A previously healthy 49‐year old woman presented for admission after a syncopal episode. She had a 4‐ month history of fever (104°F), sweats, rigors, 40‐pound weight loss, and abdominal pain associated with alternating diarrhea and constipation. Prior workup done at another hospital including pan cultures, HIV and hepatitis testing, upper and lower endoscopy, and abdominal ultrasound was negative. CT scan of the chest/abdomen/pelvis revealed only mild splenomegaly. She had persistent leukocytosis and anemia requiring transfusions. She previously received 2 courses of antibiotics for presumed urinary tract infection with minimal improvement in symptoms. She denied any rashes, muscle pain, or joint stiffness. Imaging at our institution including CT scans of the head/chest/abdomen/pelvis and renal ultrasound were all normal. Laboratory workup including HIV and hepatitis panels, Quantiferon Gold, blood cultures, urine cultures, Brucella coxiella antigen, Epstein–Barr virus, cytomegalovirus were all negative. Antinuclear antibody ratio was 1:160, and C‐reactive protein was 17. Ferritin was 4800. With persistent fevers and steady increase in the ferritin level there was a concern for lymphoproliferative disorders particularly hemophagocytic syndrome. Bone marrow biopsy was performed showing atypical noncaseating granulomata. Flow cytometry was negative for clonal T.‐cell or B.‐cell populations. She was diagnosed with extrapulmonary sarcoid and started on tapering course of steroids with significant improvement in symptoms.
There are wide variations in presentation of patients with fever of unknown origin. Detailed history, a complete physical exam and basic diagnostic tests guide further workup. While many cases go undiagnosed, the majority are infectious, neoplastic or autoimmune diseases. Sarcoidosis is a multisystem disease of unknown etiology, usually affecting the respiratory tract and other organs. Diagnosis may include typical clinicoradiologic presentation, the finding of nonnecrotizing epithelioid granulomas in tissue biopsy, and exclusion of other diseases. Corticoid steroids are first line therapy and effectively suppress tissue inflammation. This case is indicative of the challenges and need for exhaustive investigation in patients with fever of unknown origin. Our patient was hospitalized at 2 institutions and seen by multiple providers and specialists over a 5‐month period before an accurate diagnosis was made. Ultimately the finding of noncaseating granulomas in bone marrow lead to the diagnosis of extrapulmonary sarcoidosis. The patient was placed on a slow taper of prednisone with resolution of her temperature and symptoms.
The purpose in reporting this case is to educate hospitalists about the need for thorough investigation in patients with fever of unknown origin. This case also serves to remind providers to consider extrapulmonary sarcoid in such cases.
To cite this abstract:Bushee D, Apuri S, Grenier M. The Diagnostic Dilemma in Fever of Unknown Origin. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 443. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-diagnostic-dilemma-in-fever-of-unknown-origin/. Accessed May 21, 2019.