pv combo RDT as per the manufacturer's instruction. Data was analyzed by SPSS 17. This study was not sponsored by manufac-turer. Results: Among patients of age 5 - 75 years, 2196 patients were clinically suspected and 1767 cases were confirmed for malaria infection by RDT common age group suspected was 16 - 25 yaers 556 (25%). Case identification rate of RDT was 80%. Conclusion: Non-microscopic Care Start malaria Pf/Pv combo RDT has reliable diagnostic accuracy to identify confirmed cases of malaria infection and may be preferred during malaria epidemics in community setting. Key words: Community setting, Diagnostic accuracy, Histidine rich protein, Lactate dehydrogenase, Malaria infection, Rapid diagnostic test.

Bilateral breast abscesses due to Salmonella Enterica serotype typhi

Focal infection is an uncommon complication of Salmonella septicemia, particularly in immunocompetent patients. The localization of Salmonella infection to breast tissue is regarded as a rare event. We report a case of bilateral breast abscesses due to Salmonella enterica serotype Typhi in a nonlactating female and highlight the fact that Salmonella spp. should be included in differential diagnosis of abscesses in individuals coming from endemic areas with the history of recent typhoid fever and should be treated accordingly.

Transfusion-associated Babesiosis in a 7-month-old Infant after Bidirectional Glenn Procedure

We describe a case of transfusion-associated babesiosis following bidirectional Glenn procedure. This unique case highlights the importance of including babesiosis and other typically vector-borne infections in the differential diagnosis for patients with recent blood transfusions and fever without obvious source.

Lactococcus garvieae endocarditis

MOTS CLES Endocardite bacterienne ; Cirrhose hepatique ; A 64-year-old Taiwanese woman living in France was referred to the emergency department for recent onset fever. Past medical history included mitral valve replacement (Starr-Edwards prosthesis) in 1980 for rheumatoid mitral stenosis, pacemaker implantation in 2000, transient atrial fibrillation and chronic hepatitis C complicated by liver cirrhosis. Usual medications included propanolol, furosemide, warfarin and aldactone. Of note, she ate fresh seafood several times per week. On admission, her heart rate was 71 beats/minute, blood pressure was 130/70mmHg and body temperature was 38.9 ◦C. Physical examination revealed a mitral stenosis murmur. Haemoglobin concentration was 12 g/dL, white blood cell count was 14.4 g/L and platelet count was 79 g/L. C-reactive protein concentration was 18mg/L. Three blood cultures were positive for Gram-positive cocci; polymerase chain reaction identification confirmed Lactococcus garvieae, a microbial agent found in fresh seafood. Transoesophageal echocardiography revealed the presence of mobile infracentrimetric vegetation attached to mitral prosthesis, without any associated prosthesis dysfunction

Accelerator Mass Spectrometry Can Be Used to Assess Vitamin A Metabolism Quantitatively in Boys in a Community Setting1–3

A survey indicated that high-dose vitamin A (HD-VA) supplements had no apparent effect on vitamin A (VA) status, assessed by serum retinol concentrations, of Zambian children lt 5 y of age. To explore possible reasons for the lack of response, we quantified absorption, retention, and urinary elimination of either a single HD-VA supplement (209.8 μmol; 60 mg) or a smaller dose of stable isotope (SI)-labeled VA (17.5 μmol; 5 mg), which was used to estimate VA pool size, in 3- to 4-y-old Zambian boys (n = 4 for each VA dose). A tracer dose of [14C2]-labeled VA (0.925 kBq; 25 nCi) was coadministered with the HD-VA supplement or SI-labeled VA, and 24-h stool and urine samples were collected for 3 and 7 consecutive days, respectively, and 24-h urine samples at 4 later time points. Accelerator MS was used to quantify 14C in stool and urine. Estimates of absorption, retention, and the urinary elimination rate (UER) were 83.8 ± 7.1%, 76.3 ± 6.7%, and 1.9 ± 0.6%/d, respectively, for the HD-VA supplement and 76.5 ± 9.5%, 71.1 ± 9.4%, and 1.8 ± 1.2%/d, respectively, for the SI-labeled VA. Mean estimates of absorption, retention, and the UER did not differ by size of the VA dose administered. Estimated absorption and retention were negatively associated with reported fever (r = minus 0.83; P = 0.011). The HD-VA supplement and SI-labeled VA were adequately absorbed, retained, and utilized in apparently healthy Zambian preschool-age boys; absorption and retention may be affected by recent fever.

A 30-Year-Old Man With Facial Flushing and a Mediastinal Mass

A 30-year-old man presented to the ED complaining of recurrent episodes of facial flushing, described as a “sensation of fullness and redness” in his face when adopting the supine position. These symptoms started 2 months prior to presentation and were associated with headache, orthopnea, chest pain, and nonproductive cough. The patient denied any history of recent respiratory illness, diarrhea, dyspnea, weight loss, fever, diaphoresis, skin rash, dizziness, or hoarseness.

Reduced virus replication, proinflammatory cytokine production, and delayed macrophage cell death in human PBMCs infected with the newly discovered Bundibugyo ebolavirus relative to Zaire ebolavirus

Bundibugyo ebolavirus is a newly identified Ebolavirus species. The virus was responsible for a recent hemorrhagic fever outbreak in Uganda with an approximate 30% case fatality rate. In this study, we compared the pathogenesis of Bundibugyo with highly lethal Zaire Ebolavirus by using in vitro human PBMCs. We found that PBMCs infected with Bundibugyo ebolaviruses resulted in 1 to 2 log lower virus yields compared to Zaire ebolavirus and produced 2- to 10-fold lower levels of TNF-alpha, MCP-1, IL-1beta, MIP1-alpha and IL-10 than PBMCs infected with Zaire ebolavirus. In addition, flow cytometric studies have shown lower levels and delay of the macrophage cell death in Bundibugyo ebolavirus compared to Zaire ebolavirus infection. The findings of slower Bundibugyo ebolavirus replication, lower production of proinflammatory cytokines and delay in macrophage cell death provide insight into the basis of the lower case fatality observed with Bundibugyo ebolavirus.

38-Year-Old Woman With Increasing Fatigue and Dyspnea

A 38-year-old woman presented to the emergency department because of increasing fatigue and shortness of breath, worsening during the past 2 months. At the time of presentation, even minimal exertion caused her to become short of breath. She denied chest pain, cough, expectoration, orthopnea, paroxysmal nocturnal dyspnea, recent fevers, or chills. Her medical history was remarkable for a Roux-en-Y gastric bypass procedure 16 years earlier for morbid obesity. Her weight before surgery was approximately 100 kg (220 pounds), but she had lost considerable weight after surgery, with her recent weight being stable at around 57 kg (125 pounds). She had a history of frequent upper respiratory tract infections, urinary tract infections, and yeast infections since her obesity surgery.

Lipoma arborescens of the knee

Background: A 35-year-old man presented with a progressive painless swelling in the right knee. Medical history mentioned an arthroscopic partial medial meniscectomy. There was no recent trauma nor fever.

Early Helminth Infections Are Inversely Related to Anemia, Malnutrition, and Malaria and Are Not Associated with Inflammation in 6- to 23-Month-Old Zanzibari Children

Helminths aggravate anemia and malnutrition among school children. We studied this association in a cross-sectional study of 6- to 23-month-old Zanzibari children (N = 2322) and a sub-sample of 690 children matched on age and helminth infection status. Ascaris, hookworm, and Trichuris infections were diagnosed along with recent fever, malaria infection, mid-upper arm circumference (MUAC) and hemoglobin concentration (Hb). Alpha-1-acid glycoprotein (AGP), C-reactive protein (CRP), height, and weight were measured in the sub-sample. Infected children had higher Hb (beta = 5.44 g/L, P < 0.001) and MUAC-for-age Z score (beta = 0.30 Z, P < 0.001) compared with uninfected children after adjusting for covariates. Although helminths were not associated with inflammation, their association with Hb or MUAC-for-age Z score was modified by inflammation. Malaria-infected children were less likely to be infected with helminths (adjusted odds ratios 0.63 [95% confidence interval: 0.49, 0.81]). Non-anemic, better nourished, or non-malaria-infected children may be more exploratory of their environments and therefore increase their exposure to soil-transmitted helminths.

Phylogenetic analysis of recent classical swine fever virus (CSFV) isolates from Assam, India

Classical swine fever (CSF), a highly contagious viral disease of pigs, is endemic in India. As there is no information concerning the accurate genetic typing of classical swine fever virus (CSFV) isolates in India, 16 CSF viruses isolated during 2005-2007 from domestic pigs in different districts of Assam were typed in 5' UTR (150 nucleotides). To confirm the genetic typing results and to study the genetic variability, selected viruses were also analyzed in E2 (190 nt) and NS5B gene (409 nt) regions. Phylogenetic analysis revealed that all the 16 CSFV isolates analyzed belonged to group 1 and subgroup 1.1 in contrast to the situation in other Asian countries. Additionally, analysis in E2 and NS5B region placed the Indian isolates in a clearly separated clade within subgroup 1.1. The results suggest that subgroup 1.1 CSF viruses are currently circulating in India, which is important for epidemiology and control of CSF.

Adjusting for the Acute Phase Response Is Essential to Interpret Iron Status Indicators among Young Zanzibari Children Prone to Chronic Malaria and Helminth Infections ,

The extent to which the acute phase response (APR) influences iron status indicators in chronic infections is not well documented. We investigated this relationship using reported recent fever and 2 acute phase proteins (APP), C-reactive protein (CRP), and a-1-acid glycoprotein (AGP). In a sample of 690 children matched on age and helminth infection status at baseline, we measured plasma for AGP, CRP, ferritin, transferrin receptor (TfR), and erythropoietin (EPO) and whole blood for hemoglobin (Hb) concentration, zinc protoporphyrin (ZPP), and malaria parasite density, and we obtained maternal reports of recent fever. We then examined the influence of the APR on each iron status indicator using regression analysis with Hb as the outcome variable. Ferritin was inversely related to Hb in the APR-unadjusted model. Adjusting for the APR using reported recent fever alone was not sufficient to reverse the inverse Hb-ferritin relationship. However, using CRP and/or AGP resulted in the expected positive relationship. The best fit model included reported recent fever, AGP and CRP (R2 = 0.241; P < 0.001). The best fit Hb-ZPP, Hb-TfR, and Hb-EPO models included reported recent fever and AGP but not CRP (R2 = 0.253, 0.310, and 0.292, respectively; P < 0.001). ZPP, TfR, and EPO were minimally influenced by the APR, whereas ferritin was immensely affected. Reported recent fever alone cannot be used as a marker for the APR. Either AGP or CRP is useful for adjusting if only 1 APP can be measured. However, AGP best predicted the APR in this population.

Abnormal FDG PET Imaging in Tuberculosis Appearing Like Mesothelioma

Abstract:Fluoro-deoxy-glucose/positron emission tomography (FDG PET/CT) imaging has an established role in the evaluation of many malignancies. However, FDG also can be accumulated intensely by inflammatory lesions. We report a case of a 75-year-old man with recent fever and chronic cough for years.

Current issues in relapsing fever

Relapsing fever has the highest incidence of any bacterial disease in Africa and a massive epidemic potential due to current political turmoil in the Horn of Africa. This review focuses on recent advances in diagnostics, molecular biology and host-pathogen interactions. Complete relapsing fever genomes have recently been published, and the first site-specific genetic knockout complementation has been performed. Relapsing fever has gone from being a neglected disease to garnering interest in aspects such as tissue invasion, membrane biochemistry and complement evasion. Relapsing fever symptoms are variable, and the disease is commonly misdiagnosed as, for example, malaria. Although relapsing fever is considered a transient disease, it persists as a residual infection in the brain, which can be reactivated on immunosuppression. Therefore, single-dose antibiotic treatment should be avoided. Instead, treatment should cover a longer period, similar to the recommended regime for Lyme disease. Relapsing fever is a common cause of pregnancy complications such as intrauterine growth retardation and placental damage with spirochaetes crossing the maternal-foetal barrier, resulting in congenital infection. Although relapsing fever remains a big problem, recently described host-pathogen interactions, diagnostics and molecular biology advances such as completed genome sequences and the dawn of genetic tools have brought relapsing fever research into the 21st century.

Genetic typing of recent classical swine fever isolates from India

Seventeen classical swine fever virus (CSFV) isolates recovered during the period of 3 years (2006–2008) from India were subjected to nucleotide sequencing in the 5′ untranslated region (UTR). For genetic typing, 150 nucleotides within this region were used. For better epizootiological understanding, 39 nucleotide sequences of the above region, including 13 Indian CSFV sequences, available either in the Genbank or published literature were also included in the study. Based on the phylogenetic analysis, the Indian isolates could be grouped in to two subgroups, viz., 1.1 and 2.2. The study also revealed predominance of subgroup 1.1 and involvement of viruses of more than one subgroup in an outbreak.