Fever of Unknown Origin

Dr. Dumois, Dr. Jennings, Dr. Aucoin, Dr. Babiak

FUO or Fever Without
Localizing Cause
●
Definition (1961):
– >38.3 C on several occasions
– Duration >3 weeks
– Uncertain diagnosis after 1 week of study in hospital
Establishing an FUO

History and Physical Exam

Travel, animal exposure, immunosuppression, drug and toxin history,
localizing symptoms, behavior changes
Degree of fever, fever curve, response to antipyretics not useful
Repeat interviewing
CBC, CMP, Blood Culture X 3, UA, Ux
Hepatitis Panel
Chest Xray
Our Patient

History:
34 yo M, no significant PMH
6 weeks of intermittent fevers, up to 103 F
Recent epigastric/LUQ pain with N/V/D
Travel to Saudia Arabia 6 months ago, Arizona several weeks
ago
No ill family members, has a cat
Physical Exam:
LUQ tenderness
CBC, CMP, UA
Hepatitis panel -ve, Blood/urine culture no growth,
Chest xray no acute process
Diagnosic Approach
●
ESR, CRP, LDH, CPK
●
Peripheral smear, SPEP, bone marrow biopsy
●
HIV
●
Tuburculin skin test or interferon-gamma release
assay
●
RF, ANA, ANCA
●
Heterophile antibody, EBV Ab, CMV Ab
●
CT chest, abdomen/pelvis
●
Echocardiogram, LP
Our Patient
Outpatient Workup:
TSH WNL, RF -ve, ANA -ve, ESR 4, CRP 8.5, CPK
92, LDH 449
HIV NR, Quantiferon -ve
Blood Culture no growth
Inpatient Workup - Imaging
Cat Scratch Fever?
More Infectious Disease
Studies
Etiologies

Infections
Malignancies
Connective tissue diseases (vasculitis, SLE, PMR)
Infections

Most infectious FUO are atypical presentations

With ease of travel, consider foreign disease
TB, typhoid, amoebic abscess, malaria, brucellosis, kala azar, filariasis,
schistosomiasis, African tick bite fever, relapsing fever, Q fever, dengue virus,
chikungunya virus, Zika virus, Lassa fever
Changing geographic distribution of zoonotic infections
Babesiosis, ehrilichiosis, anaplasmosis, lyme, histoplasmosis,
coccidiomycosis
 A few words about CMV...
●
Diverse spectrum of illness
●
Immunocompromised vs immunocompetent
●
Seroprevalence 36% 6- to 11-yo, 91% >80 yo
●
CMV cultured from any bodily site
●
CMV Mononucleosis – fever, tonsillar exudate,
splenomegaly, cervical lymphadenopathy, atypical
lymphocytosis, increased mononuclear cells
●
Colitis, retinitis, transaminitis, Guillain-Barree,
pericarditis/myocarditis, pneumonia, enchephalitis