Leptospirosis. Description of a clinical case and review of the literature

Leptospirosis is a world-wide diffused anthropozoonosis due to many strains of Leptospira. Initial symptoms may be mild, although in many cases severe systemic symptoms, including high fever, hypotension, etc. may be present since the beginning. In these latter circumstances, the diagnosis of leptospirosis can be very difficult because of the complexity of clinical picture especially when the history is lacking or incomplete. A case report of a 45 year-old man admitted to the hospital after severe jaundice and fever of unknown origin associated to altered mental status, renal failure and hypoxemia is presented. Because of the presence of septic shock and severe respiratory failure, the patient was transferred to the intensive care unit. The diagnostic hypothesis, based on clinical history, was confirmed by laboratory tests (leptospiral IgM antibodies detection). Therapeutical approach with the use of selected antibiotics (penicillin 24,000,000 U for day) and therapy of septic shock led to improvement of the patient's clinical conditions who was then transferred to a regular medical ward.     

Granulomatous hepatitis in three children due to cat-scratch disease without peripheral adenopathy. An unrecognized cause of fever of unknown origin

OBJECTIVE: To report the clinical experience of three patients with fever of unknown origin ultimately diagnosed as having cat-scratch granulomatous hepatitis in the absence of peripheral adenopathy. DESIGN: Case-control study. SETTING: Referral center at university-based referral practice. PATIENTS: Three children with fever of unknown origin. Follow-up following presentation was 6 months for each patient. MEASUREMENT AND RESULTS: All three patients with fever of unknown origin were diagnosed radiographically to have multiple hepatic defects. The defects were shown histologically to be granulomatous. Two of the three patients had Warthin-Starry staining bacilli in the granulomas consistent with a diagnosis of Afipia felis. All three had positive cat-scratch skin test results. CONCLUSIONS: Cat-scratch disease in the absence of peripheral adenopathy is a heretofore unrecognized cause of fever of undetermined origin and may account for a small, but significant, percentage of children presenting with it.     

Dissecting aortic aneurysm manifested as fever of unknown origin

A patient with a dissecting aneurysm of the ascending aorta had fever of unknown origin. Although his clinical picture included a number of classical features of his disorder, these were initially misinterpreted, largely because fever was the patient's chief complaint. Polymorphonuclear leukocytes sequestered within the aortic hemagen as they disintegrated. This case emphasizes the protean nature of the dissecting aortic aneurysm, adding yet another distinct clinical manifestation, fever of unknown origin, with which it may be associated.     

Immunohistochemical localization of the spermadhesin AWN-1 in the equine male genital tract

Takayasu's arteritis rarely presents with fever of unknown origin. We describe a 14-year-old girl who was admitted with a 2-month history of fever of unknown origin associated with vague pain in her left upper arm. The constitutional symptoms responded to a trial of steroid therapy for suspected collagen-vascular disease, but flared up when the dose was tapered. An asymmetric radial pulse was recognized incidentally during follow-up examination; diagnosis of Takayasu's arteritis was confirmed by Duplex ultrasonography and angiography. Takayasu's arteritis must be considered when evaluating children with fever of unknown origin, especially those with a positive family history. Careful assessment of the peripheral vascular system with better interpretation of limb symptoms should allow early, appropriate treatment to prevent irreversible vascular damage.     

Gallium-67 (Ga-67) scintigraphy in tuberculosis and Mycobacterium avium-M. intracellulare infections in patients with HIV infections

BACKGROUND: Diagnosis of mycobacterioses in HIV infected patients is sometimes difficult because of atypical findings. The aim of this study was to assess the utility of gallium scintigraphy in diagnosis of AIDS related mycobacterioses in patients with fever of unknown origin. PATIENTS AND METHODS: We retrospectively reviewed the scans of 220 HIV(+) patients with fever (176 males [80%] and 44 females) who were evaluated with conventional diagnostic procedures at least of a week before. RESULTS: Gallium scintigraphy was positive in 114 patients (51%) and negative in 106 (49%). Mycobacteria were isolated in 83 patients (38%), 75 of these patients (90%) had a positive scintigraphy (sensitivity 90%; specificity 71%). Positive predictive value was 66% and negative predictive value was 92%. Mycobacterium avium-M. intracellulare (MAI) and M. tuberculosis were diagnosed in 22 (29%) and 53 (71%) HIV(+) patients, respectively. Seventy one (94%) of 75 patients with mycobacterioses had gallium uptake in at least two localizations. CONCLUSIONS: 67Ga scintigraphy is very useful in HIV(+) patients with fever of unknown origin. A negative gallium scintigraphy makes unlikely the diagnosis of mycobacterioses.     

Utility of scintigraphic methods in patients with fever of unknown origin

BACKGROUND: We assessed the utility of scintigraphy with indium 111-labeled polyclonal human IgG scintigraphy in patients with fever of unknown origin that fulfilled the criteria of temperature of 38.3 degrees C or more for at least 3 weeks and no diagnosis during 1 week of hospital admission. We compared the utility of this technique with results of scintigraphic techniques reported in the literature. METHODS: Data for all patients seen at our university hospital in whom 111In-IgG scanning was performed were analyzed and checked for the criteria for fever of unknown origin. The literature on the utility of scintigraphic techniques in patients with fever of unknown origin was reviewed. RESULTS: We studied 24 patients with fever of unknown origin. In 13 patients, focal 111In-IgG accumulation was observed. In nine (38%) of those, the positive 111In-IgG scintigram led to the final diagnosis; in the other four patients (17%), the scintigraphic findings were not helpful. In the 11 patients with negative 111In-IgG scans, extensive diagnostic workup produced no infection as the final diagnosis in nine patients (38%), one had an abscess in a renal cyst that was detected several months later, and in the other the cause of fever was an infected intravenous line. The overall sensitivity and specificity of 111In-IgG scintigraphy were 81% and 69%, respectively. The positive predictive value was 69% and the negative predictive value was 82%. CONCLUSIONS: Our results show that 111In-IgG scintigraphy significantly contributed to the diagnostic process in patients with fever of unknown origin. A positive scan increased the likelihood of finding the cause of the fever, and a negative scan ruled out an inflammatory component with a high degree of certainty. These data compare favorably with data in the literature concerning other radiopharmaceuticals; a larger prospective evaluation of this technique is indicated.     

Ergotamine-induced rectal stenosis in a patient with long-term migraine

A 36 year old woman was admitted to our hospital for treatment of a high-grade rectal stenosis of unknown origin. She had a history of migraine going back 10 years. On intensive questioning she admitted using up to 5 ergotamine-containing suppositories a day. On the basis of history and clinical investigations the rectal stenosis must be connected with the abuse of ergotamine-containing suppositories. This case demonstrates that patients with an unexplained rectal syndrome should be asked for analgetics-containing suppositories specifically. Only discontinuation of treatment in time can preserve the patient from development of a rectal stenosis. In case of a rectal stenosis surgical treatment can be avoided by means of endoscopic controlled dilatation.     

Use of glucagon in the treatment of severe contractile insufficiency of the myocardium

Glucagon hydrochloride has been used to treat severe contractile insufficiency of the myocardium. The drug was administered to cardiopathic patients who had been admitted to the intensive care unit. Results in the various groups examined were satisfactory, particularly in cases of patients with valve diseases and with chronic pulmonary heart and cardiac insufficiency recalcitrant to digitalis therapy. No important side-effects were noted.     

Agrobacterium radiobacter bacteremia in a patient with chronic obstructive pulmonary disease

Agrobacterium radiobacter is a gram-negative bacillus, which is recognized as an emerging opportunistic human pathogen. To our knowledge, there have been only 25 cases of A. radiobacter bacteremia reported. In most of these, A. radiobacter was associated with long-term indwelling plastic central venous catheters. We describe a 78-year-old man who had a history of chronic obstructive pulmonary disease with long-term use of a corticosteroid. He was admitted to the China Medical College Hospital with pneumonia caused by Serratia marcescens. His general condition gradually improved after initiation of appropriate treatment. Unfortunately, he developed A. radiobacter bacteremia while hospitalized in the medical intensive care unit. With the onset of this infection, the patient had a high fever, leukocytosis, raised C-reactive protein level, and positive blood cultures for A. radiobacter. A central venous catheter-related infection was suspected because of redness and localized tenderness at the catheter site. The patient gradually recovered after removal of the catheter and appropriate antimicrobial treatment with latamoxef 1.5 g intravenously every 8 hours for 10 days.     

A clinicopathological study of infections in burn patients and importance of biopsy

Malignant peritoneal mesothelioma is a rare disease. The most frequent initial symptoms are abdominal pain, anorexia, marked weight loss and ascites. Clinical presentation as fever of unknown origin is exceptional. We report three cases diagnosed over a period of twenty years, two cases as fever of unknown origin and the third as prolonged fever. Three patients died within two months after diagnosis and prolonged fever was the clinical manifestation at the onset of the disease. It is important to take malignant peritoneal mesothelioma in the differential diagnosis of fever unknown origin.     

Metastasis of an adenocarcinoma of unknown origin to mediastinal lymph nodes, and transient regression

A 67-year-old woman was admitted to our hospital because of fever. Chest roentgenogram showed an enlargement of mediastinal lymph nodes. Despite thorough examination, no definite diagnosis could be made. The mediastinal lymph nodes got smaller over the next 3 weeks and a chest roentgenogram taken 4 months later showed no mediastinal lymphadenopathy. The mediastinal lymphadenopathy and fever recurred 5 months later. She underwent thoracotomy and the mediastinal lymph nodes were excised. Microscopic examination of pretracheal lymph node specimens showed invasion of poorly differentiated adenocarcinoma associated with abundant tumor-infiltrating lymphocytes. The other lymph nodes showed sarcoid reaction. Although she has been followed for one year and 11 months, no primary site of the cancer has been found. Metastasis of cancer of unknown origin to mediastinal lymph nodes is extremely rare. It is also interesting that the lymph node swelling diminished spontaneously. The tumor-infiltrating lymphocytes and sarcoid reactions may have been immunological responses to the cancer and may have caused the transient regression.     

A surgical case of achalasia with empyema

A 57-year-old man who had been complicated with achalasia for thirty years was admitted because of back pain and low grade fever. Chest X-p and Chest CT showed consolidation in the left lower lung field. His respiratory condition was diagnosed as lung abscess preoperatively. After systemic chemotherapy, surgical management was done for both achalasia and this inflammatory respiratory disease. In the operation by left thoracotomy, it was revealed that this case had empyema, not lung abscess. Thus decortication of left lung and esophagomyotomy were performed simultaneously. In the treatment of achalasia, respiratory complications due to aspiration may appear. In addition, it is sometimes difficult to distinguish empyema from lung abscess preoperatively. Therefore much care should be taken during operation in order to treat these respiratory diseases.     

Clinical thinking and decision making in the practice. A patient with fever of unknown origin

A 75-year-old woman was admitted because of fever of unknown origin (FUO). In the year before the current admission she developed myalgias and was treated for polymyalgia rheumatica with low-dose prednisone. Her complaints persisted and prednisone was discontinued. Five months before the present admission she developed fever (37.7-38.9 degrees C), malaise, fatigue and occipital headache. Laboratory tests showed an elevated erythrocyte sedimentation rate (98 mm in the first hour) and a severe hypochromic, slightly microcytic, anaemia. Although a recent temporal artery biopsy was negative, a second biopsy was taken which showed giant cell arteritis. The patient was treated with high-dose prednisone (60 mg daily) and made a full recovery. It is emphasized that temporal arteritis is a common cause of FUO in the elderly.     

Comparison of mortality of patients with heart attacks admitted to a coronary care unit and an ordinary medical ward

During a 32-month period 2047 patients suspected of having heart attacks were admitted to hospital and were followed up prospectively. Out of 1480 eventually found to have definite or probable myocardial infarction, 483 had initially been admitted to an ordinary medical ward because of the shortage of coronary care unit (CCU) beds. More patients aged over 65 had been admitted to a ward than to a CCU, and more patients aged 65 or less had been admitted initially to a CCU. Within each age group, however, patients admitted initially to a CCU were clinically similar to those admitted initially to a ward. There was a higher proportion of successful resuscitations among patients admitted to a CCU, but there was no significant difference in mortality in either age group between patients admitted to a CCU and a ward.     

Oesophageal acid clearance in patients with severe reflux oesophagitis

Previous studies examining oesophageal acid clearance have employed a variety of techniques to induce or simulate acid reflux. Clearance abnormalities have been deduced from abnormal standard motility studies, barium radiology or from 24-h pH recordings. In this study a 24-h pH and oesophageal motility recording system was used to study naturally occurring acid reflux episodes in control subjects and in two groups of patients with severe acid reflux disease (erosive oesophagitis and oesophageal stricture). Acid clearance was compared between the subject groups. Patients with oesophageal stricture were found to have poor oesophageal peristaltic ability and particularly poor oesophageal acid clearance. Those with erosive oesophagitis had normal peristaltic swallowing but abnormal acid clearance. This study has characterized, for the first time, the abnormalities in acid clearance during naturally occurring acid reflux episodes in patients with severe reflux disease. A more complete understanding of these clearance abnormalities could influence future medical and surgical strategies in the management of severe gastro-oesophageal reflux disease.     

The impact of a high-dependency unit on the workload of an intensive care unit

While there has been recent support for high-dependency unit development, there are few data reporting the impact of such development on existing critical care facilities. Therefore the aim of this study was to examine the workload and capacity constraints of an adult general intensive care unit before and after the development of an adjacent high-dependency unit. Following the opening of the high-dependency unit, the total number of patients admitted increased by 49%. On the high-dependency unit, more elderly patients were admitted for longer and more frequently following midweek elective surgery. On the intensive care unit, patients' initial severity of illness was lower and their duration of admission decreased; fewer patients were admitted directly from the general wards. The financial benefits of high dependency care may be eroded by the increased use of the critical care services.     

Intermittent fever of unknown origin

HISTORY AND CLINICAL FINDINGS: A 58-year-old woman was admitted because of intermittent fever for 4 weeks accompanied by slowly developing anaemia and increase in inflammatory parameters. She was being treated for hypertension with atenolol and chlorthalidone, but until 6 weeks before the onset of the described symptoms she had only taken the beta blocker, at which time the diuretic was added because the hypertension was inadequately controlled. Other than slightly impaired general condition and nocturnal fever up to 39.5 degrees C physical examination was unremarkable. INVESTIGATIONS: She had a normochromic normocytic anaemia and the erythrocyte sedimentation rate and C-reactive protein were clearly elevated. Other biochemical tests and blood cultures as well as serological and immunological tests were negative. Bone marrow biopsy showed nonspecific reactive changes. The chest radiograph, lung scintigraphy and abdominal ultrasound were unremarkable. TREATMENT AND COURSE: There was no further fever after the antihypertensive medication had been discontinued. The patient's general condition rapidly improved and all biochemical tests became normal. The lymphocyte transformation test demonstrated stimulation by chlorthalidone. CONCLUSION: Drug fever, in this case due to a sulphonamide derivative, should always be considered in the differential diagnosis of fever of unknown aetiology. No previous case of hypersensitivity reaction to chlorthalidone has been found on a search of the literature.     

11C]beta-CIT-FE, a radioligand for quantitation of the dopamine transporter in the living brain using positron emission tomography

Patients with gastrointestinal hemorrhage are frequently admitted to critical care units, in large part to be observed for signs of hemodynamic instability. All patients admitted with gastrointestinal bleeding to our medical intensive care unit over a 1-year period (n=108) were retrospectively reviewed to determine the incidence of hemodynamic instability. In an elderly patient population with predominantly nonvariceal bleeding, only 13% of those admitted had documented hypotension that led to an intervention. Only 7% had clinically significant hypotension after the first 5 hours of admission. Admission clinical criteria were analyzed by multivariate analysis but could not reliably predict patients at increased risk for hemodynamic instability. However, patients without significant comorbid illness who have been endoscopically shown to have a low-risk lesion can be considered for early transfer to a regular bed after a short period of close observation. This could lead to better resource utilization and cost savings without jeopardizing patient care.     

Septic shock with coma revealing typhoid fever

BACKGROUND: Typhoid fever may be difficult to distinguish from malaria. Septic shock, encephalopathy and leukopenia are common features of both diseases. CASE REPORT: A 20-year-old South Korean woman was admitted to the intensive care unit with coma and shock. Vomiting and abdominal pain were followed by headache, prostration, fever and diarrhea. Leukocytopenia, lymphocytopenia, thrombocytopenia, rhabdomyolysis and hepatitis were present. Clotting tests were normal. The thick peripheral blood film was negative. Salmonella typhi was isolated from 6 blood cultures. Treatment associated ceftriaxone 4 g per day for 5 days, colloid and crystalloid fluids and dopamine. The patient was discharged 2 weeks later. DISCUSSION: Typhoid fever should be considered as a diagnosis in patients with sepsis who come from endemic zones. Abdominal symptoms, prolonged fever, coma and delayed headache are particularly contributive signs. Specific treatment should be instituted.     

Occult fever in surgical intensive care unit patients is seldom caused by sinusitis

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.