Subfebrile Temperature Research Articles

Chronic, Recurrent, Progressive Osteomyelitis of the Maxilla Caused by Methicillin-Resistant Staphylococcus Epidermidis: A Therapeutic Dilemma

A 28-year-old man was hospitalized more than 15 timesfrom 2005 to 2008 at the Department of Otolaryngology atour institutions because of chronic, recurrent osteomyelitisof the maxilla on the right side. His medical history began in1994 (when he was a healthy 16-year-old boy without anyallergies or medication intake). At that time, a simple dentalprocedure of excision of an epulis located between theupper molar teeth on the right side was performed. Theprocedure was complicated by opening of the maxillarysinus from the oral cavity, which was surgically closed atthat time. Since then, recurrent right-side sinusitis had de-veloped multiple times with several puncture proceduresand empiric antibiotic therapies. In 1995, a Caldwell-Lucprocedure was performed on the right side with bilateralinferior turbinate submucous resection. Histopathologic ex-amination showed a nonspecific chronic inflammation. Af-ter surgery, the patient felt worse and noted an ongoingsensation of pressure around the tooth, swelling of thecheek, purulent discharge from the nose, and recurrentfever. He was hospitalized at the Department of Otolaryn-gologyoftheMedicalUniversityofGdan´sk,Gdan´sk,Poland,from May to August 2001. He was admitted for facial edemaand subfebrile body temperature; the symptoms appeared afew weeks before hospitalization. Computed tomography(CT) scan showed mucous membrane edema in both max-illarysinusesandedemaoftherightcheekandlowereyelid.Bacteriologic investigations of the nose swabs were nega-tive (Table 1). The results of the other laboratory tests wereas follows: white blood cell count, 8,600 L; erythrocytesedimentation rate, 6 mm; and C-reactive protein level, 3.0mg/L. The patient was treated with intravenous empiricantibiotics (600 mg of clindamycin 3 times daily for 14 days,2.0 g of ciprofloxacin 2 times daily for 3 weeks, and 500 mgof metronidazole 3 times daily for 14 days); at the begin-ning, the symptoms ceased, but within the next 2 weeks,the symptoms returned. Bone scintigraphy showed a highmarker concentration in the right maxilla. Next, a CT scanshowed a hypodense, encapsulated lesion inside tissue ofthe thickened cheek and edema of the mucous membraneof the right maxillary sinus (in its lateral-upper recess).Blood tests for perinuclear antineutrophil cytoplasmic anti-bodies (p/ANCA) and cytoplasmic antineutrophil cytoplas-mic antibodies (c/ANCA) were negative. The patient under-went surgical treatment. On the basis of clinical andpathologic findings (inflammatory infiltration), the diagno-sis of zygomatic osteitis was established. The patient re-ceived 20 expositions of hyperbaric oxygen therapy (HBO)(with protocol of a 70-minute time of exposition, 100%oxygen concentration, and 2.5 atmospheric pressure) withgood local outcome. After that treatment, he was healthyfor 4 years with occasional fullness and tenderness in the

Unusual Detection of Tuberculosis in a Woman with Down's Syndrome

Unusual Detection of Tuberculosis in a Woman with Down's SyndromeA woman with Down's syndrome (DS) had sub-febrile temperature, nodular/patchy shadows on the chest X-ray over the right pulmonary base, and a history of recurrent respiratory infections. She was pale, asthenic, uncommunicative, mildly anemic and the erythrocyte sedimentation rate was 80/first hour. The tuberculin skin test (TST) PPD3 was negative. Mycobacterium tuberculosis was isolated from oral mucosal brushing, sensitive to the first line anti-tuberculosis drugs. Patients with DS and other mental disabilities need special care and attention during diagnostic procedures for tuberculosis (TB).

Erythrodermic cutaneous T-cell lymphoma: Two case reports / Eritrodermalni kutani limfom T-ćelija - prikaz dva slučaja

Abstract Primary cutaneous T-cell lymphomas (CTCLs) are Non-Hodgkin lymphomas where skin may be the only involved organ for a long time. The erythrodermic form of CTCL, including Sezary syndrome, with increased IgE concentration, eosinophilia and intense pruritus, may suggest atopic dermatitis, in the lack of evidence for diagnosis of T-cell lymphoproliferative disorder. After vigorous research, two patients with erythroderma, increased IgE and eosinophilia, were not diagnosed with CTCL. Adult atopic dermatitis was diagnosed, based on clinical examination and histopathologic analysis of the skin sample. Therapy with oral cyclosporin A (CsA) and systemic corticosteroids were initiated, but the improvement was minimal and short-lived. Disease progression was noted in both patients, after a month of cyclosporine therapy: malaise, subfebrile and febrile temperatures, and development of generalized skin nodules were evident. In the first patient (aged 30) repeated examinations confirmed presence of Sezary cells in peripheral blood samples, dominant T-cell clone in the skin, peripheral blood and bone marrow, whereas the last repeated histopathologic analysis revealed T-lymphoproliferative skin disorder. In the second patient, (aged 44) primary cutaneous CD30+ T-cell lymphoma was diagnosed, based on histopathologic analysis of the newly appearing skin nodule. Differential diagnosis of erythroderma is always difficult, since clinical, histopathologic and immunophenotypic findings are frequently insufficient to differentiate between inflammatory and lymphomatous erythroderma. Treatment with cyclosporin A always demands carefull evaluation of the course of the disorder.

A 17‐Year‐Old Girl with a Black Eschar

A 17-year-old girl developed a cutaneous macular lesion in the area of the right sternoclavicular joint. In the 3-week period after initial symptoms were noted, the lesion passed through papular, vesicular, and pustular stages before forming a hard black eschar (diameter, 2 cm) with erythema and edema, as well as regional lymphangitis (figure 1). In the early stage of the disease, the patient experienced malaise and had subfebrile temperatures. After treatment with several different antibiotic regimens (clindamycin-clarithromycin, then fucidine-imipeFigure 2. Hard black eschar with erythema and edema in the area of the sternoclavicular joint.

Pathology Quiz Case 1

A 23-YEAR-OLD WHITE WOMAN PRESENTED with a 2-month history of a pyoderma gangrenosum–like ulcer in the right postauricular region. The cutaneous lesion had initially started as a pustule that was associated with local pain, subfebrile temperature, night sweats, and spontaneous perforation with a whitish discharge 2 weeks after the disease onset. Necrectomy was performed, and antibiotics (clindamycin, amoxicillin and clavulanate potassium [co-amoxiclav], and azithromycin) were administered intravenously in an outpatient clinic, without success. Two months after the first symptoms appeared, the patientwasadmitted toourclinic.Shehada4.5-cm-diameter, painful, necrotic area in the right postauricular and subauricular regions. The lesion was covered with granulation tissue and mucous discharge. In the left postauricular region, there was an indurated purple pustule, 2 cm in diameter, that was solid and painful to palpation. A smaller pustule was seen in the medial part of the left scapula. The patient also had painful episcleritis and uveitis of both eyes as well as granulation tissue in the septal and conchal mucousmembranes.Antibiotic therapy(piperacillinandgentamicinsulfate)wasadministeredintravenously,andasecond necrectomyoftherightpostauricularandsubauricularareas was performed on day 5 of admission. A huge ulcer penetrating deeply into the right parotid gland, almost to the facial nerve, was found on removal of the necrotic tissue (Figure 1). The tissue was sent for cytologic, microbiologic, andhistopathologic analysis.Cultureswerenegative for aerobic and anaerobic microorganisms and fungi. Cytologicexaminationshowedgranulomatous inflammation. Thehistopathologyreport revealed fibrinoidnecrosisof the vascular wall; macrophage, lymphocyte, and neutrophilic leukocyteinfiltration;andformationofgranuloma(Figure2 and Figure 3). What is your diagnosis?

Actinomycosis mimicing advanced cancer

Actinomycosis is a rare infectious inflammatory disease caused by the bacteria of the Actinomyces species. Infection occurs following damage to the skin or mucous membrane. This report presents a case of a 50-year-old female patient with subfebrile temperature, weight loss and pain, who used to have an intrauterine device. Masses suggestive of an advanced cancer were detected in her pelvis and abdominal cavity. A diagnosis of actinomycosis was made after histopathological examination of the tissue sample.

Przypadek złuszczającego śródmiąższowego zapalenia płuc jako rzadkiej postaci samoistnego śródmiąższowego zapalenia płuc

The idiopathic interstitial pneumonias are a heterogeneous group of diseases that have similar clinical symptoms. The new classification is based mainly on differences in histologic patterns, however high-resolution computed tomography is a significant tool that helps in making a firm diagnosis. Desquamative interstitial pneumonia is relatively rare form idiopathic interstitial pneumonia. It affects mainly men in their fourth or fifth decade of life who have a history of smoking. We report a case of 50-years-old man admitted to hospital for further diagnosis of prolonged bilateral pneumonia. His main complaints were fatigue, productive cough and subfebrile body temperature. Having performed additional diagnostic procedures including videothoracoscopy, what was in accordance with contemporary guidelines, we achieved a final diagnosis of desquamative interstitial pneumonia. Treatment with systemic corticosteroids resulted in disease remission.

Erstmanifestation einer Schönlein-Henoch-Purpura bei einer 74jährigen Patientin mit Hyperthyreose

A 74-year-old woman had for 3 weeks suffered from watery diarrhoea and diffuse abdominal pain. She felt restless, had a subfebrile temperature (37.8 degrees C), tachycardia and a blood pressure of 190/90 mmHg. Shortly after admission petechiae were found over the lower legs and she complained of joint pains. Laboratory tests established hyperthyroidism. Skin biopsy showed leukocytoclastic vasculitis. Tests for antinuclear antibodies, antistreptolysin titre, rheumatoid factors, cryoglobulins and TSH-receptor antibodies were negative, immunoglobulin A (IgA) was raised. As a drug-induced vasculitis was suspected treatment was started with methylprednisolone, 100 mg daily. Proteinuria (5.6 g daily) indicated renal biopsy, which revealed focal glomerulonephritis with deposits of IgA, fibrin/fibrinogen and complement factor 3. Gastroscopic biopsy, performed after an episode of gastrointestinal bleeding, demonstrated necrotizing vasculitis, confirming the diagnosis of Schönlein-Henoch-purpura (SHP). As the patient's condition rapidly worsened, cyclophosphamide was started additionally (2 mg/kg). She died on the 17th hospital day from acute cardiac failure. The lethal course of the disease in this elderly patient illustrates a previously not reported close temporal and clinical relationship between SHP and hyperthyroidism.

Fibrinpleurodese bei malignen Pleuraergüssen

Fibrin pleurodesis was performed on 30 patients with malignant pleural effusions. A pleural catheter was inserted to empty the pleural space and effect the pleurodesis. When the pleural space was dry, 20 000 U of aprotinin were instilled intrapleurally for local fibrinolysis inhibition. 10 ml fibrinogen concentrate and 10 ml thrombin (500 U/ml) and 3000 KI U/ml aprotinin were then applied. Complete success was achieved in 19 of 27 patients, partial success in two. The results could not be evaluated in three patients. The only side-effect of the treatment was a subfebrile temperature in three of the 30 patients. Fibrin pleurodesis thus proved itself as an effective form of treatment with few side-effects (10%).

Miliar-Silikotuberkulose mit vorwiegend zerebraler Symptomatik

About 10 weeks before admission to hospital a 73-year-old woman developed a fever of up to 40 degrees C for three days. She then had subfebrile temperature for several weeks with some rises to 39 degrees C. She was known to have type II a diabetes mellitus and pulmonary silicosis, having worked in a porcelain and ceramic factory for many years. Before admission her cerebral functions were rapidly deteriorating, especially short-term memory. This was followed by increasing paraplegia of the legs with inability to walk. She finally had urinary and faecal incontinence and swallowing difficulties with tendency to aspiration, which necessitated hospitalisation. Both lactate dehydrogenase (339 U/l) and C-reactive protein (112 mg/l) were elevated; the platelet count was low (73000/microliters). Cerebrospinal fluid was unremarkable, as was computed tomography of the skull. But magnetic resonance imaging revealed multiple spotty lesions with low contrast-medium uptake throughout the brain, pointing to a disseminated bacterial or mycotic infection. 3 days later the chest-ray showed small nodular soft shadows in the lungs, and lung functions had decreased. Mycobacteria were found in the urine and liver biopsy showed granulomatous hepatitis, establishing the diagnosis of miliary tuberculosis in the presence of silicosis. Tuberculostatic treatment was instituted with four drugs (pyrazinamide, ethambutol, isoniazid and streptomycin. After 6 weeks the patient was again able to walk and continent of urine during the day. All cerebral functions gradually improved. Miliary tuberculosis should be included in the differential diagnosis of ill-defined feverish disease, especially in the elderly.

Vegetative hyperthermia: a thermoregulation disorder or a variant from the norm?

A diagnosis of low-grade idiopathic fever was made in 85 women and 15 men, examined for subfebrile temperature of unknown origin, after organic disease had been excluded. Compared with 100 healthy control subjects these patients had inadequate movement-dependent temperature elevations with a usually pronounced discrepancy between the rectal temperature, predominantly more than 38 degrees C, and a normal or only slightly raised axillary temperature recorded after bodily movement. Other characteristics were that the elevated temperature was uninfluenced by antipyretic drugs. Almost all patients initially complained about general lassitude as well as frequently about atypical functional complaints and psychological symptoms. These observations indicate that low-grade fever is a functional syndrome due to a harmless faulty regulation of body temperature. In addition to a special constitutional reactivity, psychological factors and possibly previous febrile infections are likely to be involved as precipitating causes.

Myositis mit Lungenfibrose und Eosinophilie

A 74-year old female patient suffered from dyspnoea, subfebrile body temperature, myalgias, arthralgias and presented a transitory skin rash. Further findings were an eosinophilia, synovitis, a myositis and pulmonary fibrosis. There was no evidence for a malignancy or an infectious disease. We diagnosed an Anti-Jo-1-Syndrome with a secondary Sjoegren syndrome. Immunsuppressive therapy with steroids, later in addition methotrexate led to improvement of the patient's clinical condition. Above mentioned symptoms and its differential diagnosis are discussed in this article.

Radiation Recall Pneumonitis Induced by Gemcitabine

Radiation recall pneumonitis describes a very rare reaction in a previously irradiated area of pulmonary tissue after application of pharmacological agents. A case of recall pneumonitis induced by gemcitabine is reported. A 64-year-old female patient with metastasized esophageal carcinoma received simultaneous chemoradiotherapy of the upper mediastinum with 50.4 Gy and cisplatin/5-fluorouracil. 8 months later she was scheduled for salvage chemotherapy with gemcitabine (1,000 mg/m(2) days 1 and 8) and docetaxel (75 mg/m(2) day 8) due to locally progressive disease. After having received gemcitabine on day 1 of the second course, the patient developed dry cough, subfebrile temperatures and dyspnea within 48 h. A CT of the thorax revealed newly developed bilateral pulmonary ground-glass opacity corresponding to the previous radiation fields. Chemotherapy was stopped and systemic application of prednisolone was initiated. 2 months later symptoms had resolved with a control CT of the thorax showing complete regression of the pulmonary changes. Gemcitabine-induced recall pneumonitis is a rarely reported phenomenon and should be taken into account even after extended time interval to the previous radiotherapy.

Fulminanter Verlauf einer Takayasu-Arteriitis und seltener mesenterialer Gefäßbefall

Takayasu's arteritis is a systemic disease, presenting as chronic inflammation of the main arteries. It usually affects the aorta and its large branches. General symptoms often include fatigue, subfebrile temperatures and weight loss. Complaints due to perfusion disorders are, for example, muscle pain, dizziness or claudication. Takayasu's arteritis is a rare disease which generally occurs in female patients under 40 years of age. We report on a patient with primary involvement of the mesenteric arteries. The disease process was fulminant and refractory to all therapeutic strategies. According to our knowledge this is the first case report from Germany of Takayasu's arteritis with mesenteric infarction.

33-jährige Libanesin mit rezidivierenden Hämoptysen und zystischer Raumforderung in der Lunge

A 33 year old woman from Lebanon presented with recurrent hemoptysis, subfebrile temperature, dyspnoe in stress, fatigue, weight loss, and pruritus. Serological tests and results from chest X-ray and computer tomography revealed cystic echinococcosis with pulmonary involvement. After refusal of surgical therapy a medical treatment with albendazole was implemented. Two months after the start of the therapy only a small fibrotic residuum in the lung was seen. A spontaneous healing success seems unlikely because of the duration of the pulmonary cyst and the progressive symptoms before treatment.

Pulmonale Nokardiose mit abszedierenden zerebralen, zerebellären und orbitalen Streuherden

A 71-year-old woman presented with suspected tuberculosis. She reported having productive coughs, unwanted weight loss and subfebrile temperature in the preceding 3 months. She was known to have chronic obstructive pulmonary disease treated with corticoids given systemically and by inhalation. She was a heavy smoker. Computed tomography revealed a left apical lung abscess. In the further course of the disease magnetic resonance imaging of the head demonstrated multiple abscesses in both cerebral hemispheres and an abscess, 3.4 cm in diameter, in the right side of the cerebellum, as well as a intra-orbital tumor on the right. Needle aspirate of the eyeball grew Nocardia farcinica. Over 3 weeks antimicrobial treatment was given with imipenem and amikacin, followed by oral cotrimoxazole for 12 months. The abscesses completely regressed and after 12 months no recurrence was demonstrated either radiologically or clinically. Although nocardiasis is rare in Germany it must be included in the differential diagnosis of pneumonia with abscesses. This is especially so if acid-fast bacilli are found. As the resistance pattern of N. farcinica to antibiotics varies, early treatment is essential with antibiotics to which it is sensitive.

Rezidivierende disseminierte Mycobacterium-avium-Infektionen bei einem HIV-negativen Patienten

A 64 year old man complained about progressive pain in his right upper leg and pelvis since 4 weeks without any history of trauma. He noticed a reduced general health status for several months with weight loss and subfebrile temperatures. The patient's medical history revealed several malignant tumours and recurrent infections with atypical mycobacteria and herpes viruses. Laboratory findings showed signs of chronic inflammation. Multiple disseminated osteolytic bone lesions, hepatosplenomegaly, lymphadenopathy and multiple splenic lesions were detected by CT scan. Mycobacterium avium was isolated from an osteolytic lesion of the pelvic bone. Malignant disease and acquired immunodeficiency syndrome were excluded. Lymphocyte counts showed lymphocytopenia with reduced T cells, B cells and a reduced CD4-/CD8-ratio. Interferon-gamma-pathway defects as described in patients with susceptibility to atypical mycobacteria could not be identified. Clinical and immunologic findings indicated a link between recurrent Mycobacterium avium infections and an idiopathic CD-4 T-cell lymphopenia (low CD4 syndrome). Antimycobacterial treatment at standard doses was started according to the resistance test obtained from microbiological culture. Medical and radiological checkup after 3 months of therapy showed signs of progressive disease. Osteolytic lesions can be caused by mycobacterium avium infection. Disseminated atypical mycobacteriosis is an opportunistic disease in patients with congenital or acquired immunodeficiency syndrome.

Outpatient laparoscopic supracervical hysterectomy with assistance of the lap loop

Study objective To elucidate the safety and patient satisfaction with laparoscopic supracervical hysterectomy (LSH) performed in an outpatient setting. Design Prospective case study (Canadian Task Force classification II-2). Setting Public hospital. Patients Forty-three women. Intervention Outpatient LSH performed by lap-loop. Measurements and main results The procedure was recommened by 41 out of 43 patients. Three patients (7%) were admitted to the hospital due to complications after the surgery. One patient was admitted because of a vasovagal reaction after anesthesia; she recovered quickly and was discharged after a few hours of observation. One patient was admitted because of postoperative pain and discharged the next day; she had a prolonged postoperative recovery with pain and subfebrile temperature. One patient underwent laparotomy due to major intraabdominal bleeding. Postoperative complications occurred in another five patients (12%) without need for hospitalization (infected intra-abdominal hematoma, urine retention, cystitis, cystitis combined with wound infection, and pneumonia). Conclusion Laparoscopic supracervical hysterectomy as an outpatient procedure is a safe and highly acceptable treatment.

Anthrax Vaccines

SUMMARYAnthrax, an uncommon disease in humans, is caused by a large bacterium, Bacillus anthracis. The risk of inhalation infection is the main indication for anthrax vaccination. Pre-exposure vaccination is provided by an acellular vaccine (anthrax vaccine adsorbed or AVA), which contains anthrax toxin elements and results in protective immunity after 3 to 6 doses. Anthrax vaccine precipitated (AVP) is administered at primovaccination in 3 doses with a booster dose after 6 months. To evoke and maintain protective immunity, it is necessary to administer a booster dose once at 12 months. In Russia, live spore vaccine (STI) has been used in a two-dose schedule. Current anthrax vaccines show considerable local and general reactogenicity (erythema, induration, soreness, fever). Serious adverse reactions occur in about 1% of vaccinations. New second-generation vaccines in current research programs include recombinant live vaccines and recombinant sub-unit vaccines.

Beidseitige Oberlidschwellung bei Mononucleosis Infectiosa (Hoagland-Zeichen)

Infectious mononucleosis ("kissing disease") is an infection caused by Epstein-Barr-Virus (EBV, human herpes virus 4). We present the case of an 18-year old female patient with dacryoadenitis and sub-febrile temperatures followed by a distinct feeling of sickness. Laboratory results revealed a Leukocytosis of 16.3 G/I with explicit elevation of hepatic parameters. The ultrasound scan of the orbital region showed a bilateral, echo-reduced, compressible lesion in the area of the lachrymal gland. The abdomen-ultrasound scan revealed a splenomegaly and the size of the liver was within normal limits. Serology was positive for EBV-VCA-IgG, EBV-EA-IgG and EBV-VCA-IgM. A dacryoadenitis can be the presenting symptom of an infectious mononucleosis.