Fever of unknown origin in an elderly man

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

Throughout the hospital stay, the patient was documented to have fevers spiking as high as 102 [deg]F. A repeat of the erythrocyte sedimentation rate returned at 140 mm/h. Four blood cultures were negative, and stool tests for occult blood were persistently negative. Multiple sputum smears were negative for acid-fast bacilli and fungus. A perfusion scan of the lungs was within normal limits. A pulmonary specialist was consulted, and a bronchoscopy revealed some minor inflammation, but no other abnormalities were noted. Smears and washings from the bronchoscopy also returned negative. A bone scan was within normal limits. An upper gastrointestinal series with small bowel follow-through was negative. Sinus films were negative. Pulmonary function studies were within normal limits for his age. A flexible sigmoidoscopy was within normal limits. The patient was discharged from the hospital 8 days after admission, still without a diagnosis.

I would like to introduce our discussant, Dr Navin Amin, an outstanding clinician and teacher of family medicine. We are very pleased to have him with us.

DR NAVIN AMIN (Chairman, Department of Family Practice, Kern Medical Center): As you can probably see, this patient is an individual who has certain fundamental problems that need to be addressed. One of the most frustrating problems that you will face, whether you are a primary care physician or in another specialty, is the pressure you feel, both from yourself and from your patient and his or her family, to arrive at a diagnosis and to cure the problem. A common expectation is that if you cannot find a diagnosis, then treat something. Let me caution you that you must avoid the temptation to try empiric therapy, whether it be antibiotics, steroids, or whatever. You must "hang tough" and methodically work your way to a diagnosis.

Let me start by reviewing some pertinent features at hand. First, Dr J.C. is an elderly person, but as Dr Norcross said, a fit and healthy elderly person who looks younger than his stated age. Second, his symptoms were many months in duration. Third, his symptomology was characterized by fevers, spiking from 100 [deg]F to 102 [deg]F, intermittent dry cough, fatigue, and weight loss of 20 pounds. The intermittent, bifrontal, dull headaches are also noteworthy.

On physical examination there are a few findings that bear discussion. The patient was well built and well nourished. There was no evidence of emaciation. As you will see, this finding is important. The discovery of one small anterior cervical node is of uncertain importance at this stage. The findings of normal temporal arteries, bilaterally, does not rule out a vasculitis.

The laboratory findings of note include a mild normocytic, normochromic anemia, a normal white blood count and differential, and an impressive erythrocyte sedimentation rate of 130 mm/h. The latter finding is of particular importance. The discovery of anergy to PPD tuberculin intermediate strength, Candida, and coccidioidomycosis is of uncertain significance. Anergy may be related to his underlying disease process, his advanced years, or both. A search for a malignancy was begun on this patient. A serum protein electrophoresis showed an elevation in [gamma]2globulin, suggesting an acute inflammatory response, but was reassuring that the patient did not have multiple myeloma. Likewise, the absence of occult blood in the stool on multiple occasions and the negative barium enema were also reassuring. Multiple sputum cultures were obtained in search of acid-fast bacilli and fungus, all of which were negative. Tuberculosis should always be ruled out in an elderly patient with a cough and fever.