Pt with Fever of Unknown Origin

[Firebird]

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Ok, medical mystery time. I would love some input from anyone who has some idea.

Pt is an 8 year old male with Fever of Unknown Origin x5 weeks. Pt appears well even during fever spikes and has tmax of 106F. Pt had every test known to man run on him and all came back neg. Was sent to major pediatric medical facility to ID specialist who essentially said we had done everything right. They suggested a CT scan, head to pelvis, which revealed microabscesses of the spleen and liver. So I guess it's not longer a fever of unknown origin, but rather a case of microabscesses of unknown origin. Now, the literature shows this type of presentation only in children who are immunocompromised. This child has not shown any signs of immunocompromise to this point, but immunological tests are being run.

Main DDx from literature is:

1. Listeriosis
2. Cat-scratch fever
3. TB
4. Fungus (Candidiasis, etc.)

All blood cx's have been negative. PPD is negative. Cat scratch test is negative.

Has anyone ever come across anything remotely like this? Please note that this is not a real patient.

 

[gildas]

Ok, medical mystery time. I would love some input from anyone who has some idea.

Pt is an 8 year old male with Fever of Unknown Origin x5 weeks. Pt appears well even during fever spikes and has tmax of 106F. Pt had every test known to man run on him and all came back neg. Was sent to major pediatric medical facility to ID specialist who essentially said we had done everything right. They suggested a CT scan, head to pelvis, which revealed microabscesses of the spleen and liver. So I guess it's not longer a fever of unknown origin, but rather a case of microabscesses of unknown origin. Now, the literature shows this type of presentation only in children who are immunocompromised. This child has not shown any signs of immunocompromise to this point, but immunological tests are being run.

Main DDx from literature is:

1. Listeriosis
2. Cat-scratch fever
3. TB
4. Fungus (Candidiasis, etc.)

All blood cx's have been negative. PPD is negative. Cat scratch test is negative.

Has anyone ever come across anything remotely like this? Please note that this is not a real patient.

Did they test for parasites or fungus? I think biopsy will be needed to run test on. Just a humble opinion from a Medical Technologist.

 

[14022]

A few thoughts....

Any chance this patient has an intravascular process, such as an suppurative thrombophlebitis or intravascular invasion of fungus, in an artery proximal to the liver and spleen and seeding these organs with infected emboli? Did the patient have a vascular ultrasound?

Also, did you guys think about doing a tagged white blood cell test (nuclear medicine) to see if there are any other areas of occult infection?

Sounds like an interesting case. Keep us posted. Good luck!

 

[Firebird]

All good suggestions. However, she had a head to toe CT which should have revealed any kind of thrombus.

She has been shipped back to the large medical center for their ID group to take over the case. However, I have heard that one of our attendings is saying Cat Scratch Fever, even though she had none of the clinical hallmarks (ie, lymphadenopathy). His basis is that the IgG was positive (IgM neg) and that a relative has like 20 cats.

Will continue to post w/ new info.