Archive for December 17, 2011

A comprehensive evidence-based approach to fever of unknown origin.

Arch Intern Med. 2003 Mar 10 V.163 N.5 P.545-51.

Mourad O, Palda V, Detsky AS.


Department of Medicine, University of Toronto, Ontario, Canada.



Fever of unknown origin (FUO) is defined as a temperature higher than 38.3 degrees C on several occasions and lasting longer than 3 weeks, with a diagnosis that remains uncertain after 1 week of investigation.


A systematic review was performed to develop evidence-based recommendations for the diagnostic workup of FUO. MEDLINE database was searched (January 1966 to December 2000) to identify articles related to FUO. Articles were included if the patient population met the criteria for FUO and they addressed the natural history, prognosis, or spectrum of disease or evaluated a diagnostic test in FUO. The quality of retrieved articles was rated as “good,” “fair,” or “poor,” and sensitivity, specificity, and diagnostic yield of tests were calculated. Recommendations were made in accordance with the strength of evidence.


The prevalence of FUO in hospitalized patients is reported to be 2.9%. Eleven studies indicate that the spectrum of disease includes “no diagnosis” (19%), infections (28%), inflammatory diseases (21%), and malignancies (17%). Deep vein thrombosis (3%) and temporal arteritis in the elderly (16%-17%) were important considerations. Four good natural history studies indicate that most patients with undiagnosed FUO recover spontaneously (51%-100%). One fair-quality study suggested a high specificity (99%) for the diagnosis of endocarditis in FUO by applying the Duke criteria. One fair-quality study showed that computed tomographic scanning of the abdomen had a diagnostic yield of 19%. Ten studies of nuclear imaging revealed that technetium was the most promising isotope, showing a high specificity (94%), albeit low sensitivity (40%-75%) (2 fair-quality studies). Two fair-quality studies showed liver biopsy to have a high diagnostic yield (14%-17%), but with risk of harm (0.009%-0.12% death). Empiric bone marrow cultures showed a low diagnostic yield of 0% to 2% (2 fair-quality articles).


Diagnosis of FUO may be assisted by the Duke criteria for endocarditis, computed tomographic scan of the abdomen, nuclear scanning with a technetium-based isotope, and liver biopsy (fair to good evidence). Routine bone marrow cultures are not recommended.

Comment: Diagnostic evaluation reviewed: 1)Confirm (daily temps), Fever pattern-not helpful, Stop meds-fewer resolves <48hr;2)Abd CT: yield up to 20%, Nuclear scan: variable, Endocarditis: Duke criteria; Liver bx: 14-17% yield, Temporal artery bx: 16% yield, Leg doppler: 2-6% yield. Tests considered useless: Ultrasound, bone scan, D-dimer, ESP & CRP.

Comment in

ACP J Club. 2003 Sep-Oct;139(2):49.

Arch Intern Med. 2004 Jan 12;164(1):109.

Arch Intern Med. 2003 Sep 8;163(16):1976-7; author reply 1977-8.



December 17, 2011 at 9:37 pm Leave a comment

Specific endoscopic features of ulcerative colitis complicated by cytomegalovirus infection.

World J Gastroenterol. 2010 Mar 14;16(10):1245-51.

Suzuki H, Kato J, Kuriyama M, Hiraoka S, Kuwaki K, Yamamoto K.


Department of Gastroenterology and Hepatology, Okayama University Graduate, School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan.



To identify specific colonoscopic findings in patients with ulcerative colitis (UC) complicated by cytomegalovirus (CMV) infection.


Among UC patients who were hospitalized due to exacerbation of symptoms, colonoscopic findings were compared between 15 CMV-positive patients and 58 CMV-negative patients. CMV infection was determined by blood test for CMV antigenemia. Five aspects of mucosal changes were analyzed (loss of vascular pattern, erythema, mucosal edema, easy bleeding, and mucinous exudates) as well as five aspects of ulcerative change (wide mucosal defect, punched-out ulceration, longitudinal ulceration, irregular ulceration, and cobblestone-like appearance). Sensitivity, specificity, positive predictive value, and negative predictive value of each finding for CMV positivity were determined.


The sensitivity of irregular ulceration for positive CMV was 100%. The specificity of wide mucosal defect was 95%. Punched-out ulceration and longitudinal ulceration exhibited relatively high sensitivity and specificity (more than 70% for each).


Specific colonoscopic findings in patients with UC complicated by CMV infection were identified. These findings may facilitate the early diagnosis of CMV infection in UC patients.



December 17, 2011 at 9:34 pm Leave a comment

Cytomegalovirus ileitis in an immunocompetent patient.

Rev Esp Enferm Dig. 2011 Mar;103(3):154-6.

Tejedor Cerdeña MA, Velasco Guardado A, Fernández Prodomingo A, Concepción Piñero Pérez MC, Calderón R, Prieto Bermejo AB, Sánchez Garrido A, Martínez Moreno J, Geijo Martínez F, Blanco Múñez OJ, Rodríguez Pérez A.


Department of Digestive Diseases, Hospital Universitario de Salamanca, Spain.


Cytomegalovirus (CMV) is a virus that belongs to the family of Herpesviridae. Infection can cause a serious disease in immunocompromised patients, but it can also affect immunocompetent patients, creating generally self limiting symptoms. However, in some cases it can be fatal. We present a case of CMV ileitis with serious clinical symptoms that led to an operation in an immunocompetent patient.


December 17, 2011 at 9:32 pm Leave a comment


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