Fever of unknown origin in an elderly man

Journal of Family Practice, Sept, 1990 by Navin Amin, William A. Norcross, Sidney L. Saltzstein

Dr WILLIAM A. NORCROSS (Professor of Clinical family Medicine, UCSD School of Medicine): I will begin by presenting the case of one of my own patients. Dr J.C. is an 80-year-old white married man who is a professor emeritus of economics from a major East Coast university. He came to the UCSD Medical Group facility early in February 1989. He complained of a 5-month history of daily fevers ranging from 100 [deg.]F to 102 [deg.]F; an intermittent, dry, nonproductive cough; fatigue; weight loss of 20 pounds; and intermittent, bifrontal, dull, mild headaches.

His symptoms started in October 1988 following what he described as a typical viral respiratory tract syndrome, characterized by a nonproductive cough and coryza with a low-grade fever. He saw his local physician, who gave him antibiotics for bronchitis. He was seen I month later because his symptoms did not resolve, at which time a further evaluation revealed mild anemia. A chest x-ray examination was performed, which was reported to be within normal limits. Because of the anemia, he was scheduled to see a gastroenterologist, who recommended a colonoscopy. He denied melena or hematochezia, but he had a history of intermittent, dull, left lower quadrant pain, which was mild in nature and not associated with diarrhea or constipation. He declined the endoscopic evaluation.

In August 1988 he underwent a transurethral resection of the prostate for symptoms of urinary retention, felt to be secondary to benign prostatic hypertrophy. He was also noted to have a prostatic nodule, biopsy of which revealed a well-differentiated adenocarcinoma of the prostate. At that time he elected to decline any further treatment. He had no symptoms of bone pain, and his urinary symptoms responded well to the procedure. Past medical history revealed that the patient was a smoker but gave up the habit in 1938. He drank three or four drinks per week, but had no history of alcohol or drug abuse. In 1972 he was treated for diverticulitis. In 1968 he amputated his right index finger in a lawnmower accident. His father died at age 74 years of "artetiosclerosis," and his mother died of "old age" at age 95 years.

Physical examination revealed an afebrile, well-developed, well-nourished, pleasant, and cooperative elderly man in no acute distress, who looked much younger than his stated age. His thought processes and content were intact. Recent and remote memory was intact. The neck was supple, and one small, right anterior, cervical node was mobile and slightly tender. Ear, nose, and throat examination was unremarkable. Ophthalmic examination was within normal limits. The temporal arteries, bilaterally, were 2+, were unremarkable to palpation, and were nontender. There were no carotid or intracranial bruits. The chest was clear to percussion and auscultation. The jugular venous pulses were normal, and findings on examination of the heart and abdomen were also unremarkable. Rectal examination revealed a small prostate with a 5 x 5-mm nodule on the left lateral lobe. There were no rectal masses, the stool was brown, and a test for occult blood was negative. Examination of the skin and extremities was unremarkable, except for the amputation of his right index finger. Neurological examination was completely within normal limits.

An outpatient investigation was begun. The complete blood count revealed a hemoglobin of 100.3 g/L (10.3 g/dL) and a hematocrit of 0.31. Leukocyte count was 8.3 x 10[sup.9]/L, with 0.86 segmented neutrophils, 0.07 band cells, 0.09 lymphocytes, 0.03 monocytes, and 10.0 eosinophils. The mean corpuscular volume was 86.7 fL (86.7 [micro]m[sup.3). The sedimentation rate was 130 mm/h. Skin tests revealed anergy with no response to protein purified derivative (PPD) tuberculin intermediate strength, Candida, or coccidioidomycosis. The urinalysis showed a trace of protein, but was otherwise unremarkable. Findings on the chest x-ray examination were within normal limits for age. The serum protein electrophoresis revealed a mild increase in [alpha][sub.2]-globulins, compatible with acute inflammation. Two stool specimens were negative for occult blood, ova, and parasites. Two sputum examinations were negative for acid-fast bacilli in the smear, and revealed some Candida albicans in culture. The sensitive thyrotropin returned at 2.98 mU/L (2.98 [micro]U/mL), which is within normal limits. The serum iron was 4.30 [micro]mol/L (24 [micro]g/ dL), which is low, and the total iron-binding capacity was 40.12 [micro]mol/L (224 g/dL). The chemistry panel was unremarkable, except for a cholesterol of 3.46 mmol/L (134 mg/dL). An abdominal ultrasound revealed a normal liver and gallbladder. An echogenic focus in the perinephric area was felt to be of questionable significance. A barium enema was within normal limits.

Approximately 2 weeks after his initial presentation, the patient was admitted to the UCSD Medical Center for further diagnostic evaluation. A rheumatology consultation was obtained, but the consultant did not believe there was sufficient evidence to consider his disease to be a rheumatologic disease. The suggestion was made by the rheumatologist to consult a gastroenterologist as well as a pulmonary specialist. A computed tomographic (CT) study of the abdomen was performed and the findings were unremarkable. Specifically, the questionable renal abnormality noticed on ultrasound was not apparent on the abdominal CT scan. A hematologist was consulted, and a bone marrow aspiration was performed, which was within normal limits.