Unusual IVDU case

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BRNHILL

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24 y/o white man presents with low-grade fever (37.6 C), palpitations and cough 7 days after consuming (both oral and iv) 1g of MDMA. History of anabolic steroids use. No signs of skin infection. Infective endocarditis was suspected.

WBC - 6.0 ( ref. 4-10) (seg. 59%, band. 3%)
RBC - 6.6 (4-6.5)
HGB - 199 (130-170)
CRP - 0.7 (ref. 0-5)
ESR - 5 (1-10)
Procalcitonin - 0.05
Two blood cultures were taken - negative.
Hep C, HIV, TORCH inf., CMV - neg.
Chest X-ray, Head MRI - normal, ultrasound shows liver enlargment.
EKG - sinus tachicardia.
TTE on 8 day - negative for vegetations
TTE on 15 day - neg.
TEE on 15 day -neg.
TEE on 40 day - neg.
He is still has fever.

Can we rule out IE?
Differential? I would appreciate any ideas. Thanks.
 
Last edited:
BRNHILL said:
24 y/o white man presents with low-grade fever (37.6 C), palpitations and cough 7 days after consuming (both oral and iv) 1g of MDMA. History of anabolic steroids use. No signs of skin infection. Infective endocarditis was suspected.

WBC - 6.0 ( ref. 4-10) (seg. 59%, band. 3%)
RBC - 6.6 (4-6.5)
HGB - 199 (130-170)
CRP - 0.7 (ref. 0-5)
ESR - 5 (1-10)
Procalcitonin - 0.05
Two blood cultures were taken - negative.
Hep C, HIV, TORCH inf., CMV - neg.
Chest X-ray, Head MRI - normal, ultrasound shows liver enlargment.
EKG - sinus tachicardia.
TTE on 8 day - negative for vegetations
TTE on 15 day - neg.
TEE on 15 day -neg.
TEE on 40 day - neg.
He is still has fever.

Can we rule out IE?
Differential? I would appreciate any ideas. Thanks.
Click to expand...

broaden your differential. why is his liver enlarged at age 24?
 
surge55 said:
why is his liver enlarged at age 24?
Click to expand...

He was anabolic steroid user in the past.

Hypersensitivity myocarditis - elevateted Creatine Kinase, serum myoglobin, but no change on ECG and echo, ESR and CRP are normal.
Toxic hepatitis - he was on Heptral 400mg/day IV for 10 days, liver enzymes back to normal.
 
BRNHILL said:
He was anabolic steroid user in the past.

Hypersensitivity myocarditis - elevateted Creatine Kinase, serum myoglobin, but no change on ECG and echo, ESR and CRP are normal.
Toxic hepatitis - he was on Heptral 400mg/day IV for 10 days, liver enzymes back to normal.
Click to expand...

what does his urine look like?

heptral is interesting. I hadn't heard of it until now.

checked a TSH?
 
surge55 said:
what does his urine look like?

heptral is interesting. I hadn't heard of it until now.

checked a TSH?
Click to expand...

Both TSH and TPO antibodies are normal, thyroid ultrasound too.
Urinalysis - protein 0.066 g/l, no blood/bacteria/WBC.
No pathologic changes on kidneys ultrasound and adrenal glands MRI.
 
Last edited:
BRNHILL said:
24 y/o white man presents with low-grade fever (37.6 C), palpitations and cough 7 days after consuming (both oral and iv) 1g of MDMA. History of anabolic steroids use. No signs of skin infection. Infective endocarditis was suspected.

WBC - 6.0 ( ref. 4-10) (seg. 59%, band. 3%)
RBC - 6.6 (4-6.5)
HGB - 199 (130-170)
CRP - 0.7 (ref. 0-5)
ESR - 5 (1-10)
Procalcitonin - 0.05
Two blood cultures were taken - negative.
Hep C, HIV, TORCH inf., CMV - neg.
Chest X-ray, Head MRI - normal, ultrasound shows liver enlargment.
EKG - sinus tachicardia.
TTE on 8 day - negative for vegetations
TTE on 15 day - neg.
TEE on 15 day -neg.
TEE on 40 day - neg.
He is still has fever.

Can we rule out IE?
Differential? I would appreciate any ideas. Thanks.
Click to expand...

No significant inflammation, negative blood cultures, negative TEEs, seems very unlikely to be endocarditis unless your TEE docs suck. In my experience in a center that sees an absolute ton of endocarditis, the vast majority of endocarditis is not so occult.

Sounds to me like you have a fever of uknown origin. There area handful of fabulous articles on this subject. Scanning the chest/abdomen pelvis, connective tissue and malignancy rule which should include smears/BMBs to rule out HLH, lymphomas and leukemias in a young guy,. Occult infections (where I am this includes histo/blasto/TB) and if those are negative look for rare **** like PNH and the like.
 
I have no real idea what could be going on with this guy, though I suspect the liver is a huge clue. I'd want to know more about the characteristics of the liver; radiology should be of help in this instance.

But as a general rule: atypical presentations of common diseases are way more common than zebras. Let that sentence be your guide as you work to find the diagnosis.
 
Hmmm... I don't know why you're suspecting endocarditis in the first place. Negative cultures, negative TEE.

PET would probably be the next thing to do, might have an occult abscess somewhere. Or it could lead you to a wild goose hunt.
 
flipmd said:
Hmmm... I don't know why you're suspecting endocarditis in the first place. Negative cultures, negative TEE.

PET would probably be the next thing to do, might have an occult abscess somewhere. Or it could lead you to a wild goose hunt.
Click to expand...

Yup...PET and stick a needle in whatever you find. If you don't find anything, send to Rheumatology...that's what they're there for.
 
MDMA can cause persistent loss of thermoregulation. His hypothalamus was just in a fight with Floyd Mayweather.
 
This is a classic FUO, and if you want to get to the bottom of it you have to dig a bit deeper.

There's a cute way of remembering general categories of FUO causes (Big 3 and Little 6)...the big 3 are:
-infection
-neoplasm
-autoimmune

The Little 6 are a bit more interesting...
- regional enteritis
- drug fever
- factitious fever
- PE
- familial mediterranean fever
- granulomatous dz

Your infection workup needs to be broadened pretty substantially...I just worked up a case like this, and we sent out a raft of serologies and titers. Occult infections are a big part of this...not sure how much of a problem tickborne dz is in your area, but Lyme, Ehrlichiosis, Babesiosis, etc are big players around here...leptospirosis can definitely cause a prolonged low-grade fever too, as can malaria. Has this dude had any recent sick contacts? Travel? Insect bites? Contact with animals?

If he hasn't had blood smears already, he needs them...possibly a BMBx too.

I agree that with the ESR, procalcitonin, etc at the levels described, a non-infectious etiology is more likely.

Keep in mind that in at least one relatively large case series, something like 51% of FUOs went undiagnosed - but most of those people fared very well in the long run. Many undiagnosed FUOers run low grade fevers for a few months but ultimately become afebrile and have no other problems. (The mortality rate in people with FUOs is under 3%, iirc.) What symptoms does this guy have? Is he miserable, or is he basically chilling comfortably with a slight fever?
 
BRNHILL said:
24 y/o white man presents with low-grade fever (37.6 C), palpitations and cough 7 days after consuming (both oral and iv) 1g of MDMA. History of anabolic steroids use. No signs of skin infection. Infective endocarditis was suspected.

WBC - 6.0 ( ref. 4-10) (seg. 59%, band. 3%)
RBC - 6.6 (4-6.5)
HGB - 199 (130-170)
CRP - 0.7 (ref. 0-5)
ESR - 5 (1-10)
Procalcitonin - 0.05
Two blood cultures were taken - negative.
Hep C, HIV, TORCH inf., CMV - neg.
Chest X-ray, Head MRI - normal, ultrasound shows liver enlargment.
EKG - sinus tachicardia.
TTE on 8 day - negative for vegetations
TTE on 15 day - neg.
TEE on 15 day -neg.
TEE on 40 day - neg.
He is still has fever.

Can we rule out IE?
Differential? I would appreciate any ideas. Thanks.
Click to expand...

Pardon my asking, but was this guy spiking temperatures before he came in and happened to take some Tylenol prior to arrival? Because it seems to me that this guy's temp doesn't even meet the definition of "fever" by any criteria I've seen (99.7 F). You've got 0 major and 1 minor criteria for clinical endocarditis diagnosis. May I ask what the heck it was that compelled this guy to come in for evaluation, let alone admission? Was it the enlarged liver?
 
greatnt249 said:
Pardon my asking, but was this guy spiking temperatures before he came in and happened to take some Tylenol prior to arrival? Because it seems to me that this guy's temp doesn't even meet the definition of "fever" by any criteria I've seen (99.7 F). You've got 0 major and 1 minor criteria for clinical endocarditis diagnosis. May I ask what the heck it was that compelled this guy to come in for evaluation, let alone admission? Was it the enlarged liver?
Click to expand...

Yeah, this is a good point too...I hadn't looked that closely at what his actual temp was.

Why is this guy still in the hospital?
 
Because they are hospitalized in the Czech republic.
 
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