Examination of a febrile patient with an unclear diagnosis in a polyclinic. Fever

From a tactical point of view, the following points are most important.

Before assigning a large number of studies to the patient, it is necessary to exclude the most common diseases (pneumonia, sinusitis, urinary tract infections).

The decision on the urgency of conducting a variety of studies is made depending on the general condition of the patient, the presence of risk factors (for example, immunosuppression) and local manifestations.

Before re-assigning tests, you should again collect an anamnesis and conduct an objective examination.

The diagnosis of "fever of unknown origin" is made if the rise in body temperature above 38 ° C persists for more than 2-3 weeks, and the cause of the fever remains unclear even after conventional (routine) studies. Usually the cause of the increase in body temperature is a serious disease, often curable. A thorough examination of the patient, preferably in a hospital, is necessary to identify the cause of the fever. The final diagnosis in approximately 35% of patients is infection, 20% malignancy, 15% systemic connective tissue disease, and 15% other diseases. In about 15% of patients, the cause of the fever remains unexplained.

Diagnostics

1. The following common diseases should be ruled out before further testing.

Pneumonia (based on chest x-ray and auscultation). Chest x-rays may also reveal pulmonary tuberculosis, sarcoidosis, alveolitis, pulmonary infarction, or lymphoma.

Urinary tract infection (urinalysis, its bacteriological examination).

Urinalysis may suggest hemorrhagic fever with renal syndrome or kidney tumor.

Sinusitis (ultrasound or radiography of the skull).

2. Examination to identify the alleged etiology of the disease. The following factors are of great importance

Presence and duration of fever (measurement of body temperature is mandatory!)

Travel, place (country) of birth and residence

Past illnesses, especially tuberculosis and valvular heart disease

Taking drugs, including those sold without a prescription

Alcohol abuse

Data from an objective clinical examination that the patient has previously undergone.

3. Laboratory and instrumental research.

Primary Research

Blood Hb, white blood cell count (with leukocyte count) and platelet count

Urinalysis and bacteriological examination of urine
- CRP and ESR

AST and ALT

It is possible to freeze a blood serum sample for subsequent serological studies

Chest X-ray

Ultrasound or radiography of the paranasal sinuses

Further research

Ultrasound of the abdominal organs

Bone marrow aspirate study

Serological studies [Yersinia species, tularemia, HIV infection, Borrelia burgdorferi, antiviral antibodies, HBsAg and antibodies to hepatitis C virus in blood serum, ANAT, passive haemagglutination test with salmonella, complement fixation test and indirect hemagglutination test with von Prowacek rickettsiae]

Bacteriological blood test

Smear and thick blood spot method for the detection of malarial plasmodium in the blood

Bone marrow aspirate study.

4. Before carrying out further research, it is necessary to consider the subsequent tactics (Table 1).

Table 1. Diagnostic tactics for prolonged fever

5. It is necessary to study the following list of causes of fever, so as not to miss any of them.

Tuberculosis (any localization).

Bacterial infections

sinusitis

Urinary tract infections

Inflammatory diseases of the abdominal organs (acute cholecystitis, acute appendicitis, abscesses)

pararectal abscess

Abscesses of the chest organs (lungs, mediastinum)

bronchiectasis

Salmonellosis, shigellosis (generalized forms)

Osteomyelitis.

Bacteremia without a focus of infection (much more often occurs as an acute illness than in the form of a prolonged fever).

Intravascular infections

Infective endocarditis

Infections of vascular prostheses.

Generalized viral and bacterial infections

Infectious mononucleosis

Cytomegalovirus infection, Coxsackie virus infections

Hepatitis

HIV infection

Chlamydia infections (psittacosis and/or psittacosis)

Toxoplasmosis

Lyme disease

Tularemia

Malaria.

Benign hyperthermia after an infectious disease.

Chronic Fatigue Syndrome.

Sarcoidosis.

Subacute thyroiditis.

thyrotoxicosis.

hemolytic diseases.

Post-traumatic tissue injury and hematoma.

Vascular thrombosis, pulmonary embolism.

Kawasaki disease.

Nodular erythema.

drug fever.

Malignant neuroleptic
syndrome.

Allergic alveolitis. "Lung
farmer."

Connective tissue diseases

Polymyalgia rheumatica, temporal arteritis

Rheumatoid arthritis

Systemic lupus erythematosus (SLE)

Still's disease in adults

Acute rheumatic fever

Vasculitis

Nodular periarteritis

Wegener's granulomatosis.

Inflammatory Bowel Disease

Regional enteritis (Crohn's disease)

Nonspecific ulcerative colitis.

Cirrhosis of the liver, alcoholic hepatitis.

Malignant neoplasms

Kidney cancer (hypernephroma)

Sarcomas

Hodgkin's disease, other lymphomas

Metastases (kidney cancer, melanoma, sarcoma).

01.04.2015

Criteria allowing to regard the clinical situation as a fever of unknown origin (FUE):

body temperature ≥38 °C;
duration of fever ≥3 weeks or intermittent episodes of fever during this period;
ambiguity of the diagnosis after the examination using generally accepted (routine) methods.

Classification of LNG according to Durack:

classic version of LNG;
LNG on the background of neutropenia (the number of neutrophils<500/мм 3);
nosocomial LNG:
- absence of infection during hospitalization;
- duration of intensive examination >3 days;
LNG associated with HIV infection (mycobacteriosis, cytomegalovirus infection, histoplasmosis).

Causes of LNG:

generalized or local infectious and inflammatory processes - 40-50%;
oncopathology - 20-30%;
systemic connective tissue diseases - 10-20%;
lymphoproliferative diseases (lymphogranulomatosis, lymphocytic leukemia, lymphosarcoma) - 5-10%;
other diseases, diverse in etiology (odontogenic sepsis, drug fever, intestinal diverticulosis, coronary heart disease after cardiac surgery) - 5%.

In about 9% of patients, the cause of the fever cannot be identified. The most common acute infections are: infective endocarditis (IE), sepsis, cholangitis, purulent bronchitis, pyelonephritis, infectious mononucleosis, granulomatous periodontitis, post-injection abscesses, abdominal and pelvic abscesses. Short-term fever can be caused by bacteremia due to diagnostic manipulations (Table 1).

Fever Features

1. "Naked fever" is characteristic of the debut of systemic lupus erythematosus, leukemia.

2. Fever against the background of multiple organ lesions is characteristic of sepsis, IE, lymphosarcoma.

Infective endocarditis

With IE, the endocardium and valvular apparatus of the heart are involved in the process, generalization of the infectious process is possible with damage to internal organs (endocardium, myocardium, lungs, liver, kidneys, spleen, blood vessels, etc.) and the subsequent development of severe autoimmune pathology and multiple organ failure.

The debut of IE is characterized by the presence of:

prolonged fever;
clinical picture of an infectious disease with severe intoxication;
rapid weight loss;
multiple organ lesions (lungs, kidneys, liver, blood vessels, etc.) with subsequent development of multiple organ failure;
persistently expressed inflammatory changes in the blood - leukocytosis, stab shift to the left, increased erythrocyte sedimentation rate (ESR);
protein in the urine, microhematuria.

Often at the onset of the disease, thromboembolic complications are observed: thromboembolism of the vessels of the upper and lower extremities, retina (with complete loss of vision), mesenteric arteries, cerebral vessels.

In recent years, IE has developed more frequently in people who use drugs; in patients with chronic foci of infection, against the background of a decrease in the activity of the immune system; in patients who have undergone valve replacement (the so-called prosthetic IE). The nosocomial form of IE is also registered.

Diagnostics:

Echocardiography is performed in all patients with suspected IE;
transthoracic echocardiography (TTEchoCG) is initially recorded;
a positive test with echocardiography is the detection of vegetation;
at a high risk of IE, transesophageal echocardiography (TEEchoCG; informative value - 100%) should be performed;
information content of TTEchoCG ~ 63%;
TTEchoCG in 100% reveals vegetations larger than 10 mm.

! Nota bene! Negative EchoCG results do not exclude the diagnosis of IE!

Cases have been recorded when the clinical picture of IE is typical, with multiple organ lesions, there were laboratory confirmations, and vegetations were not determined even with transesophageal ultrasound (ultrasound) of the heart. We present the case of patient B., 19 years old. At the onset of the disease, the fever lasted for about 2 months, then clinical and paraclinical evidence of the presence of infectious myocarditis, a diffuse form with the development of heart failure, appeared. With repeated ultrasound of the heart, vegetations were not determined. Based on the data obtained, the diagnosis of infectious myocarditis was made. Three months later, the patient developed an ischemic stroke. IE was diagnosed (although valvular vegetations were not detected). And only during a sectional study of a macropreparation of the heart, an extensive warty endocarditis with pustules on the tops of warty formations was found (Fig. 1).

Rice. 1. Warty endocarditis

Sepsis

Sepsis can be an independent nosological unit or a complication of any serious infectious disease (acute pyelonephritis, pneumonia with bacteremia), etc.

The main causative agents of sepsis

With sepsis, unlike IE, there is an entrance gate (with the exception of IE in drug addicts); the valvular apparatus of the heart is affected less frequently (40%) and delayed; hepatolienal syndrome is more often diagnosed in the debut; thromboembolic and hemorrhagic syndromes, staging and chronic course of the disease are not typical.

Klebsiellosis is an infectious disease with a primary lesion of the gastrointestinal tract (often in the form of gastroenteritis) and lungs. The disease progresses rapidly, up to the development of sepsis. The causative agent of infection - Klebsiella pneumoniae - belongs to the family of enterobacteria. Due to the presence of the capsule, Klebsiella persists in the environment for a long time, is resistant to disinfectants and many antibiotics. Klebsiella is one of the most common nosocomial infections, and can also be the cause of sepsis and purulent postoperative complications. Pneumonia caused by Klebsiella is characterized by destruction of lung tissue and the formation of abscesses. Pneumonia always starts suddenly with chills, cough, and pain in the side. There is a fever of a constant type, rarely remitting. Sputum is sputum in the form of jelly with an admixture of blood.

The etiological role of Klebsiella should be suspected in any severe form of pneumonia that occurs suddenly in an elderly patient. Abscesses in the lungs develop after 2-3 days. X-ray examination reveals homogeneous darkening of the upper lobe, more often of the right lung. Some strains of Klebsiella cause damage to the urinary tract, meninges, joints, and can also cause sepsis. Klebsiella is detected in feces and smears from the mucous membranes. Antibodies to Klebsiella are found in the blood. The most severe is the generalized septic-pyemic variant of the disease, often leading to death.

Localization of the focus of infection allows you to determine the spectrum of the most likely pathogens:

with abdominal sepsis - enterobacteria, enterococci, anaerobes;
with angiogenic sepsis - S. aureus; . with urosepsis - E. coli, Pseudomonas spp., Klebsiella spp.;
in patients with immunodeficiency - P. aeruginosa, Acinetobacter spp., K. pneumoniae, E. coli, Enterobacter spp., S. aureus and fungi.

An obligatory component of sepsis is a systemic inflammatory response (SIRS), the signs of which include:

body temperature >38 °C or<36 °С;
heart rate >90 bpm;
breathing rate<20/мин;
leukocytes >12,000/mL or<4000/мл или >10% immature neutrophils.

Features of indicators of peripheral blood in sepsis:

rapidly growing anemia;
hemolytic nature of anemia (jaundice, enlarged liver, spleen, hyperbilirubinemia);
leukocytosis, a sharp shift of the leukocyte formula to the left, toxic granularity of neutrophils;
leukopenia with Pseudomonas aeruginosa sepsis;
lymphopenia.

The marker of sepsis is procalcitonin - a reliable criterion for the infectious nature of fever, in contrast to its other causes. An increase in the level of procalcitonin by several tens of times is a marker of the severity of the infection.

Stage of the disease:

sepsis;
multiple organ failure syndrome;
septic shock.

Septic shock is accompanied by dysfunction of the lungs, liver and kidneys, changes in the blood coagulation system (thrombotic hemorrhagic syndrome).

Depending on the gate of infection, there are:

percutaneous sepsis;
obstetric-gynecological sepsis;
oral (tonzilo-, odontogenic) sepsis;
otogenic sepsis;
sepsis resulting from surgical interventions and diagnostic manipulations;
cryptogenic sepsis.

Risk factors for developing sepsis:

diabetes mellitus, cancer, neutropenia, liver cirrhosis, HIV;
septic abortions, childbirth, injuries, extensive burns;
the use of immunosuppressants and broad-spectrum antibiotics;
surgeries and invasive procedures.

Features of fever in sepsis:

appears early and reaches 39-40 °C, has a remitting character with daily fluctuations of 2-3 °C;
characterized by rapid warming up, fever, the maximum duration of fever is several hours;
advanced tachycardia >10 bpm by 1 °C;
the decline is often critical, with profuse sweat;
heat transfer prevails over heat generation, which is manifested by a feeling of cold, chills, muscle tremors, "goose bumps";
always accompanied by severe intoxication.

Features of fever in sepsis in the elderly:

maximum body temperature - 38.5-38.7 ° C;
appears later.

Entrance gate for nosocomial sepsis:

wound sepsis in patients with diabetes mellitus;
lactational mastitis (apostematous form);
purulent peritonitis;
clostridial infection with the formation of multiple ulcers in the liver and other organs.

HIV/AIDS

A special group of infectious pathology in cases of LNG is HIV infection. Diagnostic search for LNG must necessarily include examination for the presence of not only HIV infection, but also those infections that are often associated with AIDS (mycobacteriosis, etc.).

Classification of HIV/AIDS (WHO):

stage of acute infection;
stage of asymptomatic carriage;
stage of persistent generalized lymphadenopathy;
AIDS-associated complex;
AIDS (infections, invasions, tumors).

Clinical stages of AIDS (WHO, 2006):

Acute HIV infection:

asymptomatic;
acute retroviral syndrome.

Clinical stage 1:

asymptomatic;
persistent generalized lymphadenopathy.

Clinical stage 2:

seborrheic dermatitis;
angular cheilitis;
recurrent oral ulcers;
herpes zoster;
recurrent respiratory tract infections;
fungal nail infections;
papular pruritic dermatitis.

Clinical stage 3:

unexplained chronic diarrhea lasting more than 1 month;
recurrent oral candidiasis;
severe bacterial infection (pneumonia, empyema, meningitis, bacteremia);
acute ulcerative necrotic stomatitis, gingivitis or periodontitis.

Clinical stage 4:

pulmonary tuberculosis;
extrapulmonary tuberculosis;
unexplained weight loss (more than 10% within 6 months);
HIV-wasting syndrome;
pneumocystis pneumonia;
severe or radiologically confirmed pneumonia;
cytomegalovirus retinitis (with/without colitis);
encephalopathy;
progressive multifocal leukoencephalopathy;
Kaposi's sarcoma and other HIV-related malignant neoplasms;
toxoplasmosis;
disseminated fungal infection (candidiasis, histoplasmosis);
cryptococcal meningitis.

AIDS criteria (according to WHO protocols, 2006)

Bacterial infections:

pulmonary and extrapulmonary tuberculosis;
severe recurrent pneumonia;
disseminated mycobacteremia;
salmonella septicemia.

Fungal infections:

candidal esophagitis;
cryptococcal meningitis;
pneumocystis pneumonia.

Viral infections:

infection caused by the herpes simplex virus (chronic ulcers on the skin / mucous membranes, bronchitis, pneumonitis, esophagitis);
cytomegalovirus infection;
papillomavirus (including cervical cancer);
progressive multifocal leukoencephalopathy.

Protozoal infections:

toxoplasmosis;
cryptosporidiosis with diarrhea lasting more than 1 month.

Other diseases:

Kaposi's sarcoma;
cervical cancer;
non-Hodgkin's lymphoma;
HIV encephalopathy, HIV wasting syndrome.

Laboratory diagnostics:

detection of antibodies to HIV;
determination of virus antigen and viral DNA;
virus culture detection.

Methods for detecting antibodies to HIV:

enzyme immunosorbent assay;
immunofluorescent analysis;
confirmatory test - immunoblotting;

Non-specific markers of HIV infection:

cytopenia (anemia, neutropenia, thrombocytopenia);
hypoalbuminemia;
increase in ESR;
decrease in the number of CD 4 (T-killers);
increased levels of tumor necrosis factor;
increase in the concentration of β-microglobulin.

Indicator diseases with insufficient information:

opportunistic infections;
lymphoma of unknown origin.

Pneumocystis pneumonia characterized by the presence of fever, persistent cough, shortness of breath, shortness of breath, increased fatigue, weight loss. In 20% of cases, there is a mild clinical and radiological picture (diffuse and symmetrical interstitial inflammation with foci of infiltration). As a diagnosis, a study of saliva is used; the final diagnosis is established when cysts or trophozoites are detected in the tissue or alveolar fluid.

In the context of the problem of AIDS, it is appropriate to paraphrase a well-known Ukrainian medical saying in case of difficulty in diagnosing: "If it's not so, think about AIDS and cancer."

Splenomegaly

In some patients with LNG, at the onset of the disease, an increase in the size of the spleen is detected with the help of ultrasound of the abdominal organs. Less commonly, in such patients, a slight increase in the spleen is determined by doctors by palpation.

Reasons for the development of splenomegaly (Fig. 2)

Infections:

bacterial acute (typhoparatyphoid diseases, sepsis, miliary tuberculosis, IE);
bacterial chronic (brucellosis, tuberculosis of the spleen, syphilis);
viral (measles, measles rubella, acute viral hepatitis, infectious mononucleosis, infectious lymphocytosis, etc.);
protozoan (malaria, toxoplasmosis, leishmaniasis, trypanosomiasis);
mycoses (histoplasmosis, blastomycosis);
helminthiases (schistosomiasis, echinococcosis, etc.).

Anemia:

hemolytic, sideroblastic, pernicious, hemoglobinopathies;
plenogenic neutropenia (cyclic agranulocytosis);
thrombotic thrombocytopenic purpura.

Systemic diseases of the hematopoietic organs:

acute and chronic leukemia;
thrombocythemia;
myelofibrosis;
malignant lymphomas;
myeloma.

Autoimmune diseases:

systemic lupus erythematosus;
nodular periarteritis;
rheumatoid arthritis.

Circulatory disorders:

general (Peak's cirrhosis with constrictive pericarditis);
local (portal hypertension).

Focal lesions of the spleen:

tumors (benign and malignant);
cysts;
abscesses;
heart attacks.

By density, the spleen is very soft, easily slipping on palpation (as a rule, with its septic "swelling") or dense (a sign of a longer process).

The high density of the spleen is noted in leukemic processes, Hodgkin's disease, leishmaniasis, protracted septic endocarditis and malaria.

A less dense spleen is determined with hepatolienal lesions (with the exception of cholangitis) and hemolytic jaundice. Differential diagnosis of splenomegaly, which is most often accompanied by prolonged fever, is presented in Table 2.

It is appropriate to remind primary care physicians about the nature of changes in the lymph nodes. In infectious diseases, the lymph nodes are enlarged, painful and not soldered to the underlying tissues. Enlarged, painless, often "packed" lymph nodes are characteristic of lymphoproliferative diseases.

Granulomatous periodontitis

Granuloma of the tooth is one of the causes of fever.

Before the appearance of periostitis (flux), the symptoms are not pronounced. Fever develops early, sometimes mimics sepsis. Some patients complain of pain when chewing, others complain of nocturnal toothache. The granuloma is usually located in the area of the root of a carious, often destroyed tooth. Even dentists clearly underestimate the importance of this pathology as a factor in the development of fever. In case of suspicion of the presence of granulomatous periodontitis, the therapist should prescribe an x-ray examination of teeth characterized by severe carious lesions, and if a granuloma is detected, initiate the removal of such a tooth.

In most cases, the causes of hospital fever are pneumonia (70%), abdominal uroinfection (20%) and wound, angiogenic infection (10%). The most common pathogens:

staphylococcus epidermidis, golden;
gram-negative intestinal bacteria;
Pseudomonas aeruginosa;
clostridia;
tuberculosis bacillus.

Tuberculosis

The most common forms of TB associated with LNG are:

miliary pulmonary tuberculosis;
disseminated forms with the presence of various extrapulmonary complications (specific damage to peripheral and mesenteric lymph nodes, serous membranes (peritonitis, pleurisy, pericarditis), as well as tuberculosis of the liver, spleen, urogenital tract, spine).

! Nota bene! X-ray studies do not always make it possible to detect miliary pulmonary tuberculosis. Conducting tuberculin tests allows you to assess only the state of cellular immunity; they may be negative in patients with reduced protective function (in persons suffering from chronic alcoholism, elderly patients and patients receiving glucocorticoid therapy).

If tuberculosis is suspected, microbiological verification, a thorough examination of various biological materials (sputum according to the DOTS method, bronchoalveolar fluid, abdominal exudates, etc.), as well as gastric lavage, are necessary.

One of the most reliable methods for identifying mycobacteria is polymerase chain reaction - this method has 100% specificity.

If disseminated forms of tuberculosis are suspected, ophthalmoscopy is recommended to detect tuberculous chorioretinitis.

The key in determining the direction of the diagnostic search may be the identification of calcifications in the spleen; morphological changes in organs and tissues (lymph nodes of the liver, etc.). A trial treatment with tuberculostatic drugs is considered a justified approach in case of reasonable suspicion of tuberculosis. Aminoglycosides, rifampicin and fluoroquinolones should not be used. When the diagnosis is unclear and tuberculosis is suspected, patients with LNG are not recommended to prescribe glucocorticoids because of the danger of generalization of a specific process and the high risk of its progression.

Abscesses

Abscesses of the abdominal cavity and pelvis (subdiaphragmatic, subhepatic, intrahepatic, interintestinal, intraintestinal, tuboovarian, pararenal) are recognized as the main causes of fever in surgical practice.

! Note bene! A subdiaphragmatic abscess may develop in a patient 3-6 months after surgery in the abdominal cavity. If a subdiaphragmatic abscess is suspected, attention should be paid to the high standing of the dome of the diaphragm, as well as the possibility of a pleural effusion. The presence of a pleural effusion should not lead the diagnostic search down the wrong path to exclude pulmonary pathology.

Liver abscesses

Hepatic abscesses often occur in elderly patients with infectious pathology of the biliary tract. Aerobic gram-negative flora, anaerobic bacteria and enterococci, in particular clostridia, have an etiological role. The characteristic signs of a hepatic abscess are fever, chills, and nonspecific gastrointestinal symptoms.

Pathology of the gastrointestinal tract and hepatobiliary system

The presence of symptoms of intrahepatic cholestasis, expansion of the intrahepatic bile ducts (according to ultrasound of the abdominal cavity) gives reason to diagnose cholangitis. In some patients with cholangitis, fever is cyclical, resembling that of malaria. There is a moderately pronounced dyspeptic syndrome. Laboratory signs of intrahepatic cholestasis can be determined.

Apostematous nephritis should be suspected in a patient with fever, low-intensity urinary syndrome, severe intoxication, an increase in the size of the kidney, limitation of its mobility, pain on palpation in the side. The main risk factors for the development of purulent processes in the abdominal cavity:

surgical interventions;
injuries (bruises) of the abdomen;
bowel disease (diverticulosis, ulcerative colitis, Crohn's disease);
diseases of the biliary tract (cholelithiasis, etc.);
severe background diseases (diabetes mellitus, chronic alcohol intoxication, cirrhosis of the liver) or therapeutic regimens (treatment with glucocorticoids), accompanied by the development of immunodeficiency.

In order to timely diagnose purulent-inflammatory processes localized in the abdominal cavity, it is necessary to conduct repeated ultrasound (even in the absence of local symptoms), computed tomography, laparoscopy, and diagnostic laparotomy.

Diagnosis of bacterial infectious diseases (salmonellosis, yersiniosis, brucellosis, erysipelas), viral infections (hepatitis B and C, cytomegalovirus, Epstein-Barr virus) is based on microbiological and serological research methods.

Bacterial infection can be localized in the pyelocaliceal system of the kidneys with minimal changes in the urine.

There have also been cases of cholangitis, cholecystocholangiohepatitis, in which fever was the main or only symptom at the onset of the disease.

Osteomyelitis

The clinical symptoms of osteomyelitis are extremely variable - from slight discomfort during exercise, movement to intense pain, which significantly limits motor function. A history of skeletal trauma suggests the presence of osteomyelitis. Consideration should also be given to the nature of patients' professional activities, which may be associated with an increased risk of injury. If osteomyelitis is suspected, x-ray examination of the corresponding parts of the skeleton and computed tomography are mandatory, magnetic resonance imaging is desirable. A negative x-ray result does not always rule out osteomyelitis.

diverticulitis

Diverticulitis can be caused by aerobic and anaerobic intestinal bacteria. The main clinical manifestations are discomfort or pain in the left lower quadrant of the abdomen. Fever is associated with intoxication, leukocytosis, and often hypochromic anemia. The pain develops gradually, dull character, may be constant or intermittent, reminiscent of intestinal colic. Constipation is often noted. On examination, pain is determined along the course of the infiltrated thickened wall of the colon. It is necessary to exclude a tumor of the large intestine, thrombosis of the mesenteric arteries, as well as gynecological pathology.

Infectious mononucleosis

Infectious mononucleosis can have an atypical course and a protracted course in the absence of altered lymphocytes and lymphadenopathy. An increase in the cervical lymph nodes and the size of the liver and spleen is short-term, often not diagnosed by a family doctor. If infectious mononucleosis is suspected, it is necessary to conduct an early polymerase chain reaction to determine antibodies to the Epstein-Barr virus.

Neutropenic fever

Intensive chemotherapy used for the treatment of oncopathology is associated with an increase in toxicity (primarily hematological). One of the most severe manifestations of the latter are neutropenia and associated infectious complications. Infections that have arisen against the background of neutropenia are characterized by a number of features, in particular, they progress rapidly and can lead to death in a short time. In the case of neutropenia, a tissue focus of infection is not always detected. Often the only sign of infection is LNG. In 80% of cases, fever in patients with neutropenia is provoked by an infection, in 20% of cases hyperthermia is of non-infectious origin (tumor decay, allergic reactions, intravenous administration of blood products, etc.). Neutropenic fever is hyperthermia in neutropenic patients. Neutropenia is diagnosed when the neutrophil count<0,5×10 9 /л; часто это обусловлено проведением химио- или лучевой терапии. Определяющим фактором развития инфекционных осложнений является как уровень, так и длительность нейтропении. Наиболее частыми бактериальными патогенами у пациентов с нейтропенией являются грамположительные микроорганизмы.

Risk factors for the development of febrile neutropenia:

severe damage to the mucous membranes as a result of chemotherapy;
decrease in general immunity;
symptoms of a catheter-associated infection;
detection of methicillin-resistant Staphylococcus aureus, pneumococcus resistant to penicillins and cephalosporins.

Tumor processes of various localization

Tumor processes of various localization occupy the 2nd place in the structure of the causes of LNG.

The most commonly diagnosed lymphoproliferative tumors (lymphogranulomatosis, lymphosarcoma), kidney cancer, liver tumors (primary and metastatic), bronchogenic cancer, cancer of the colon, pancreas, stomach and some other localizations.

Lymphogranulomatosis (Hodgkin's lymphoma)

At the onset of the disease, fever is noted. It is accompanied by general weakness, itching of the skin, profuse night sweats. The patient's body weight rapidly decreases, then the lymph nodes in the neck, armpit and groin increase in size. They are dense, painless, mobile. Often the first symptom of the disease on the part of the internal organs is difficulty breathing or coughing due to the pressure of the lymph nodes on the bronchi. To verify the diagnosis, it is necessary to conduct a biopsy of the affected lymph node, followed by morphological and immunological studies to determine the Berezovsky-Sternberg cells specific for this disease. Radiation diagnostics is also used.

Lymphosarcoma

Fever is accompanied by fever, night sweats, rapid weight loss. Isolated fever may persist for 2 months or more. Then, in 50% of patients, the lymph nodes of the neck are the first to be affected. First, one lymph node increases, then neighboring lymph nodes are involved in the tumor process. They are painless, densely elastic consistency, merge into large groups, not soldered to the skin. The first focus of the tumor can also occur in the tonsils, causing sore throat when swallowing, a change in the timbre of the voice, less often in the chest cavity. The patient develops cough, shortness of breath, swelling of the face, veins in the neck. Possible damage to the gastrointestinal tract.

Hypernephroma

In 50% of patients, hypernephroma in the debut is manifested by fever with chills. This period can last up to 2 months. Then gradually there is a triad characteristic of this disease: a tuberous large kidney, back pain and hematuria.

Primary liver cancer

Primary liver cancer is characterized by a rapid increase in the size of the liver, the appearance of jaundice, less often - pain in the right hypochondrium. The liver is dense, bumpy. Unlike cirrhosis of the liver, the spleen does not enlarge with this disease.

Pancreas cancer

The first manifestations of pancreatic cancer include persistent nocturnal pain that is not relieved by non-narcotic analgesics. The patient has a sharp decrease in body weight, then fever joins.

The presence of a tumor in LNG may be indicated by such non-specific syndromes as erythema nodosum (especially recurrent) and migrating thrombophlebitis.

The mechanism of fever in tumor processes is associated with the production of various pyrogenic substances (interleukin-1, etc.) by the tumor tissue, and not with decay or perifocal inflammation.

Fever does not depend on the size of the tumor and can be observed both with a widespread tumor process and in patients with a single small node.

Immunological research methods should be used more often to identify some specific tumor markers:

α-fetoprotein (primary liver cancer);
CA 19-9 (pancreatic cancer);
CEA (colon cancer);
PSA (prostate cancer).

paraneoplastic syndrome

Paraneoplastic syndrome combines various lesions of organs and tissues remote from the main tumor focus, and metastases. Clinical manifestations of paraneoplastic syndromes may precede the manifestation of a malignant tumor. Based on the analysis of modern literature, paraneoplastic syndromes can be systematized in the following way:

cancer cachexia;
fever resistant to antibiotics;
violations of the water-salt balance (hypercalcemia, hyponatremia);
endocrinopathy (Cushing's syndrome, hypoglycemia, gynecomastia);
cancerous immune-mediated lesions (systemic scleroderma, dermatomyositis, arthropathies, myopathies, lesions of the central nervous system);
coagulopathy (chronic DIC, thrombophlebitis, thrombosis, pulmonary embolism);
violation of hematopoiesis (thrombocytosis, leukocytosis, leukopenia);
immune-mediated vasculitis.

Systemic diseases

This group is represented by the following pathologies:
systemic lupus erythematosus (SLE);
rheumatoid arthritis;
various forms of systemic vasculitis (nodular, temporal arteritis, etc.);
cross (overlap) syndromes.

Isolated fever often precedes the appearance of articular syndrome or other organ disorders in systemic diseases.

The combination of myalgia, myopathy with fever, especially with an increase in ESR, gives reason to suspect diseases such as dermatomyositis (polymyositis), polymyalgia rheumatica.

Fever may be the only or one of the main manifestations of deep vein thrombophlebitis of the lower extremities, pelvis.

Such situations occur most often after childbirth, bone fractures, surgical interventions, in the presence of intravenous catheters, in patients with atrial fibrillation, heart failure.

Fever associated with medication

Drug-induced fever does not have specific features to distinguish it from fever of other origins. The only difference should be considered its disappearance after the withdrawal of the suspected drug. Normalization of body temperature does not always occur in the first days, it can be observed even a few days after stopping the drug.

An increase in body temperature can provoke the following groups of drugs:

antimicrobial agents (isoniazid, nitrofurans, amphotericin B);
cytostatic drugs (procarbazine, etc.);
cardiovascular agents (α-methyldopa, quinidine, procainamide, hydralazine);
drugs acting on the central nervous system (carbamazepine, chlorpromazine, haloperidol, thioridazine);
anti-inflammatory drugs (acetylsalicylic acid, ibuprofen);
various groups of drugs, including iodine, antihistamines, allopurinol, metoclopramide, etc.

Principles of diagnostic search

The success of determining the nature of LNG largely depends on the thoroughness of the history taking and the quality of the objective examination of the patient. Important aspects of the survey are information about the severity of fever, contact with a patient with an infectious disease, previous examinations and instrumental interventions, traumatic injuries of the skin and mucous membranes, tooth extraction, the presence of foci of chronic infection, business trips to hot countries preceding the disease, pregnancy and childbirth.

Examination of a patient with LNG should be carried out in the absolute absence of clothing, since some patients with fever unconsciously hide the furuncle of the perineum, as well as suppurating post-injection (magnesium sulfate) infiltrates. It is necessary to pay attention to the possible presence of a pustular infection (streptoderma, furunculosis) on the skin, a rash of any nature; traces of intravenous drug injections in young people. The anterior and posterior cervical lymph nodes and lymph nodes of all accessible areas should be carefully palpated, to exclude the presence of Virchow's metastases. As part of the diagnosis of deep vein thrombophlebitis, it is necessary to pay attention to the swelling of one of the lower extremities. Then it is necessary to identify possible structural and functional disorders of the internal organs, the lymphatic system, etc., and also assess the condition of the teeth and tonsils. To exclude diseases of the pelvic organs, which may be the cause of sepsis, it is necessary to repeatedly conduct rectal and vaginal examinations, which will eliminate the presence of an abscess in the rectum and pelvis.

There are several options for diagnosing diseases in patients with LNG. According to the recommendations, after a fever, additional signs of the disease (heart murmurs, articular and hepatolienal syndromes, etc.) may appear, based on the identification of which a preliminary diagnosis should be established and an appropriate examination should be carried out. In the case of sepsis, leukemia, systemic lupus erythematosus, and oncological diseases, this approach makes the diagnostic process much more complicated. In other versions of the algorithm, it is proposed to use research methods in ascending order - from less informative to more informative. Verification of the diagnosis in patients with LNG should be carried out in 3 stages, taking into account the frequency of occurrence of diseases in this population: infectious, malignant diseases, systemic diseases of the connective tissue. The most common causes of LNG are infections (50%), less often - oncological diseases, in some cases - systemic diseases of the connective tissue.

First stage. Verification of infectious foci (tonsillitis, sinusitis, tooth granuloma, purulent cholangitis, abscesses in the abdominal cavity, pyelonephritis) or a generalized process (IE, sepsis, tuberculosis) is carried out.

Common signs of these infectious diseases:

chills (mainly in the afternoon);
sweating;
sweating without chills (typical of tuberculosis; so-called wet pillow syndrome);
severe intoxication;
signs of a pronounced inflammatory response in peripheral blood;
positive blood culture (approximately 50% of patients);
the presence of an entrance gate (with sepsis, this is intravenous administration of drugs, abscesses of the abdominal organs can develop as a result of an abdominal injury, after surgical interventions);
DIC (often develops with sepsis);
slightly enlarged soft spleen;
the presence of chronic foci of infection;
early (after 1 month of fever) appearance of signs of multiple organ damage (IE);
recurring chills (sepsis, IE, purulent cholangitis, pyelonephritis, paranephritis, tooth granuloma, developing abscess, phlebitis (pelvic thrombophlebitis), malaria);
weight loss by 10% or more (IE, sepsis, generalized tuberculosis);
early decrease in the level of hemoglobin in the blood serum (IE, sepsis).

Given the history, the nature of the fever and the presence of additional changes in the internal organs, the circle of suspected diseases narrows; a selective examination of the patient is carried out according to the diagnostic version.

The following methods are used: sowing from the pharynx, triple blood culture for hemoculture, urine culture for bacteriuria, sputum culture (if any).

All patients with fever should be tested for HIV.

It is necessary to determine the markers of an acute inflammatory response: procalcitonin and C-reactive protein in dynamics, fibrinogen; conducting spiral computed tomography of the chest and abdominal organs with amplification; determination of antibodies to the Epstein-Barr virus and cytomegalovirus.

! Note bene! An increase in the level of immunoglobulin M is of diagnostic importance. Markers of viral hepatitis B and C must be determined. The rest of the viruses can be excluded after 3 weeks of the disease.

Biochemical tests: liver tests, determination of blood protein fractions, tuberculin tests. With a reasonable suspicion of tuberculosis, the polymerase chain reaction method is used; to exclude inflammatory and oncological diseases of the pelvic organs, repeated vaginal examinations are carried out, as well as a rectal examination; consultations of specialists of a narrow profile are appointed.

Clinical criteria for the onset of HIV infection:

weight loss of 10% or more within a few months for no apparent reason;
persistent causeless fever that persists for more than 1 month;
causeless diarrhea for more than 1 month;
constant increased night sweating;
malaise, fatigue;
an increase in more than two groups of lymph nodes, excluding inguinal.

Second phase. If the results of the diagnostic search are negative, at the first stage of the examination, the second stage is carried out, aimed at excluding oncological diseases.

Fever in oncological diseases is characterized by:

severe intoxication;
absence of acute inflammatory changes in peripheral blood;
increase in ESR up to 50 mm/h;
hypercoagulability with subsequent development of thrombotic complications (migratory thrombophlebitis);
early decrease in hemoglobin levels;
weight loss;
the presence of paraneoplastic symptoms, syndromes (erythema nodosum, osteoarthropathies, migratory thrombophlebitis, scleroderma).

! Note bene! In patients with cancer, the pyrogenic substance is interleukin-1, and not tumor decay, perifocal inflammation, etc.

The presence of Savitsky's signs contributes to the early diagnosis of gastric cancer. The most pyrogenic are kidney and liver tumors, sarcoma and myeloma. Recurring chills are characteristic of lymphosarcoma, hypernephroma, and lymphoma.

The second stage of diagnosis includes:

repeated general blood test;
determination of oncomarkers: - α-fetoprotein (primary liver cancer); -CA 19-9 (pancreatic cancer); - CEA (colon cancer); - PSA (prostate cancer);
conducting repeated ultrasound to assess the condition of the lymph nodes of the neck and exclude an increase in para-aortic lymph nodes;
repeated ultrasound of the abdominal organs;
a biopsy of an enlarged lymph node, for which the most dense lymph node should be chosen, and not the largest or more accessible.

When performing a biopsy of the lymph node, preference should be given to its resection with subsequent histological examination. With reasonable suspicion of oncopathology of the abdominal organs, laparoscopy should be used, less often - laparotomy.

In the absence of results of deciphering the causes of LNG at the second stage, one should proceed to the next stage.

Third stage. The main task is to exclude systemic connective tissue diseases. Among them, such diseases as SLE, polyarteritis nodosa, rheumatoid arthritis (usually juvenile) most often debut with fever. In patients with SLE, in most cases, the first clinical manifestation of the disease against the background of fever is articular syndrome. Polyarteritis nodosa is easier to diagnose. In these patients, already at the onset of the disease (on average, after 3-4 weeks from the onset of fever), a decrease in body weight is recorded. Patients complain of severe pain in the muscles of the lower leg, up to the inability to stand on their feet.

Today, Still's syndrome in adults is much more common, manifested by prolonged fever. It is characterized by less pronounced symptoms. There are no specific laboratory tests. Against the background of fever in the debut of the disease, arthralgia always occurs, later - arthritis, maculopapular rash, neutrophilic leukocytosis, lymphadenopathy, enlargement of the spleen, and polyserositis are possible. Rheumatoid factor and antinuclear antibodies are not detected. More often, the diagnosis of sepsis is mistakenly established and massive antibiotic therapy is prescribed, which does not improve well-being.

Of particular difficulty is the early diagnosis of leukemia.

The feverish period lasts 2 months or more. It is practically impossible to normalize body temperature through the action of non-steroidal anti-inflammatory drugs. There is a decrease in body weight. The first informative sign of this disease is the sudden detection of blast cells in the peripheral blood. Prior to this, the attending physician is in complete uncertainty, because "there is a patient, but there is no diagnosis." Sternal puncture allows you to establish the presence of a blood disease. Prior to this, the diagnosis sounds like LNG. You should not unreasonably establish a preliminary diagnosis of sepsis, as is often the case.

It is necessary to strive to ensure that a patient with LNG is subjected not to a total, but to a selective examination in accordance with the clinical situation. Also, the consistent use of methods with increasing complexity, informativeness and invasiveness is not always justified. Already at the initial stages of the examination, invasive methods may be the most informative (for example, a biopsy of the lymph node with moderate lymphadenopathy or laparoscopy with a combination of fever with ascites). Fever in combination with organ damage is more often observed with infections, and isolated fever is more common with pathological changes in the blood (leukemia) and systemic connective tissue diseases (SLE, Still's disease in adults).

Diagnostic search facilitates the appearance of changes in the peripheral blood in the patient against the background of fever. Thus, anemia indicates the need for differential diagnosis between a malignant tumor, a blood disease, hypernephroma, sepsis, infective endocarditis, and a systemic connective tissue disease. Left-shifted neutrophilic leukocytosis and toxic neutrophil granularity usually indicate an inflammatory infection. With a steady increase in the number of leukocytes with a “rejuvenation” of the formula to myelocytes, it is necessary to exclude blood diseases. Agranulocytosis is observed in infectious diseases and acute leukemia. Eosinophilia is typical for drug-induced fever and oncopathology, less often for lymphosarcoma, leukemia. Lymphocytosis is often recorded with Epstein-Barr virus and cytomegalovirus infection, as well as with lymphocytic leukemia.

Severe lymphopenia may indicate the presence of AIDS. Monocytosis is characteristic of tuberculosis and infectious mononucleosis. Changes in urine sediment - albuminuria, microhematuria - in a patient with fever testify in favor of infective endocarditis, sepsis. Acute glomerulonephritis with fever is extremely rare. Difficulties in differential diagnosis in a patient with fever remain even with the appearance of multiple organ lesions. In cardiology practice, in this clinical situation, infective endocarditis is more often diagnosed (G.V. Knyshov et al., 2012).

Infective endocarditis should be suspected if fever is associated with:

the appearance of a new murmur of valvular regurgitation;
episodes of embolic complications of unknown origin;
the presence of intracardiac prosthetic material;
recent parenteral manipulations;
new signs of congestive heart failure;
new manifestations of cardiac arrhythmias and conduction;
focal neurological symptoms;
renal, splenic abscesses.

To treat or not to treat?

The question of the advisability and validity of prescribing treatment to patients with LNG before its decoding cannot be resolved unambiguously and should be considered individually, depending on the specific situation. In most cases, when the condition is stable, treatment is not carried out, but the use of non-steroidal anti-inflammatory drugs is possible.

! Note bene! Antibacterial therapy is often prescribed, and in the absence of an effect and with the situation remaining unclear, glucocorticoids. Such an empirical approach to treatment should be considered unacceptable.

In some situations, the use of a trial treatment as one of the methods of diagnosis ex juvantibus (for example, tuberculostatic drugs) may be discussed. In some cases, it is advisable to prescribe heparin for suspected deep vein thrombophlebitis or pulmonary embolism; antibiotics that accumulate in bone tissue (lincomycin) - if osteomyelitis is suspected. In patients with suspected urinary tract infection, especially those with chronic pyelonephritis, second-generation fluoroquinolones (ciprofloxacin intravenously) can be used.

! Note bene! The use of third-generation fluoroquinolones in patients with LNG is strictly prohibited, since they have a tuberculostatic effect and can erase the clinical picture and complicate further differential diagnosis.

A special approach to the treatment of febrile neutropenia is required. Given the aggressiveness of the infectious process in this category of patients, it should be considered as the cause of fever until proven otherwise. Therefore, antibiotic therapy is necessary.

It should be remembered that antibiotic therapy prescribed without sufficient justification for patients with LNG can worsen the course of SLE and other systemic connective tissue diseases.

Unreasonable appointment of hormone therapy can lead to serious consequences - generalization of infection. The use of glucocorticoids is rational in cases where their effect is of diagnostic value (for example, with suspected polymyalgia rheumatica, subacute thyroiditis). It should be taken into account that glucocorticoids are able to reduce or eliminate fever in lymphoproliferative diseases.

You should not be guided solely by the advice of narrow specialists (otorhinolaryngologists, dentists, urologists, phthisiatricians). The fact is that they do not reveal the typical course of the profile disease in patients with LNG, not taking into account the fact that patients have fever and an atypical course of the pathology.

! Note bene! It is more correct to interpret not an atypical course, but an atypical onset of the disease. In the future, it usually proceeds typically.

Establishing the cause of LNG is a complex and time-consuming step. For its successful implementation, the attending physician must have sufficient knowledge in all areas of medicine and act in accordance with approved diagnostic algorithms.

When writing this article, we used literature data, as well as our own many years of clinical experience.

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Fever of unknown origin (syn. LNG, hyperthermia) is a clinical case in which elevated body temperature is the leading or only clinical sign. This state is said when the values persist for 3 weeks (in children - longer than 8 days) or more.

Possible causes may be oncological processes, systemic and hereditary pathologies, drug overdose, infectious and inflammatory diseases.

Clinical manifestations are often limited to an increase in temperature up to 38 degrees. This condition may be accompanied by chills, increased sweating, asthma attacks and pain sensations of various localization.

The object of diagnostic search is the root cause, so the patient is required to undergo a wide range of laboratory and instrumental procedures. Primary diagnostic measures are required.

The therapy algorithm is selected individually. With a stable condition of the patient, treatment is not required at all. In severe cases, a trial regimen is used, depending on the alleged pathological provocateur.

According to the international classification of diseases of the tenth revision, fever of unknown origin has its own code. The ICD-10 code is R50.

Etiology

A feverish condition that lasts no more than 1 week indicates an infection. It is assumed that prolonged fever is associated with the course of any serious pathology.

Fever of unknown origin in children or adults may be the result of an overdose of drugs:

antimicrobial agents;
antibiotics;
sulfonamides;
nitrofurans;
anti-inflammatory drugs;
drugs that are prescribed for diseases of the gastrointestinal tract;
cardiovascular drugs;
cytostatics;
antihistamines;
iodine preparations;
substances that affect the CNS.

The medicinal nature is not confirmed in those cases when, within 1 week after discontinuation of the drug, the temperature values \u200b\u200bremain high.

Classification

Based on the nature of the course, fever of unknown origin is:

classical - against the background of pathologies known to science;
nosocomial - occurs in persons who are in the intensive care unit for more than 2 days;
neutropenic - there is a decrease in the number of neutrophils in the blood;
HIV-associated.

According to the level of temperature increase in LNG, it happens:

subfebrile - varies from 37.2 to 37.9 degrees;
febrile - is 38–38.9 degrees;
pyretic - from 39 to 40.9;
hyperpyretic - above 41 degrees.

According to the type of changes in values, the following types of hyperthermia are distinguished:

constant - daily fluctuations do not exceed 1 degree;
relaxing - variability throughout the day is 1-2 degrees;
intermittent - there is an alternation of the normal state with the pathological, the duration is 1-3 days;
hectic - there are sharp jumps in temperature indicators;
wavy - the thermometer indicators gradually decrease, after which they increase again;
perverted - indicators are higher in the morning than in the evening;
wrong - has no patterns.

The duration of a fever of unknown origin can be:

acute - lasts no longer than 15 days;
subacute - the interval is from 16 to 45 days;
chronic - more than 1.5 months.

Symptoms

The main, and in some cases the only, symptom of a fever of unknown origin is an increase in body temperature.

The peculiarity of this condition is that the pathology for a rather long period of time can proceed completely asymptomatically or with erased symptoms.

Main additional manifestations:

muscle and joint pain;
dizziness;
feeling short of breath;
increased heart rate;
chills;
increased sweating;
pain in the heart, in the lower back or in the head;
lack of appetite;
stool disorder;
nausea and vomiting;
weakness and weakness;
frequent mood swings;
strong thirst;
drowsiness;
pallor of the skin;
decrease in performance.

External signs occur in both adults and children. However, in the second category of patients, the severity of concomitant symptoms may be much higher.

Diagnostics

To identify the cause of fever of unknown origin, a comprehensive examination of patients is required. Before the implementation of laboratory and instrumental studies, primary diagnostic measures are necessary, carried out by a pulmonologist.

The first step in establishing a correct diagnosis includes:

study of the medical history - to search for chronic diseases;
collection and analysis of life history;
a thorough physical examination of the patient;
listening to a person with a phonendoscope;
measurement of temperature values;
a detailed survey of the patient for the first time of occurrence of the main symptom and the severity of concomitant external manifestations and hyperthermia.

Laboratory research:

general clinical and biochemical blood tests;
microscopic examination of feces;
general analysis of urine;
bacterial culture of all human biological fluids;
hormonal and immunological tests;
bacterioscopy;
serological reactions;
PCR tests;
Mantoux test;
AIDS tests and.

Instrumental diagnosis of fever of unknown origin involves the following procedures:

radiography;
CT and MRI;
scanning of the skeletal system;
ultrasonography;
ECG and echocardiography;
colonoscopy;
puncture and biopsy;
scintigraphy;
densitometry;
EFGDS;
MSCT.

Consultations of specialists from various fields of medicine are necessary, for example, gastroenterology, neurology, gynecology, pediatrics, endocrinology, etc. Depending on which doctor the patient goes to, additional diagnostic procedures may be prescribed.

The differential diagnosis is divided into the following main subgroups:

infectious and viral diseases;
oncology;
autoimmune diseases;
systemic disorders;
other pathologies.

Treatment

When a person's condition is stable, experts recommend refraining from treating fever of unknown origin in children and adults.

In all other situations, trial therapy is performed, the essence of which will differ depending on the alleged provocateur:

with tuberculosis, anti-tuberculosis substances are prescribed;
infections are treated with antibiotics;
viral diseases are eliminated with the help of immunostimulants;
autoimmune processes - a direct indication for the use of glucocorticoids;
for diseases of the gastrointestinal tract, in addition to medicines, diet therapy is prescribed;
when malignant tumors are detected, surgery, chemotherapy and radiotherapy are indicated.

If medicinal LNG is suspected, the medications taken by the patient should be discontinued.

As for the treatment of folk remedies, it must be agreed with the attending physician - if this is not done, the possibility of aggravating the problem is not excluded, the risk of complications increases.

Prevention and prognosis

To reduce the likelihood of developing a pathological condition, it is necessary to adhere to preventive recommendations aimed at preventing the occurrence of a possible disease provocateur.

Prevention:

maintaining a healthy lifestyle;
complete and balanced nutrition;
avoiding the influence of stressful situations;
prevention of any injury;
permanent strengthening of the immune system;
taking medications in accordance with the recommendations of the clinician who prescribed them;
early diagnosis and full treatment of any pathologies;
regular passage of a complete preventive examination in a medical institution with a visit to all specialists.

Fever of unknown origin has an ambiguous prognosis, which depends on the underlying cause. The complete absence of therapy is fraught with the development of complications of one or another underlying disease, which often ends in death.

Is everything correct in the article from a medical point of view?

Answer only if you have proven medical knowledge

To conduct a qualified differential diagnosis in febrile patients, the therapist needs to know the clinical manifestations and course of not only numerous diseases of internal organs, but also related pathology, which is the competence of infectious disease specialists, oncologists, hematologists, phthisiatricians, neuropathologists and neurosurgeons. Difficulties are increased by the fact that there is no direct relationship between the height of fever and objectively detectable data.

Anamnesis

At the first stage of the diagnostic search scheme, it is necessary to analyze the anamnestic information, conduct a thorough clinical examination of the patient and perform simple laboratory tests.

When collecting an anamnesis, attention is paid to the profession, contacts, past diseases, allergic reactions in the past, previous medication, vaccinations, etc. The nature of the fever (temperature level, type of curve, chills) is clarified.

Clinical examination

During the examination, the condition of the skin, mucous membranes, palatine tonsils, lymph nodes, joints, venous and arterial systems, lungs, liver and spleen is analyzed. A thorough clinical examination helps to detect the affected organ or system, which should be followed by a search for the cause of the febrile syndrome.

Laboratory research

The simplest laboratory tests are performed: a general blood test with the determination of the level of platelets and reticulocytes, a general urinalysis, the total protein and protein fractions, blood sugar, bilirubin, AsAT, AlAT, urea are examined.

To exclude typhoid and paratyphoid diseases and malaria, all febrile patients with an unclear diagnosis are prescribed a blood test for blood culture, Vidal reaction, RSK, malaria (thick drop), antibodies to HIV.

An x-ray (not fluoroscopy!) of the chest organs is performed, an ECG is taken.

If at this stage a pathology of any system or a specific organ is revealed, further search is carried out purposefully according to the optimal program. If fever is the only or leading syndrome and the diagnosis remains unclear, it is necessary to proceed to the next stage of the search.

With a feverish patient, a conversation should be held so that when the body temperature rises, he does not panic and does not become a “slave of the thermometer”.

Consultations of narrow specialists

With monosymptomatic hyperthermia against the background of normal laboratory parameters, it is necessary to exclude: artificial hyperthermia, thyrotoxicosis and violations of central thermoregulation. Subfebrile condition can occur after a hard day's work, emotional stress and physical exertion.

If there are changes in laboratory parameters, taking into account clinical manifestations, characteristics of the blood reaction, the nature of the febrile curve, appropriate specialists can be involved in the diagnostic process. If necessary, the patient can be consulted by an infectious disease specialist, gynecologist, hematologist, ENT doctor, oncologist and other specialists. However, examination of the patient by a narrow specialist in order to clarify the diagnosis does not remove the responsibility and the need for a complete examination by the attending physician.

If the cause of the fever remains unclear, you need to move on to the next stage of the search. Taking into account the age, the patient's condition, the nature of the temperature curve and the blood picture, the doctor must orient himself regarding the nature of the fever and attribute it to one of the groups: infectious or somatic.

Sometimes there are cases when the patient's body temperature rises (more than 38 ° C) almost against the background of complete health. Such a condition may be the only sign of the disease, and numerous studies do not allow to determine any pathology in the body. In this situation, the doctor, as a rule, makes a diagnosis - a fever of unknown origin, and then prescribes a more detailed examination of the body.

ICD code 10

Fever of unknown etiology R50 (except for labor and puerperal fever, as well as neonatal fever).

R 50.0 - fever, accompanied by chills.
R 50.1 - persistent fever.
R 50.9 - unstable fever.

ICD-10 code

R50 Fever of unknown origin

Symptoms of a fever of unknown origin

The main (often the only) present sign of a fever of unknown origin is considered to be an increase in temperature. Over a long period, an increase in temperature can be observed without accompanying symptoms, or proceed with chills, increased sweating, cardiac pain, and shortness of breath.

There must be an increase in temperature values.
The type of temperature increase and temperature characteristics, as a rule, do little to reveal the picture of the disease.
There may be other signs that usually accompany an increase in temperature (pain in the head, drowsiness, body aches, etc.).

Temperature indicators can be different, depending on the type of fever:

subfebrile (37-37.9°C);
febrile (38-38.9°C);
pyretic (39-40.9°C);
hyperpyretic (41°C >).

Prolonged fever of unknown origin can be:

acute (up to 2 weeks);
subacute (up to one and a half months);
chronic (more than one and a half months).

Fever of unknown origin in children

Fever in a child is the most common problem that is addressed to a pediatrician. But what kind of temperature in children should be considered a fever?

Doctors separate fever from just high fever, when readings are over 38°C in infants and over 38.6°C in older children.

In most young patients, fever is associated with a viral infection, a smaller percentage of children suffer from inflammatory diseases. Often such inflammations affect the urinary system, or there is a hidden bacteremia, which in the future can be complicated by sepsis and meningitis.

Most often, the causative agents of microbial lesions in childhood are such bacteria:

streptococci;
gram (-) enterobacteria;
listeria;
hemophilic infection;
staphylococci;
salmonella.

Diagnosis of fever of unknown origin

According to the results of laboratory tests:

general blood test - changes in the number of leukocytes (with a purulent infection - a shift of the leukocyte formula to the left, with a viral lesion - lymphocytosis), acceleration of ESR, a change in the number of platelets;
general urinalysis - leukocytes in the urine;
blood biochemistry - elevated levels of CRP, elevated levels of ALT, AST (liver disease), fibrinogen D-dimer (TELA);
blood culture - demonstrates the possibility of bacteremia or septicemia;
urine bakposev - to exclude the renal form of tuberculosis;
bacteriological culture of bronchial mucus or feces (according to indications);
bacterioscopy - if malaria is suspected;
diagnostic complex for tuberculosis infection;
serological reactions - if syphilis, hepatitis, coccidioidomycosis, amoebiasis, etc. are suspected;
AIDS test;
thyroid examination;
examination for suspected systemic diseases of the connective tissue.

According to the results of instrumental studies:

radiograph;
tomographic studies;
scanning of the skeletal system;
ultrasonography;
echocardiography;
colonoscopy;
electrocardiography;
bone marrow puncture;
biopsy of lymph nodes, muscle or liver tissue.

The algorithm for diagnosing fever of unknown origin is developed by the doctor on an individual basis. To do this, the patient is determined at least one additional clinical or laboratory symptom. This may be a disease of the joints, a low level of hemoglobin, an increase in lymph nodes, etc. The more such auxiliary signs are found, the easier it will be to establish the correct diagnosis, narrowing the range of suspected pathologies and determining targeted diagnostics.

Differential diagnosis of fever of unknown origin

The differential diagnosis is usually divided into several main subgroups:

infectious diseases;
oncology;
autoimmune pathologies;
other diseases.

When differentiating, attention is paid not only to the symptoms and complaints of the patient at the moment, but also to those that were before, but have already disappeared.

It is necessary to take into account all the diseases that preceded the fever, including surgical interventions, injuries, psycho-emotional states.

It is important to clarify hereditary characteristics, the possibility of taking any medications, the subtleties of the profession, recent travels, information about sexual partners, about animals present at home.

At the very beginning of the diagnosis, it is necessary to exclude the deliberateness of the febrile syndrome - it is not uncommon for there to be cases of the intended introduction of pyrogenic agents, manipulations with a thermometer.

Of great importance are skin rashes, heart problems, enlargement and soreness of the lymph nodes, signs of disorders of the fundus.

Treatment of fever of unknown origin

Experts do not advise blindly prescribing drugs for fever of unknown origin. Many doctors are in a hurry to apply antibiotic therapy or corticosteroid treatment, which can blur the clinical picture and make it difficult to further reliably diagnose the disease.

Despite everything, most doctors agree that it is important to establish the causes of a feverish condition, using all possible methods. In the meantime, the cause is not established, symptomatic therapy should be carried out.

As a rule, the patient is hospitalized, sometimes isolated, if suspicion falls on an infectious disease.

Drug treatment can be prescribed taking into account the detected underlying disease. If such a disease is not found (which happens in about 20% of patients), then the following medications can be prescribed:

antipyretic drugs - non-steroidal anti-inflammatory drugs (indomethacin 150 mg per day or naproxen 0.4 mg per day), paracetamol;
the initial stage of taking antibiotics is a penicillin series (gentamicin 2 mg / kg three times a day, ceftazidime 2 g intravenously 2-3 times a day, azlin (azlocillin) 4 g up to 4 times a day);
if antibiotics do not help, start taking stronger drugs - cefazolin 1 g intravenously 3-4 times a day;
amphotericin B 0.7 mg/kg daily or fluconazole 400 mg daily intravenously.

Treatment is continued until the general condition is completely normalized and the blood picture is stabilized.

Prevention of fever of unknown origin

Preventive measures are to detect diseases in time, which can later cause a rise in temperature. Of course, it is equally important to correctly treat the detected pathologies, based on the recommendations of the doctor. This will avoid many adverse effects and complications, including fever of unknown origin.

What other rules should be followed to avoid diseases?

Contact with carriers and sources of infection should be avoided.
It is important to strengthen the immune system, increase the body's resistance, eat well, consume enough vitamins, remember about physical activity and follow the rules of personal hygiene.
In some cases, specific prophylaxis in the form of vaccinations and vaccinations may be used.
It is desirable to have a permanent sexual partner, and in case of casual relationships, barrier methods of contraception should be used.
When traveling to other countries, you must avoid eating unknown foods, strictly observe the rules of personal hygiene, do not drink raw water and do not eat unwashed fruits.