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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 11  |  Issue : 4  |  Page : 137-140

Pyrexia of unknown origin: A diagnosis and treatment challenge in a resource-limited setting


1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Nursing, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication16-Mar-2017

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Nigeria
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DOI: 10.4103/1858-5000.202359

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  Abstract 

The term pyrexia of unknown origin (PUO) was first described by Petersdorf and Beeson in 1961. It is characterized by a temperature of more than 38.3°C on several occasions lasting for more than 3 weeks or for more than 1 week of inpatient investigation. The etiology of PUO is extensive but could be broadly classified into infectious and noninfectious causes. Infection accounts for 34% of cases; the case of a 6-month-old boy who presented with fever of 2 months duration is reported. He had series of investigations without the etiology identified. Furthermore, he was placed on empiric antibiotics on admission but the fever persisted; however, he was discharged after 3 weeks; and while on follow-up visit, the fever resolved. This report highlights how bizarre PUO may present.

Keywords: Antibiotics, child, fever, investigations, pyrexia of unknown origin


How to cite this article:
Aliyu I, Ibrahim ZF. Pyrexia of unknown origin: A diagnosis and treatment challenge in a resource-limited setting. Sudan Med Monit 2016;11:137-40

How to cite this URL:
Aliyu I, Ibrahim ZF. Pyrexia of unknown origin: A diagnosis and treatment challenge in a resource-limited setting. Sudan Med Monit [serial online] 2016 [cited 2017 Apr 14];11:137-40. Available from: http://www.sudanmedicalmonitor.org/text.asp?2016/11/4/137/202359




  Introduction Top


The term pyrexia of unknown origin (PUO) was first described by Petersdorf and Beeson in 1961.[1],[2] It is characterized by a temperature of more than 38.3°C on several occasions lasting for more than 3 weeks or for more than 1 week of inpatient investigation.[3],[4] The etiology of PUO is extensive but could be broadly classified into infectious and noninfectious causes. Infection accounts for 34%[5] of cases. Common presentation of PUO includes atypical presentation of common infectious agent such as tuberculosis and Epstein-Barr viral infection while uncommon organisms which are not routinely sought for in our investigative search such as catch-scratch disease may also be implicated whereas, noninfectious causes include atypical presentations of diseases such as collagen vascular diseases and other connective tissue disorders, neoplasm, and endocrine diseases.[6] This could pose a diagnostic challenge in a setting with limited investigative resources.[3] Therefore, this communication highlights the travails of a 6-month-old boy who had fever for 2 months without any identifiable cause and persisted despite series of antibiotics but later resolved after discharge.


  Case Report Top


A 6-month-old boy presented with fever of 2 months and this was of high grade; however, there was no history of convulsion, vomiting or diarrhea and no history of a cough or difficulty with breathing; the physical examination was not remarkable except for the documented fever which hovered between 38.5°C and 39°C. He had series of investigations; the full blood count showed leukocytosis with neutrophilia and erythrocyte sedimentation rate was also persistently elevated; the urinalysis and urine culture were not remarkable. Blood cultures on two occasions grew Staphylococcus aureus and Enterococcus faecalis, respectively. Their sensitivity patterns were established and he was placed on appropriate antibiotics, which also included vancomycin, while on vancomycin, he developed generalized redness of the skin (Redman syndrome), for which the medication was withheld, despite these antibiotics, fever persisted. The chest X-ray, lumbar puncture and echocardiography reports were not remarkable. After 3 weeks on antibiotics without resolution of fever, the drugs were withheld for 3 days but fever persisted and all investigations were repeated; However the blood culture became negative while the thyroid function test was normal. At this point, the parents were exhausted and requested for discharge; parents were adequately counseled to ensure compliance with instructions. He was discharged on oral medication (cefixime) and was followed up on short appointment visits. The parents were taught how to take and document the patient's temperatures, which were reviewed on every follow-up visit. Fever subsequently subsided on the 3rd week after discharge.


  Discussion Top


Fever is elevation of core body temperature as a result of a reset of the hypothalamic temperature regulatory thermostat; it is body's response to stress such as trauma and infection and one of the body's defenses against microbial inversion.[7] However, fever could be a useful indicator of benign and as well as a lethal medical disorder, and a common indication for hospital visit in children; this is because infection such as malaria is still prevalent in Nigeria [8] and the “fever phobia” whereby caregivers associate it with the risk of neurologic damage is still rife.[9] This constitutes a huge burden on the health-care system. Although it is common practice for caregivers in resource-limited settings to institute home management for fever [10] and those who fail to respond present late to the hospital, this practice also involves the indiscriminate use of antibiotics, hence increasing the risk of antibiotic resistance. More worrisome and challenging is treating cases that fail to respond to conventional therapy. Therefore, managing PUO is challenging where diagnostic test is limited. Our case initially had a positive blood culture on two occasions but failed to respond to the conventional medications based on the sensitivity pattern, which made the possibility of the incriminated organisms from the culture reports as contaminants. However, the fever subsided 3 weeks later after discharge on oral antibiotics; the reason for this response is not clear and will be difficult to attribute the resolution to the antibiotics, rather the disease might have followed its natural course and resolved spontaneously, hence the possibility of a viral infection cannot be overruled. However, spontaneous resolution of PUO is not uncommon.[5] Our patient improved on outpatient care; therefore, cases of nonlife-threatening prolong febrile illnesses could be managed on an outpatient basis, provided the red flags are absent. This will involve a highly selected group of patients with no other complaints other than fever. This may relieve the level of anxiety experienced by both caregivers and physicians with prolonged hospital admission and also eliminate the risk of nosocomial infection.

Effective counseling at every patient/caregiver contact increases patient compliance with medical therapy; this will also avoid caregivers unnecessarily attending multiple health facilities for the same illness, hence resulting in patient confusion and poor compliance with health instructions.[11] The parents of the index cases were adequately educated on the concept of “fever phobia;” this allayed their worries, therefore ensuring honoring follow-up visits.


  Conclusion Top


Managing PUO is challenging, especially where extensive diagnostic facilities are not readily available. However, home management can still be an option in patients without life-threatening features; this will go a long way in limiting parental anxiety associated with prolonged hospital stay. Furthermore, parental counseling in dealing with the menace of “fever phobia” which may result in parents visiting multiple health facilities is important in ensuring compliance with treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arnow PM, Flaherty JP. Fever of unknown origin. Lancet 1997;350:575-80.  Back to cited text no. 1
    
2.
Petersdorf RG, Beeson PB. Fever of unexplained origin: Report on 100 cases. Medicine (Baltimore) 1961;40:1-30.  Back to cited text no. 2
    
3.
Dienye PO, Gbeneol PK. Fever of unknown origin in an infant with an unexpected blood film report: A case report. Rural Remote Health 2010;10:1242.  Back to cited text no. 3
    
4.
Gaeta GB, Fusco FM, Nardiello S. Fever of unknown origin: A systematic review of the literature for 1995-2004. Nucl Med Commun 2006;27:205-11.  Back to cited text no. 4
    
5.
Akpede GO, Akenzua GI. Management of children with prolonged fever of unknown origin and difficulties in the management of fever of unknown origin in children in developing countries. Paediatr Drugs 2001;3:247-62.  Back to cited text no. 5
    
6.
Joshi N, Rajeshwari K, Dubey AP, Singh T, Kaur R. Clinical spectrum of fever of unknown origin among Indian children. Ann Trop Paediatr 2008;28:261-6.  Back to cited text no. 6
    
7.
Smitherman HF, Macias CG. Definition and Etiology of Fever in Neonates and Infants (Less Than Three Months of Age); 2012. Available from: http://www.uptodate.com. [Last accessed on 2012 Jun 07].  Back to cited text no. 7
    
8.
Egbe CA, Enabulele OI. Aetiologic agents of fevers of unknown origin among patients in Benin City, Nigeria. Malays J Med Sci 2014;21:37-43.  Back to cited text no. 8
    
9.
Schmitt BD. Fever phobia: Misconceptions of parents about fevers. Am J Dis Child 1980;134:176-81.  Back to cited text no. 9
    
10.
Chukwuocha UM, Nwakwuo GC, Emerole C, Dozie IN, Nwuda OE. Prevalent home management techniques and outcome among mothers of febrile children in Eastern Nigeria. J Public Health Epidemiol 2014;6:111-8.  Back to cited text no. 10
    
11.
Palmer RC, Midgette LA. Preventive health patient education and counseling: A role for medical assistants? J Allied Health 2008;37:137-43.  Back to cited text no. 11
    




 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References

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