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Forum Name: Other infections

Question: PUO with Raised ESR and CRP


 miakbar - Fri Aug 06, 2010 2:04 pm

Past History
1. Had operation of Hernia in 1958.
2. Operation of rhinitis and DNS in 1959, for that had ionization, turbinate caoutry, and tonsillectomy and finally SMR. Relieving the symptoms of rhinitis by 50%. Even till today have to take some decongestant medicines off and on.
3. Had a depressed fracture of first lumbar vertebra in 1965 (in a car accident). It got healed in 3 months with the use of a plastic jacket.
5. Had operation for fistula anno, in 1978.
6. Had a kerri spine of 8th and 9th dorsal vertebra in 1981, after use of anti tubercular and plastic jacket for 1 year it got healed.
7. In 1987 had coronary heart disease, at that time which was attributed to my being overweight. An angiography was done but due to a minor lesion only weight reduction was advised, which was done so successfully and being maintained till today.
8. All the parameters including blood pressure, blood sugar, lipid profile, LFT’s and renal parameters remained normal throughout the life.
Present Condition
1. Had fever 101 – 102 °F for that started Amoxiclav 625 mg bd for 4 days. (26th June 2010).
2. With fever there was a slight headache , para nasal sinus congestion along with body aches and pains.
3. The fever did not subside with Amoxiclav. Considering that there is some strong infection had Ceftriaxon, 500 mg IM BD for 5 days. In the meantime, the headache started increasing with a slight lethargy and fatigue. No loss of appetite, bowel habits remained normal, no urinary burning no cough, no expactoration.
4. Even after 5 day’s use of Ceftriaxon, no reduction in fever and which continued to appear in the morning, evening, and rising up to 101°F. In between, however there used to be no temperature.
5. There was no shivering, all joints were clear with no pain or rigidity.
6. Next anti biotic used was Cefixiam, 400 mg for 5 days BD.
7. In the meantime (1 July 2010) had few blood tests, XRay PNS, X Ray chest. Results were as follows:
a. Hemoglobin - 10.7 g/dl.
b. ESR - 36mm.
c. TLC 10x9/L - 5.7
d. Differential
1) Neutrophile - 60%
2) Lymphocytes - 32%
3) Eosinophils - 05%
4) Monocytes - 03%
5) Platelet C (10x9/L) - 236
6) RBC Count (10/l) - 5.9
7) PCV - 30.0%
8) MCV (fl) - 56.4
9) MCH (pg) - 17.8
10) MCHC g/dl - 31.5
11) Blood for MP - No MP seen.
Chemistry.
a. Glucose (R) mg/dl - 116
b. T. Cholesterol mg/dl - 184
c. T. Bilirubin mg/dl - 1.0
d. ALT (SGPT) iu/l - 34
e. Creatinine mg/dl - 1.0
X Ray Report of Para nasal Sinus (PNS) done on 1 July 2010, is as follows,
a. Relative opacification of left maxillary antrum observed.
b. Right maxillary antrum , ethomoidal and frontal sinuses are adequately aerated.
c. Nasal septum is central with partial loss of the left nasal cavity volume.
d. There is no detectable bony lesion related to the visible areas of skeleton.
e. No foreign body seen in visible soft tissues.
Conclusion: Left maxillary sinusitis.
X Ray chest frontal (PA) image report is as follows:
a. There is no recognizable acute or chronic exudative lesion in visible areas of lung fields.
b. No hilar or para hilar abnormality observed.
c. Cardiac silhouette is normal with normal cardio thoracic ratio of this respiratory status and age of the patient.
e. No significant upper lobe vessels prominence observed.
f. No pleural fluid observed.
g. Invisible areas normal and intact skeleton observed.
h. Extra thoracic soft tissues are normal.
Conclusion: No acute or active chronic lung field lesion, hilar or mediastinal ymphadenopathy observed.
8. After taking two antibiotics the fever pattern changed slightly with it only appearing during the midday’s or after noon’s and continues till taking of anti pyretic.
9. Tumor marker report, done on 13 July 2010. Tested for PSA – 0.3 ng/ml
10. Widal test done on 23 June 2010, for which the result was negative.
11. On 27 July 2010, after consulting the medical specialist who advised 3 g a day for 4 days IV, (injection Tienam), no change in the fever pattern was observed.
12. Blood Test report as on 27 July 2010 is as follows:
a. Hemoglobin - 9.3 g/dl.
b. ESR - 70mm.
c. TLC 10x9/L - 9.8
d. Differential
1) Neutrophile - 70%
2) Lymphocytes - 22%
3) Eosinophils - 05%
4) Monocytes - 03%
5) Platelet C (10x9/L) - 345
6) RBC Count (10/l) - 5.0
7) PCV - 27.1%
8) MCV (fl) - 56.1
9) MCH (pg) - 17.9
10) MCHC g/dl - 32

USG of Abdomen (29 July 2010)
Liver It is normal in size and shows increased echogenecity with smooth margins. No focal lesion or dilated channels seen. Rt dome of diaphragm moves freely. No pleural effusion is seen.
Gall Bladder It shows a 1.3 cm calculus. No mass or thickening of its walls is seen. No fluid collection is seen around it. CBO is of normal caliber.
Pancreas It shows normal echotexture. No mass or focal lesion is seen. Pancreatic duct is normal in caliber.
Spleen It is normal in size and echotexture. No focal lesion is seen.
Rt kidney It is normal in size, shape and echotexture. No mass cyst, calculus or hydronephrosis is seen. The ureter is not dilated.
Lt Kidney Normal in size, shape and echotexture. No mass cyst, calculus or hydronephrosis is seen. The ureter is not dilated.
Urinary Bladder It is partially filled. No stone or mass is noted.
No ascites detected.
No para-aorrtic lymphadenopathy is seen.
Impression Cholelithiasis.
Fatty liver.
13. On 31st July 2010 consulted another medical specialist who advised few other tests and also advised anti malaria course which was completed. Reports and tests are as follows:
ANA was negative.
QRA was normal.
MP was negative. 2 August 2010.
CRP was elevated i-e 9 mg/dl.
14. As mentioned earlier there is no cough or sputum, no vomiting or no diherroea,. There is also no muscular aches or joints rigidity.
15. However on the onset of the temperature there is a severe headache, slight nasal congestion with throat irritation which subsides with the lowering of the fever. This pattern of fever is continued till today. Presently, since last 10 days it starts around midday starting from 99 °F and goes up to 101 °F. It subsides with an antipyretic followed by a gap of no temperature till next day.
16. No anorexia, change of weight, Melina or history of piles .
17. Routine walking is possible but gets fatigue symptoms are very quick to appear and there is general feeling of tiredness with recurring fever.
 Dr.M.jagesh kamath - Sat Aug 21, 2010 11:58 am

User avatar Hello,PUO is diagnosed if a paitent has more than 38C in several occasions in 3 weeks and inability to diagnose in 1 week of inpatient treatment after investigations.
Most of these ultimately turn out to be either infections,cancers or autoimmune disorders.Bacterial causes would include abscesses,tuberculosis,urinary infections,HIV,Brucellosis(History of contact with cattle),tick bites(lyme disease)Drug fever(Betalactams),collagen disease,etc.
In your case tuberculosis still needs to be ruled out despite normal xrays.Mantoux test,early moring gastric aspirates,culture of urine for AFB may be required.Also many patients with PUO over 50 have been diagnosed with connective tissue disorders thus needing ANA testing.Lymphomas need to be ruled out too.
In tropics the first to ruled out would be tuberculosis.
Best wishes.

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