LA CONSULTA SEMANAL

NOVIEMBRE 2000

CONSULTA

Postgrad Med 2000 Feb;107(2):259-62, 265-6 [Texto completo]
Fever without source in children. Recommendations for outpatient care in those up to 3.
Park JW
Department of Pediatrics, Texas Tech University Health Sciences Center, Odessa 79763, USA. pedojwp@tthsc8.odessa.ttuhsc.edu
It is the author's goal to reduce risk to a minimum in children with fever without source at a reasonable cost with guidelines that are practical for office-based physicians. Recommendations are as follows: All febrile infants and children up to 36 months of age who have toxic manifestations are to be hospitalized for parenteral antibiotic therapy after an expeditious evaluation of their condition that includes cultures of blood, urine, and cerebrospinal fluid. All febrile infants 7 days of age or less should be hospitalized for empirical antibiotic therapy after a complete evaluation for sepsis and meningitis has been done. Some low-risk febrile infants 8 to 28 days of age who appear well may be observed closely, either in hospital (with or without empirical antibiotic therapy) or as outpatients if the physician believes that close follow-up is ensured. Febrile infants 28 to 90 days of age should have an evaluation to determine whether they are in a low-risk group. Those not meeting low-risk criteria should be hospitalized for a complete "sepsis workup" and close observation, with or without empirical antibiotic therapy. Those who are considered low-risk can be treated as outpatients, as described, if close follow-up is ensured. No laboratory tests or antibiotics are needed in a child over 90 days of age who has a temperature of less than 39 degrees C (102.2 degrees F) without identifiable source. A return visit is recommended if the child's fever persists for more than 2 to 3 days or if the condition deteriorates. A child with a fever of 39 degrees C or above can also be treated as an outpatient without antibiotics if close follow-up is ensured. Otherwise, a WBC count or ANC should be done. In those whose WBC count is 15,000/mm3 or more or whose ANC is 10,000 cells/mm3 or more, a blood culture should be done, and pending results, a single injection of ceftriaxone, 50 mg/kg, should be given.
Publication Types:
  Review
  Review literature
  Review, tutorial

Emerg Med Clin North Am 1999 Feb;17(1):97-126, viii-ix
Evaluation of the infant with fever without source: an evidence based approach.
Slater M, Krug SE
Division of Emergency Medicine, Northwestern University Medical School, Chicago, Illinois, USA.
The infant with fever without an obvious source upon physical examination offers a challenging clinical problem. A combination of detailed history, physical examination, and selected laboratory tests allows the clinician to discern which infants are at lower risk for bacterial illness. Implications for management and future research are discussed herein.
Publication Types:
  Review
  Review, tutorial

Clin Infect Dis 1999 Feb;28(2):341-5
Human immunodeficiency virus-associated fever of unknown origin: a study of 70 patients in the United States and review.
Armstrong WS, Katz JT, Kazanjian PH
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0378, USA.
To characterize the clinical features of human immunodeficiency virus (HIV)-associated fever of unknown origin (FUO) in the United States, we performed a retrospective analysis of cases that fulfilled specific criteria (published by Durack and Street in 1991) at two medical centers in the United States between 1992 and 1997. Seventy cases met criteria for HIV-associated FUO; the mean CD4 cell count was 58/mm3, and the mean duration of fever was 42 days. A cause of FUO was found in 56 of the 70 cases; 43 were of a single etiology, and in 13 cases multiple conditions were established. The most common diagnoses were disseminated Mycobacterium avium infection (DMAC; 31%), Pneumocystis carinii pneumonia (13%), cytomegalovirus infection (11%), disseminated histoplasmosis (7%), and lymphoma (7%). In this United States series, FUO occurs most often in the late stage of HIV infection, individual cases often have multiple etiologies, and DMAC is the most common diagnosis.
Publication Types:
  Review
  Review of reported cases

MSMR 1998;v03-n4 [Texto completo en formato PDF]
Hospitalizations Among Active Duty Soldiers for 'Fevers of Unknown Origin' Surveillance Trends

If the rigor of diagnostic evaluations of febrile soldiers were to decline over time, or if soldiers were to acquire etiologically obscure ( emerging ) infectious diseases in clus-ters or at progressively higher rates, then hospital-izations with discharge diagnoses of fever of unknown origin might be expected to increase. This report assesses trends and characteristics of recent hospitalizations of soldiers with fevers of unknown origin. In contrast, at MTF A after September 1994, the FUO rate was 4.8 per month, there were 19 months with three or more cases, nearly half (45.9%) of cases were among Privates/ E- 1, and the mean length of a hospitalization was 1.2 days. Thus, at MTF A after October 1994 compared to before, FUO hospitalizations affected lower rank-ing soldiers, were nearly four- times more frequent, and were approximately one- tenth as long. 01 11 Ft Sill Ft McClellan Ft Leonard Wood Ft Benning Figure III. ARD surveillance rates, submitted by Army TRADOC posts ARD Surveillance Update Legend ARD Rate = (ARD cases / Trainees) 100 SASI* = ARD Rate Strep Rate Heat Injuries Cold Injuries Reporting MTF/ Post** Heat Exhaustion Heat Stroke Frostbite Hypothermia Immersion Unspecified

An Med Interna 1997 Nov;14(11):585-92
[Fever of unknown origin in internal medicine. The experience of Spanish authors over 20 years].
Ramos Rincon JM, Ramos Guevara R, Herrero Huerta F
Servicio de Medicina Interna, Hospital General Universitario Morales Meseguer, Murcia.
The diseases responsible of fever of unknown origin (FUO) have changed in the last years. With the object of study the etiologic spectrum and diagnostic attitude in the FUO in a national level in the last 25 years, we has revised 14 articles of FUO realized in Internal Medicine published from 1970 to 1995, without aids patients. We use MEDLINE and Indice Medico Espanol to search the publications about FUO. In 14 articles, 914 cases of FUO was evaluated, the infection was the principal cause (41.2%), followed by tumor (19.2%) and collagenoses/vasculitis (13.7%). In the infection group, the disease more frequent was the tuberculosis (134/377) (35.5%) follow by brucellosis (15.6%) y abscesses (11.6%). Half of malignancy group was due to lymphoma. Systemic lupus erythematous, polyarteritis nodosa and temporal arteritis were caused of FUO in 28.8%, 21.6% y 20% of collagenoses/vasculitis group. In the miscellaneous group emphasized granulomatous diseases (38.8%) (including sarcoidosis, idiopathic granulomatous hepatitis and chronic granulomatous disease). The improve of diagnostic procedures has conditioned a change of spectrum of the diseases, with a decrease of infectious causes (as brucellosis or salmonellosis) and increase or neoplasia and collagenoses/vasculitis (except lupus).
Publication Types:
  Review
  Review, tutorial

Clin Infect Dis 1997 Sep;25(3):551-73
1997 guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. Infectious Diseases Society of America.
Hughes WT, Armstrong D, Bodey GP, Brown AE, Edwards JE, Feld R, Pizzo P, Rolston KV, Shenep JL, Young LS
Fever and Neutropenia Guideline Panel, Infectious Diseases Society of America, Alexandria, Virginia, USA.
This is the first in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of these guidelines is to provide assistance to clinicians when making decisions on treating the conditions specified in each guideline. The targeted providers are internists, pediatricians, and family practitioners. The targeted patients and setting for the fever and neutropenia guideline are hospitalized individuals with neutropenia secondary to cancer chemotherapy. Panel members represented experts in adult and pediatric infectious diseases and oncology. The guidelines are evidence-based. A standard ranking system was used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary, algorithms, and tables highlight the major recommendations. The guideline will be listed on the IDSA home page at http://www.idsociety.org.
Publication Types:
  Guideline
  Practice guideline
  Review
  Review, academic

Lancet 1997 Aug 23;350(9077):575-80 [Texto completo]
Fever of unknown origin.
Arnow PM, Flaherty JP
Department of Medicine, University of Chicago, University of Chicago Hospitals, IL 60637, USA.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Lancet 1997 Nov 8;350(9088);1401-2
  Comment in: Lancet 1997 Dec 13;350(9093):1782

Clin Infect Dis 1997 Mar;24(3):291-300; quiz 301-2
Fever of unknown origin in adults.
Hirschmann JV
Seattle Veterans Affairs Medical Center, Washington 98108, USA.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Clin Infect Dis 1998 Feb;26(2):534-5

Am Fam Physician 1996 Dec;54(8):2503-12
Fever without source in infants and young children.
Daaleman TP
University of Kansas Medical Center, Kansas City, Kansas.
Febrile infants and young children pose a challenge to primary care physicians because the clinical appearance of children who present with fever without source that is related to a viral illness may be similar to the appearance of those with occult bacteremia. The evaluation of the febrile infant and child comprises a comprehensive history, a thorough physical examination and judicious use of laboratory studies. The information derived from this evaluation will help clinicians with the two key management decisions that face physicians caring for this vulnerable population: the initiation and use of antimicrobial therapy, and inpatient versus outpatient management. Although no optimal diagnostic and therapeutic schema exists, physicians should take a structured and rational approach to these patients, depending on their own clinical experience and interpretation of the literature on this topic.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Am Fam Physician 1996 Dec;54(8):2362-4, 2366

Arch Intern Med 1996 Mar 25;156(6):618-20
Long-term follow-up of patients with undiagnosed fever of unknown origin.
Knockaert DC, Dujardin KS, Bobbaers HJ
Department of General Internal Medicine, Gasthuisberg University Hospital, Leuven, Belgium.
BACKGROUND: A casual diagnosis cannot be established in 10% to 25% of the patients who are studied for fever of unknown origin (FUO). The long-term clinical outcome of these patients cannot be inferred from the literature. This study describes the results of a 5-year follow-up of 61 patients studied for FUO and discharged from the hospital with no causal diagnosis being established. METHODS: Patients meeting the classic criteria for FUO who were studied in the 1980s and discharged from the hospital without a casual diagnosis were followed up for at least 5 years or until death. Follow-up was performed by review of the patients' medical records or by consulting the treating physician and occasionally the patients themselves. The final diagnosis, clinical course (resolution of the fever and required treatments), and morality rate were studied. RESULTS: Of a cohort of 199 patients with FUO, 61 individuals (30%) were discharged from the hospital without a final diagnosis being established. A definite diagnosis could be established in 12 cases, mostly (eight of 12) within 2 months after discharge. Thirty-one individuals became symptom free during hospitalization or shortly following discharge. Eighteen patients had persisting or recurring fever for several months or even years after discharge, but 10 of them were considered to be finally cured. Four patients were treated with corticosteroids and six patients required intermittent therapy with nonsteroidal anti-inflammatory agents. Six patients died, but the cause of death was considered to be related to the disease that caused FUO in only two cases. CONCLUSION: No single disease, particularly not tuberculosis, was found to be a cause of undiagnosed FUO. Most cases resolved spontaneously, and corticosteroids were seldom required. Most symptomatic patients could be treated with nonsteroidal anti-inflammatory drugs. The mortality rate in patients with undiagnosed FUO who were followed up for 5 years or more was only 3.2%.

Infect Dis Clin North Am 1996 Mar;10(1):93-9
Fever in the elderly.
Norman DC, Yoshikawa TT
West Los Angeles Veterans Affairs Medical Center, California, USA.
Fever in elderly persons is only one clinical presentation that can be used to assist the clinician at suspecting a serious disease, such as an infection. Infections, like all other illnesses in the geriatric patient, may occur with a variety of nonspecific, atypical, nonclassic, and unusual manifestations. The clinician caring for elderly patients should be aware of these nonclassical presentations of infections in this age group. Unexplained change in functional capacity, worsening of mental status, weight loss or failure to thrive, weakness and fatigue, falls, and generalized pain are only some of the clues that may aid the clinician in considering infection in elderly persons. Key concepts of fever in older adults are: Fever generally indicates presence of serious infection, most often caused by bacteria. Fever may be absent in 20%-30% of elderly patients harboring a serious infection. Criteria for fever in elderly patients should also include an elevation of body temperature of at least 2 degrees F from baseline values. FUO in elderly persons is caused by infections (30%-35%), CTD (25%-30%), and malignancies (15%-20%) in the majority of cases.
Publication Types:
  Review
  Review, tutorial

Infect Dis Clin North Am 1996 Mar;10(1):149-65
Fever in patients with HIV infection.
Sullivan M, Feinberg J, Bartlett JG
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Fever is a common sign during the course of HIV infection, usually represents a superimposed opportunistic infection, and is almost always a treatable condition. Proper management generally requires detection of the underlying cause, and the diagnostic evaluation is largely driven by the clinical symptoms, associated conditions such as injection drug use, and stage of disease based largely on the absolute CD4 cell count. This article provides guidelines for the management of fever in the patient with HIV infection.
Publication Types:
  Review
  Review, tutorial

Infect Dis Clin North Am 1996 Mar;10(1):111-27
Fever of unknown origin.
Cunha BA
Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, USA.
Fever of unknown origin (FUO) is defined as a temperature elevation of 101 degrees F (38.3 degrees C) or higher for 3 weeks or longer, the cause of which is not diagnosed after 1 week of intensive in-hospital investigation. This article discusses the causes, diagnosis, and treatment of FUOs.
Publication Types:
  Review
  Review, tutorial

Clin Infect Dis 1995 Dec;21(6):1492-4
Inflammatory pseudotumor presenting as fever of unknown origin.
Fisher RG, Wright PF, Johnson JE
Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Inflammatory pseudotumor (IPT) is an uncommon benign neoplasm of uncertain etiology that classically has been associated with the lung, where it is generally asymptomatic. In recent years, IPT has been increasingly recognized in other sites. Hepatic, abdominal, and pelvic IPTs produce a spectrum of nonspecific symptoms including fever, malaise, anemia, and weight loss. Because prolonged fever is a prominent feature of extrapulmonary IPT, patients with this condition may first come to the attention of specialists in infectious diseases. We describe an illustrative case of pelvic IPT and discuss its presentation, diagnosis, and treatment; we also suggest that infectious disease specialists should be familiar with this entity as a possible diagnosis for patients with fever of unknown origin.
Publication Types:
  Review
  Review of reported cases

Med Clin (Barc) 1995 Nov 11;105(16):615-6
[Fever of unknown origin in HIV infection. New facets of an old problem].
Barbado Hernandez FJ, Pena Sanchez de Rivera JM
Publication Types:
  Editorial
  Review
  Review, tutorial
Comments:
  Comment in: Med Clin (Barc) 1996 Jun 29;107(5):198

Pediatr Clin North Am 1995 Oct;42(5):999-1015
Fever of unknown origin.
Miller ML, Szer I, Yogev R, Bernstein B
Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA.
The causes of fever in a child can vary from minor brief illnesses to life-threatening infectious, malignant, or autoimmune diseases. The physician often has to evaluate children with fevers of as yet undiagnosed cause lasting fewer than 2 weeks, in whom it is important to determine whether localizing findings are present. Fever without localizing signs and fevers complicating chronic disease and resulting from specific localized infection are considered in the sections concerning infectious causes, immunodeficiency diseases, and rheumatic diseases. The diagnostic and therapeutic approaches to the child with both prolonged fever and fever of unknown origin are then discussed, with emphasis on rheumatic diseases.
Publication Types:
  Review
  Review, tutorial

Am Fam Physician 1994 Dec;50(8):1717-27
The role of scintigraphy in the evaluation of fever of unknown origin.
Weissman AF, Fig LM, Sisson J, Seow A, Shapiro B
Division of Nuclear Medicine, University of Michigan Medical Center, Ann Arbor.
Nuclear medicine imaging techniques are an important adjunct to other currently used modalities in the evaluation of patients with fever of unknown origin. Bone scanning performed with technetium-labeled phosphonate agents may identify osteomyelitis when plain radiography fails and may disclose sites of joint
inflammation or unsuspected osseous tumor metastasis. Indium-labeled autologous leukocytes localize at sites of inflammation in the same manner as unlabeled leukocytes. Gallium citrate accumulates in areas of inflammation and in some tumors, most notably lymphomas. In most cases, scintigraphy is best used to determine the location of a lesion rather than to specifically identify the pathologic process.
Publication Types:
  Review
  Review, tutorial

J Am Geriatr Soc 1993 Nov;41(11):1187-92
Fever of unknown origin in elderly patients.
Knockaert DC, Vanneste LJ, Bobbaers HJ
University Hospital Gasthuisberg, Catholic University of Leuven, Belgium.
OBJECTIVE: To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients. DESIGN: Subgroup analysis of a prospectively collected case series followed more than 2 years. SETTING: General Internal Medicine Service based at University hospital, Leuven, Belgium. PATIENTS: Forty-seven consecutive patients, older than 65 years, meeting the classic criteria of fever of unknown origin. MEASUREMENTS: The final diagnosis established and the clinical value of diagnostic procedures. RESULTS: Infections, tumors and multisystem diseases (encompassing rheumatic diseases, connective tissue disorders, vasculitis including temporal arteritis, polymyalgia rheumatica, and sarcoidosis) were found in 12 (25%), six (12%) and 15 patients (31%), respectively. Drug-related fever was the cause in three patients (6%), miscellaneous conditions were found in five patients (10%), and six patients (12%) remained undiagnosed. Microbiologic investigations were diagnostic in eight cases (16%), serologic tests yielded one diagnosis, immunologic investigations had a diagnostic value in four cases, standard X-rays yielded a diagnostic contribution in 10 cases, ultrasonography and computed tomography were diagnostic in 11 cases, Gallium scintigraphy had a diagnostic contribution in 17 cases, and biopsies yielded the final diagnosis in 18 cases. CONCLUSIONS: Multisystem diseases emerged as the most frequent cause of fever of unknown origin in the elderly, and temporal arteritis was the most frequent specific diagnosis. Infections, particularly tuberculosis, remain an important group. The percentage of tumors was higher in our elderly patients than in the younger ones but still clearly lower than in other recent series of FUO in adults. The number of undiagnosed cases was significantly lower in elderly patients than in younger individuals (P < or = 0.01). The investigation of elderly patients with FUO should encompass routine temporal artery biopsy and extensive search for tuberculosis if the classic tests such as blood count, chemistry, urinalysis, cultures, chest X-rays, and abdominal ultrasonography do not yield any clue. Gallium scintigraphy should be considered as the next step and not as a last-resort procedure.
Publication Types:
  Review
  Review, multicase