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M ORTALITY & M ORBIDITY CONFERENCE C ASE S ERIES - FUO

This morbidity conference case series discusses two distinct cases of patients presenting with prolonged fever. The objective is to discuss the step-by-step approach in the management of fever of unknown origin.

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M ORTALITY & M ORBIDITY CONFERENCE C ASE S ERIES - FUO

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  1. MORTALITY & MORBIDITY CONFERENCE CASE SERIES - FUO NERISSA ANG SORRAH FIEL BRIONES ERICK VERANO February 15, 2007 Ledesma Hall

  2. Objectives • To present two distinct cases of patients presenting with prolonged fever • To be able to discuss the step by step approach in the management of patients’ with fever of unknown origin

  3. FEVER OF UNKNOWN ORIGIN Case Presentation

  4. General Data • I.S. • 29 year old male • single

  5. Chief Complaint • Work up for on and off • Fever 1 month duration

  6. 6 weeks PTA (+) intermittent fever Tmax: 39.5ºC (-) associated signs and symptoms Temporary relief by paracetamol 500 mg PO History of Present Illness

  7. 5 weeks PTA (+) intermittent fever Tmax 39ºC (+) 3 episodes LBM Admitted at a local hospital Dx Typhoid fever (+) Typhidot IgG + IgM Rx Chloramphenicol x 7 days (+) fever episodes Discharged for holiday season History of Present Illness

  8. 3 weeks PTA (+) intermittent fever Tmax 39ºC Self medicate Paracetamol Cotrimoxazole Amoxicillin No relief Readmitted again History of Present Illness

  9. Diagnostics • Malarial Smear – NEGATIVE • Peripheral Smear – NORMAL • Blood GS – NO GROWTH • HIV ELISA – NON REACTIVE • ANA – 1.054 – WEARLY POSITIVE • Thyroid Fxm Test – NORMAL • UTZ of the abdomen – NORMAL SONOGRAPHICS

  10. Diagnostics • Fecalysis – NO OVA / PARASITE SEEN • Urinalysis – NORMAL • CT of the Abdomen – RENAL CORTICAL CYST (R)

  11. History of Present Illness • He was given ceftriaxone 3G IV OD x 3 days but developed HPS rxn • Shifted to cefixime 200 mg BID x 7 days • Patient remained to have intermittent fever Tmax 38.5º despite of antibiotic coverage • Opted to be discharged • Consult • Admission

  12. Past Medical History • (-) HPN • (-) diabetes mellitus • (-) asthma • (-) Hs of other hospitalization in the past

  13. Family History • (+) HPN mother • (-) heredofamilial diseases • e.g. CA, mumps, leukemia

  14. Personal and Social History • Non smoker • Non alcoholic beverage drinker • (-) history of travel

  15. Review of System • (-) anorexia • (-) weight loss • (-) cough and colds • (-) rashes • (-) photophobia • (-) alopecia • (-) oral ulcers • (-) bleeding tendencus

  16. Physical Examination • Conscious, coherent not in cardiorespiratory distress • BP: 120/80 mmHg, CR: 82, RR: 19, Tº: 38.9ºC • Pink palpebral conjunctive, anicteric sclerae (-) TPC, (-) CLAD • ECE, (-) Retraction, Clear breath sounds (-) crackles • Adynamic precordium, normal rate regular rhythm, (-) murmur

  17. Physical Examination • Flat, soft abdomen, NABS, (-) masses, (-) tenderness • (-) gross deformities, full equal pulses, (-) cyanosis (-)edema

  18. Salient Features • 29 y/o male • 1 month history of intermittent fever • Normal physical examination • Came in for work-up

  19. Admitting Impression • Fever of unknown origin

  20. Course in the Ward • Upon admission • CBC, ESR, CRP • Blood CS x 2 sites • Monospot test • Spec 16 • Urinalysis • ANA, LE panel • CT of the Chest • Transesophageal echocardiography • Hematology referral for BMA

  21. Laboratory Results

  22. LE Panel • ANA – weakly positive • Anti DNA (-) • Anti SM (-) • Anti RNP (-) • Anti SSA (-) • Anti SSB (-) • Anti JO-1 (-)

  23. Transesophageal Echocardiography • There is no echocardiography evidence of endocardial vegetation on all four cardiac valves • Thickened anterior mitral valve with mild systolic proplase • Mild posterolaterally-directed mitral regurgitation • Mild tricuspid regurgitation • Normal ventricular size and systolic function • Ejection fraction 64%

  24. 1st Hospital Day • Patient was scheduled for BMA • CT Scan of the chest • Result: • INH 300 mg 1 tab OD • Rif – 400 mg 1 tab OD • PZA – 500 mg 3 tabs OD • Ethambutol – 400 mg 3 tabs OD

  25. 2nd Hospital Day • CXR PA Lateral view • Result • CD4 CD8 • Post Bone marrow aspiration biopsy

  26. 3rd Hospital Day • Vit A 2500 ml 2 tabs 4 x a day x 8 doses

  27. 4th Hospital Day • Bone marrow aspiration GS – No growth • Bone marrow aspiration biopsy – normal • Normal cellular component • Normal megakaryocytes, erythroid and myeloid cells • No abnormal tumor cells

  28. 5th – 7th Hospital Day • Afebrile

  29. 8th Hospital Day • Discharged • Take home medications c/o DOTS

  30. FINALDIAGNOSIS Miliary Tuberculosis

  31. Temperature Pattern

  32. CASE NO. 2 G. F.,a 64 year-old female Chief complaint: fever

  33. HISTORY OF PRESENT ILLNESS 3 weeks PTA intermittent fever (Tmax 38.8 0C) (+) loose watery stools x 5 days after taking Dulcolax generalized crampy abdominal pain

  34. HISTORY OF PRESENT ILLNESS admitted at Asian Hospital Dx: Diverticulitis, sigmoid, (confirmed by CT- scan), Infectious diarrhea and UTI given Metronidazole and Ciprofloxacin x 10 days pending urine C/S

  35. HISTORY OF PRESENT ILLNESS 1 week PTA recurrence of fever (Tmax 39 0C), chills (+) hypogastric pain, dysuria CBC: Hgb 11.8 Hct 0.35 wbc 9.3 seg 80 lym 11 mon 8 plt 533,000

  36. HISTORY OF PRESENT ILLNESS Urinalysis: rbc: 3-5 wbc: >150 bacteria: +1 fecalysis: color: greenish brown consistency: semi-formed rbc: 1-2/hpf wbc: 2-4/hpf ova/parasites: none

  37. HISTORY OF PRESENT ILLNESS 3 days PTA persistence of symptoms ID consult Dx: Diverticulitis vs UTI given Cotrimoxazole 2 days PTA urine C/S: 1.E.coli 25,000 cfu/mL resistant to Ciprofloxacin 2. Klebsiella pneumonia 15,000 sensitive to Ciprofloxacin ADMISSION

  38. REVIEW OF SYSTEMS No headache No alopecia, rash, photophobia No night sweats No oral ulcers No cough, colds, dyspnea No chest pain, palpitations (+) weight loss of 10 lbs No bleeding tendencies

  39. PAST MEDICAL ILLNESS (+) HPN – 5 months, on Losartan 50mg OD UBP 120-130/80 HBP 150/80 (-) DM, BA, PTB Post colonoscopy , November 2006 - normal Post appendectomy – 15 years old

  40. FAMILY HISTORY (+) HPN, CVA, CA (breast) – mother (+) DM – paternal side

  41. PERSONAL & SOCIAL HISTORY Non smoker Non alcoholic beverage drinker No history of travel

  42. PHYSICAL EXAMINATION Conscious, coherent, not in cardio-respiratory distress BP 120/70 CR 89bpm RR 18 T 37.7 0C Wt: 57kg Ht: 156cm BMI 23.4kg/m2 Pink palpebral conjunctivae, anicteric sclerae Moist buccal mucosae, non- hyperemic posterior pharyngeal walls, tonsils not enlarged Supple neck, no palpable cervical lymphadenopathies

  43. PHYSICAL EXAMINATION Symmetrical chest expansion, no retractions, clear lungs Adynamic precordium, AB 5th LICS MCL, no murmurs Flabby abdomen, normoactive bowel sounds, soft, non-tender, no hepatosplenomegaly, no CVA tenderness No edema, no cyanosis, pulses full and equal

  44. IMPRESSION Fever of Unknown Origin

  45. LABORATORY

  46. LABORATORY Urinalysis: rbc 3.4 WBC 6.3 epi cells 0.7 bacteria: 323.9 Urine C/S: no growth Fecalysis: color: brown consistency: soft Pus cells: 8-10/hpf mucus: moderate Ova/parasite: none Stool C/S: normal flora Blood C/S: no growth

  47. LABORATORY

  48. 2-D ECHO Normal left ventricular dimension with normal wall thickness, wall motion and contractility. Normal EF 65%. No preicardial effusion nor evidence of vegetation.

  49. CT SCAN OF THE CHEST Minimal fibrosis, both apices otherwise normal CT of the chest

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