A 66 years old man with a long history of diabetes, hypertension and ischemic heart disease, suffer from fever for 1 week. Initially body temperature was arround 38 and was intermittent then become around 38.5 and continuous, with no response to empiric antibiotic therapy with oral 3rd generation cephalosporin. Additional symptoms: myalgia, fatigue (intermittent), chills, and anorexia. ESR = 120. Chest X ray clear, general urine exam with very few pus cells.
Dear Jose Gustavo, what do you mean by Desidratação?
Further information about the case include:
WBC count 9720, then on second day 8540
mild monocytosis and eosinophilia
There is mild left shift as shown by blood film
HB 12.6 then on second day 12.4
Platelet normal
Now after 5 days with antibiotics (cefdinir) and newly added clarithromycin (for last 3 days) fever subside, but there is night sweat, no fatigue, no cough, no any pain and also appetite returned to normal
This sounds very much like an occult infection. Being a Cardiologist i believe this could well be a case of Infective Endocarditis. I would recommend 3 sets of blood culture within 24 hours, send MSU for culture and sensitivity. Get an urgent Transthoracic echocardiogram and stop empirical antibiotics. Treat the infection as per bloods culture results and seek microbiologist advise.
Dear Syed, Echo study shows no endocarditis, with good EF, now temp. settle down at 36.8 C with empiric therapy after 6 days
Search also or cancer (fever continuous, high ESR, monocytosis and night sweats). Lymphoma in particular
Dear Maurizio Salvadori, there is no fever and no night sweat after a course of 8 days of empiric antibiotic therapy... so is lymphoma is also possible?
Is there continuity of fever and chillis , of this "criptogenic pyrexy" ? ' if "yes", one must suspect "mild cryptogenic septic focus somewhere in urogenmital og hepatobiliar tracts, or some kind of monoclonal paraproteinemic disease, or autoimmune disease?? What about eosinophylia ? Transient or sustained? Also a possibility of some parasitic invasion! In any case, chills meians allmost always foreign protein in blood stream, transient or sustained.. What about lab ( SRP, rheuma factrors, fibrinogen etc.)?
As one can imagine, there are many differential diagnostic procedures to be done, in the case the disease is still present..
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