Fever of unknown origin (FUO) caused by miliary tuberculosis: Diagnostic significance of morning temperature spikes

Cunha, Burke A.; Krakakis, James; McDermott, Brian P.

doi:10.1016/j.hrtlng.2008.03.002

Cited by 23 publications

(18 citation statements)

References 23 publications

(57 reference statements)

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“…Occurrence of daily morning temperature spikes is reported to be characteristic of miliary TB 43. However, fever may be absent and the patients may present with progressive wasting strongly mimicking a metastatic carcinoma (cryptic miliary TB) 21,44,45.…”

Section: Clinical Presentationmentioning

confidence: 99%

Diagnosis and management of miliary tuberculosis: current state and future perspectives

Ray¹,

Talukdar²,

Kundu³

et al. 2013

TCRM

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Tuberculosis (TB) remains one of the most important causes of death from an infectious disease, and it poses formidable challenges to global health at the public health, scientific, and political level. Miliary TB is a potentially fatal form of TB that results from massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli. The epidemiology of miliary TB has been altered by the emergence of the human immunodeficiency virus (HIV) infection and widespread use of immunosuppressive drugs. Diagnosis of miliary TB is a challenge that can perplex even the most experienced clinicians. There are nonspecific clinical symptoms, and the chest radiographs do not always reveal classical miliary changes. Atypical presentations like cryptic miliary TB and acute respiratory distress syndrome often lead to delayed diagnosis. High-resolution computed tomography (HRCT) is relatively more sensitive and shows randomly distributed miliary nodules. In extrapulmonary locations, ultrasonography, CT, and magnetic resonance imaging are useful in discerning the extent of organ involvement by lesions of miliary TB. Recently, positron-emission tomographic CT has been investigated as a promising tool for evaluation of suspected TB. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, and rapid culture methods for isolation of M. tuberculosis in sputum, body fluids, and other body tissues aid in confirming the diagnosis. Several novel diagnostic tests have recently become available for detecting active TB disease, screening for latent M. tuberculosis infection, and identifying drug-resistant strains of M. tuberculosis. However, progress toward a robust point-of-care test has been limited, and novel biomarker discovery remains challenging. A high index of clinical suspicion and early diagnosis and timely institution of antituberculosis treatment can be lifesaving. Response to first-line antituberculosis drugs is good, but drug-induced hepatotoxicity and drug–drug interactions in HIV/TB coinfected patients create significant problems during treatment. Data available from randomized controlled trials are insufficient to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS, and the role of adjunctive corticosteroid treatment has not been properly studied. Research is going on worldwide in an attempt to provide a more effective vaccine than bacille Calmette–Guérin. This review highlights the epidemiology and clinical manifestation of miliary TB, challenges, recent advances, needs, and opportunities related to TB diagnostics and treatment.

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Section: Clinical Presentationmentioning

confidence: 99%

Diagnosis and management of miliary tuberculosis: current state and future perspectives

Ray¹,

Talukdar²,

Kundu³

et al. 2013

TCRM

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“…50,55 Morning temperatures spikes suggests miliary tuberculosis, typhoid/enteric fever or Whipple's disease. [50][51][52] Relative bradycardia is a cardinal finding in typhoid/enteric fever, malaria, babesiosis, ehrlichiosis/anaplasmosis, leptospirosis and Q fever. 44,45 Twice daily fever spikes (double quotidian fevers) suggests malaria, miliary tuberculosis or visceral leishmaniasis.…”

Section: Miscellaneous Disordersmentioning

confidence: 99%

Fever of Unknown Origin: A Clinical Approach

Cunha

Lortholary

Cunha

2015

The American Journal of Medicine

Self Cite

106

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Fevers of unknown origin remain one of the most difficult diagnostic challenges in medicine. Because fever of unknown origin may be caused by over 200 malignant/neoplastic, infectious, rheumatic/inflammatory, and miscellaneous disorders, clinicians often order non-clue-based imaging and specific testing early in the fever of unknown origin work-up, which may be inefficient/misleading. Unlike most other fever-of-unknown-origin reviews, this article presents a clinical approach. Characteristic history and physical examination findings together with key nonspecific test abnormalities are the basis for a focused clue-directed fever of unknown origin work-up.

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“…Owing to non-specific clinical symptoms and atypical presentations, the diagnosis of miliary TB poses a formidable challenge to physicians. With the advent of immunosuppressant and biological medications, increasing occurrence of organ transplantation and the global pandemic of HIV, the epidemiology of miliary TB has been altered 3. Historically, before the advent of antitubercular medication, miliary TB was considered a childhood disease, but it is now increasingly recognised in adults.…”

Section: Discussionmentioning

confidence: 99%

“…No single sign or symptom is diagnostic and clinicians should look for a constellation of symptoms such as peripheral lymphadenopathy, hepatosplenomegaly, pleural and pericardial effusions. Morning temperature spikes have a diagnostic significance and are reported to be characteristic, with patients presenting with ‘pyrexia of unknown origin’ and few systemic clues 3. Several papers have described sweat engraving the patient's silhouette on the bed, closely resembling a body's shadow, otherwise known as the ‘damp shadow sign’ 5…”

Section: Discussionmentioning

confidence: 99%

Miliary tuberculosis in an immunocompetent male with a fatal outcome

2016

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A man aged 33 years, born in Nepal, but resident in the UK for 7 years presented to the emergency department with a 4-day history of general malaise, fever (temperature 38.6°C) and a non-productive cough. His medical history was unremarkable and no high-risk behaviour was identified. Clinical examination confirmed decreased air entry bilaterally with bibasal crackles. He was tachycardic, with a heart rate of 120 bpm. Further investigation with a 12-lead ECG confirmed supraventricular tachycardia (SVT) which was terminated with vagal manoeuvres. His chest radiograph demonstrated left basal consolidation. His white cell count was 11×10/L and his C reactive protein was 43.2 mg/L. His blood cultures revealed no growth. He was diagnosed with community-acquired pneumonia and started treatment with amoxicillin and clarithromycin. 3 days post admission, he was intubated for 24 hours in the Department of Intensive Care Medicine. Further episodes of SVT were observed and an ECHO showed a severely dilated and impaired left ventricle. Further chest radiographs illustrated diffuse consolidation with evidence of pulmonary oedema. HIV serology was negative. He developed transaminitis and thrombocytopenia. An ultrasound scan of his liver showed no obvious liver pathology. He remained tachypnoeic and due to worsening pulmonary oedema and extensive consolidation, he was readmitted to the intensive care unit. A CT abdomen with contrast showed an unusual pattern of lymphadenopathy with disproportionately enlarged coeliac axis nodes (5×7×5 cm) and minor para-aortic adenopathy, suspicious for lymphoma. On inserting his central venous catheter in his right internal jugular vein, pus was inadvertently aspirated from his right neck. Acid alcohol fast bacilli (AAFFB) were isolated from the pus and was subsequently identified as Mycobacterium tuberculosis He started treatment with antitubercular medication rifater: a combination of rifampicin 720 mg od, isoniazid 300 mg po od and pyrazinamide 1750 mg. In addition, he received ethambutol 1000 mg po od and pyridoxine 5 mg. He developed worsening metabolic acidosis, pH 7.19, loss of respiratory compensation and pancytopenia. Right heart strain was evident on his Focused Intensive Care Echo. He developed an increased oxygen requirement and respiratory distress on the ventilator. An erect chest radiograph showed bilateral pneumothoraces and bronchopleural fistulae. A chest drain was inserted. Following discussion with the Cardiothoracic Surgeons, pleurodesis was not deemed possible. He developed inotropic-dependent shock with worsening lung compliance. As a result of his deteriorating ventilation, acidosis and hyperkalaemia, he started treatment with continuous veno-venous haemofiltration. With a diagnosis of miliary tuberculosis and SVT causing cardiogenic pulmonary oedema, this man sadly died with his family at his bedside 10 weeks following initial hospital presentation.

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Fever of unknown origin (FUO) caused by miliary tuberculosis: Diagnostic significance of morning temperature spikes

Cited by 23 publications

References 23 publications

Diagnosis and management of miliary tuberculosis: current state and future perspectives

Diagnosis and management of miliary tuberculosis: current state and future perspectives

Fever of Unknown Origin: A Clinical Approach

Miliary tuberculosis in an immunocompetent male with a fatal outcome

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