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Medical Forum / General / General / June 2006Prolonged Fever
My cousin sister, 34, is suffering from fever for the last one month. She was hospitalized for almost two weeks and went through all sort of tests which yielded no great clues to the cause. Please find below the abstract of HAEMATOLOGY reports of tests conducted over a period of three weeks at an average 4 days intervel. Figures in brackets() indicate the normal range: TC: (4 - 9.8) 23.12 -- 21.7 -- 23.6 -- 26.5 -- 22.9 -- 22.5 D C Granulocytes (42 - 70) 86 -- 78 -- 88 -- 80 -- 86 -- 86 Lymphocytes (22 - 48) 10 -- 16 -- 9 -- 17 -- 12 -- 11 Eosinophils (2 - 6) 2 -- 2 -- 2 -- 2 -- 1 -- 2 Monocytes (2 - 4) 2 -- 4 -- 1 -- 1 -- 3 -- 1 Basophils (0 - 2) 0 -- 0 -- 0 -- 0 -- 0 ESR 55 -- 38 --- --- --- 110 --- 120 Hb 13.5 -- 12.9 -- 10.9 -- 10.7 -- 10.9 -- 10.7 RBC 4.7 -- 4.45 --- --- 3.78 -- 3.78 -- 3.90 Platelets (160 - 350) 269 -- 346 -- 457 -- 470 -- 450 S G O T (1- 40) 41 -- 41 --- --- --- S G P T (1- 42) 87 -- 77 -- 87 -- 35 --- G G T (7- 32) --- --- --- 356 --- --- Creatinine (0.2 - 1.2) 0.9 -- 0.8 -- 0.9 -- 0.9 -- 0.7 -- 0.53 Urea (10 - 50) --- --- 10 --- ---- --- T S H (0.45 - 4.7) ---- ---- ---- 0.96 ---- Protein (6.4 8.3) --- 7.32 --- --- 7.32 Alkaline Phosphate (98 - 279) ---- 87 --- 693 ---- ---- Sodium (134 - 146) --- --- 133 --- 138 --- ----- Pottassium (3.5 - 5.5) --- --- 3.3 --- 3.4 --- --- She had occasionally complained of some discomfort in her throat, which was examined and ruled out by an ENT specialist. The fever comes systematically at least two times a day accompanied by shivering and goes away with intake of paracetamol (oral and later suppository). Sadly, this pattern of fever did not change after all the medication. She was discharged from the hospital ten days back and was advised to undergo more investigation in another hospital. A doctor friend of mine, who is an experienced surgeon but not one of who treated her, suggested that this could be a medicine-induced fever and that the fever shall subside when the medicines are withdrawn or their courses are over. Now she is under his watch. He ordered a complete scan of her body yesterday, in which he did not find anything negative. He has not started any medicine yet as he is still studying her case trying to rule out other possibilities. We are in a dilemma. After five weeks since it started, the fever still comes as it came on the very first day. Can any one help us with a proper advise? (I apologize if I am not posting this to the right group. Somebody out there please give me the right link.) > My cousin sister, 34, is suffering from fever for the last one month. > She was hospitalized for almost two weeks and went through all sort of [quoted text clipped - 51 lines] > (I apologize if I am not posting this to the right group. Somebody out > there please give me the right link.) There is a moderate elevation of neutrophilia. The differential or breakdown of the white cells is from an autodifferential instrument I presume. IT really helps when an experienced person looks at the blood smear so I would hope that a pathologist review of the smear was asked for. I would look at the white cell morphology of whether they are immature granulocytes or mature granulocytes and for any toxic changes and for atypical lymphocytes were noted or not. I would look at the RBC morphology for clues to the anemia that are also present although a strong possibility is anemia of chronic disease. The most striking of all the labs here is the sedimentation rate of 120 mm/hr. I would be concerned with malignancy, rheumatologic disease, and infection. Those are the biggest in terms of fever of unkown origin. There is another group of miscellanous things such as meds as mentioned. Medication induced fevers tend to resemble strep throat and can involve band forms with atypical lymphs present in the blood often mistaken as viral or strep throat. The workup for UFO is very long and tedious and may involve a liver biopsy as there is liver involvement here if nothing obvious has shown up until then. The liver enzymes show a pattern of intrahepatic cholestasis and not necrotic based on the SGOT and SGPT with elevated ALK and GGT. Intrahepatic cholestasis can be caused by drugs. ALP predominance over ALT and AST accompanied by a normal bilirubin points to focal intrahepatic disease (eg, metastases, lymphoma or leukemia, or granuloma). Those are some things noted about the labs above that one has to rule out. Hope it helps. where is she from? any recent travels? pets? HIV excluded (sorry we have to incldue all possiblities).. although more than a month of fever is unusual for just acute retroviral syndrome. HIV + another infections is possible. I agree with the reply: 3 biggies are Infection (check out for chronic granulomatous processes), connective tissue disease, and malignancy. A pan CT scan + possible looking into the liver with these LFT abnormalities I think is indicated at this point. A bone marrow is in process after a careful review of previosu smears. Posted via medical forums at http://medical.gr77.com > where is she from? any recent travels? pets? > HIV excluded (sorry we have to incldue all possiblities).. although [quoted text clipped - 8 lines] > > Posted via medical forums at http://medical.gr77.com Thanks a lot for your interest. She is Indian, now living in Dubai. A respected housewife, not working. No pets. No travel other than a trip to her home in India four months back. Two important points I missed to include in my above post: 1) She had similar episodes of fever four years back, going through all the tests and medication as she had this time, but the army of doctors not reaching any conclusion till the end of the 6th week, when the fever subsided. 2) She has two sons. The first one 8 years and the younger one just 8 months old. Her menstrual cycle did not get regularized after the last delivery. She did not have a period for the last four to five months. But no doctors have thought that way yet, I believe, as this subject has not come up during their investigation. This is just a thought that we had today. Any thoughts contributed here will be a great help for the several families around her that pray for her recovery. To add to my above post: When she was ill four years back as mentioned in (1) above, she had undergone bone marrow tests and liver biopsy. Results were in her favor. > > where is she from? any recent travels? pets? > > HIV excluded (sorry we have to incldue all possiblities).. although [quoted text clipped - 29 lines] > Any thoughts contributed here will be a great help for the several > families around her that pray for her recovery. > To add to my above post: > When she was ill four years back as mentioned in (1) above, she had > undergone bone marrow tests and liver biopsy. Results were in her > favor. By looking at the spelling of Haematology rather than hematology I knew we where dealing with UK influence and my lack of regional prevailing diseases. Familial Mediterrean fever is on the list although it quite doesn't fit. Amenorrhea and all symptoms should be reported to the doctor for evaluation. The TSH is normal Diseases of the pituarity, adrenal, thyroid, and hypothalamus can present with ovulation problems. Those giving FUO involve addisons disease and thyrotoxicosis. Liver problems can also give that symptom although the extent of liver is not complete with the test shown. Albumin, total bilirubin and Protime not shown. There does not seem to be a lot of symptoms in her other than fever and amenorrhea? I am somewhat confused by your mention of a non-diagnostic liver biopsy or bone marrow. Was the intrahepatic cholestasis present at the time or is this a new finding? There was no histologic evidence of cholestasis on the liver biopsy? Unexplained intrahepatic cholestasis is one indication in doing a liver biopsy along with FUO. Granulomas of the liver are the most missed diagnosis on biopsy. Do they routinely give BCG vaccine in india to prevent TB? Birth control pills are known to cause intrahepatic cholestasis although they usually have jaundice and no fever. Did they do a 67 Galium Citrate Scan? The reason I ask is because of the high white count and platelet counts indicating acute inflammation. The Galium scan can pick up abscess and tumors. I would be interested in following a white cell and seeing where it goes. Unfortunately about 10 percent of FUO are still unresolved after studies and more time has to pass before something shows itself that is more definitive. Don't want to step on any toes here but HIV testing is really a mandatory thing. Good luck Thank you very much for your response. I will write later today after collecting any missing information on the history of previous and current test results and any other symptoms that I missed to mention. I am also passing your views to the doctor. God bless you. Please find the following additional information: Chest X-ray (PA view)result = Normal X-ray PNS (Water's view) = Findings suggestive of right maxillary polyp with hypertrophied right nasal turbinate Other blood test results during 12 to 28 May when she was hospitalized: HIV 1 & 2 - negative Smear for MP/ML - negative WIDAL - negative MONTOUX - negative Stool Occult Blood - negative SGPT - normal TSH - normal Anti Myco Plasma antibody level - equivocal 1:40 S. Creatinine - normal She had taken the following medicines during the above period (12 to 28 May): 1. Suprax 500mg tab - 5 days 2. Zinnat 500 mg tab - 5 days 3. Inj. Maxipime 2 gm - 10 doses 4. Inj. Meropenom 1gm - 20 doses 5. Inj. Metrolag 500mg - 23 doses 6. Inj Amikacin 500mg - 15 doses 7. Inj. Fortum 2gm - 6 doses On 6 June: Sonography of Abdomen & Pelvis. Please see results below: 1. Gall Bladder: Physiologically distended with multiple Echogenic floting calculi in gall bladder. Wall thickness of g/b is normal. No obvious mass noted. No perichotecystic collection noted. 2. Ovaries: There is no ascites or obvious retropertoneal adenopathy. 3. Uterus : Uterus is anteverted,measures 3.4x4.5x7.4 cm. and shows inhomogeneous myometrial echoes. Small cysts of of approx. 2 to 3mm in size noted in the myometrium suggestive of? adenomyosis. No focal lesions are noted in the uterus. Other findings: Cholelithiases (which was reported also in the earlier scan) After 28 May, she had only Voltaren 100 and Adol 500 both suppository. And, since the last two days, Dostinex 0.5 to stop breasmilk as she was still feeding when went ill. Last night, she had fever crossing 103F. Had Adol 500 suppository. Applied ice pack. Thank you. 1) i would go back and review her history. Are there any other symptoms aside from the fever? chills (i presume)? does she look generally unwell? weight loss? etc. 2) if she had the same symptoms years ago then I would put malignancy down in my list; but yeah at times being parsimonious has its pitfalls. the fever years back could be unrelated to the event right now. 3) less likey medication-induced but worth the try. she had fever before the drugs but again there are cases where an initial non drug-related fever was exacerbated by trying to treat an infection which is the common scenario 4) what happened to the ALP and GGT? as noted they are quite high. i would suspect a biliary process or an intermittent passage of stones but there seems to be paucity of right upper quadrant symptoms. i would get a HIDA. better yet why would hse have multiple stones in here gallbladder . does she have a hemolytic process??? mmmm...malaria? certainly no babesia in india- don't think its endemic there? rbc membrane defects? (g6pd and all). i don't know if i missed the hemolytic panel. was the spleen normal? 5) no murmurs? 6) the high ESR, fever and anemia are quite non-specific. again i go back t my 3 biggies: a) connective tissue disease- (female & young); ANa screen perhaps and RF (juvenile RA?) b) infectious - zoonotic (trial of doxycycline? - - relapsing and chronic fevrs? weiggh risk benefit ratio) - search for granulomatous diseases (TB, schisto, leishmaniasis) c) malignancy- go for the buck - at least check out uterus with a gynecologist 7) how i would proceed depends if the fevr bothers the md or the patient. i would do : repeat LFT's, LDH or haptoglobin , coomb's test (both direct and indirect), have the smears reviewed taken at the height of the fever, HIDA if available, gyne consult re ? adenomyosis, ANA and RF. maybe a trial of doxy or pred but i would go searching first. i leave it up to the docs back home just giving my opion. Posted via medical forums at http://medical.gr77.com Thank you very much. Your opinion will be passed on to the doctor. Will go through your post in detail and feed back. Last night, had fever and the usual suppository. |
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