de origen desconocido
Med 2000 Feb;107(2):259-62, 265-6 [Texto
Fever without source in children. Recommendations for outpatient care
in those up to 3.
Department of Pediatrics, Texas Tech University Health Sciences Center,
Odessa 79763, USA. email@example.com
It is the author's goal to reduce risk to a minimum in children with fever
without source at a reasonable cost with guidelines that are practical for
office-based physicians. Recommendations are as follows: All febrile
infants and children up to 36 months of age who have toxic manifestations
are to be hospitalized for parenteral antibiotic therapy after an
expeditious evaluation of their condition that includes cultures of blood,
urine, and cerebrospinal fluid. All febrile infants 7 days of age or less
should be hospitalized for empirical antibiotic therapy after a complete
evaluation for sepsis and meningitis has been done. Some low-risk febrile
infants 8 to 28 days of age who appear well may be observed closely,
either in hospital (with or without empirical antibiotic therapy) or as
outpatients if the physician believes that close follow-up is ensured.
Febrile infants 28 to 90 days of age should have an evaluation to
determine whether they are in a low-risk group. Those not meeting low-risk
criteria should be hospitalized for a complete "sepsis workup"
and close observation, with or without empirical antibiotic therapy. Those
who are considered low-risk can be treated as outpatients, as described,
if close follow-up is ensured. No laboratory tests or antibiotics are
needed in a child over 90 days of age who has a temperature of less than
39 degrees C (102.2 degrees F) without identifiable source. A return visit
is recommended if the child's fever persists for more than 2 to 3 days or
if the condition deteriorates. A child with a fever of 39 degrees C or
above can also be treated as an outpatient without antibiotics if close
follow-up is ensured. Otherwise, a WBC count or ANC should be done. In
those whose WBC count is 15,000/mm3 or more or whose ANC is 10,000
cells/mm3 or more, a blood culture should be done, and pending results, a
single injection of ceftriaxone, 50 mg/kg, should be given.
Emerg Med Clin North Am 1999 Feb;17(1):97-126, viii-ix
Evaluation of the infant with fever without source: an evidence based
Slater M, Krug SE
Division of Emergency Medicine, Northwestern University Medical School,
Chicago, Illinois, USA.
The infant with fever without an obvious source upon physical examination
offers a challenging clinical problem. A combination of detailed history,
physical examination, and selected laboratory tests allows the clinician
to discern which infants are at lower risk for bacterial illness.
Implications for management and future research are discussed herein.
Clin Infect Dis 1999 Feb;28(2):341-5
Human immunodeficiency virus-associated fever of unknown origin: a
study of 70 patients in the United States and review.
Armstrong WS, Katz JT, Kazanjian PH
Department of Internal Medicine, University of Michigan Medical Center,
Ann Arbor 48109-0378, USA.
To characterize the clinical features of human immunodeficiency virus
(HIV)-associated fever of unknown origin (FUO) in the United States, we
performed a retrospective analysis of cases that fulfilled specific
criteria (published by Durack and Street in 1991) at two medical centers
in the United States between 1992 and 1997. Seventy cases met criteria for
HIV-associated FUO; the mean CD4 cell count was 58/mm3, and the mean
duration of fever was 42 days. A cause of FUO was found in 56 of the 70
cases; 43 were of a single etiology, and in 13 cases multiple conditions
were established. The most common diagnoses were disseminated
Mycobacterium avium infection (DMAC; 31%), Pneumocystis carinii pneumonia
(13%), cytomegalovirus infection (11%), disseminated histoplasmosis (7%),
and lymphoma (7%). In this United States series, FUO occurs most often in
the late stage of HIV infection, individual cases often have multiple
etiologies, and DMAC is the most common diagnosis.
Review of reported cases
MSMR 1998;v03-n4 [Texto
completo en formato PDF]
Hospitalizations Among Active Duty Soldiers for 'Fevers of Unknown
Origin' Surveillance Trends
the rigor of diagnostic evaluations of febrile soldiers were to decline
over time, or if soldiers were to acquire etiologically obscure ( emerging
) infectious diseases in clus-ters or at progressively higher rates, then
hospital-izations with discharge diagnoses of fever of unknown origin
might be expected to increase. This report assesses trends and
characteristics of recent hospitalizations of soldiers with fevers of
unknown origin. In contrast, at MTF A after September 1994, the FUO rate
was 4.8 per month, there were 19 months with three or more cases, nearly
half (45.9%) of cases were among Privates/ E- 1, and the mean length of a
hospitalization was 1.2 days. Thus, at MTF A after October 1994 compared
to before, FUO hospitalizations affected lower rank-ing soldiers, were
nearly four- times more frequent, and were approximately one- tenth as
long. 01 11 Ft Sill Ft McClellan Ft Leonard Wood Ft Benning Figure III.
ARD surveillance rates, submitted by Army TRADOC posts ARD Surveillance
Update Legend ARD Rate = (ARD cases / Trainees) 100 SASI* = ARD Rate Strep
Rate Heat Injuries Cold Injuries Reporting MTF/ Post** Heat Exhaustion
Heat Stroke Frostbite Hypothermia Immersion Unspecified
An Med Interna 1997 Nov;14(11):585-92
[Fever of unknown origin in internal medicine. The experience of
Spanish authors over 20 years].
Ramos Rincon JM, Ramos Guevara R, Herrero Huerta F
Servicio de Medicina Interna, Hospital General Universitario Morales
The diseases responsible of fever of unknown origin (FUO) have changed in
the last years. With the object of study the etiologic spectrum and
diagnostic attitude in the FUO in a national level in the last 25 years,
we has revised 14 articles of FUO realized in Internal Medicine published
from 1970 to 1995, without aids patients. We use MEDLINE and Indice Medico
Espanol to search the publications about FUO. In 14 articles, 914 cases of
FUO was evaluated, the infection was the principal cause (41.2%), followed
by tumor (19.2%) and collagenoses/vasculitis (13.7%). In the infection
group, the disease more frequent was the tuberculosis (134/377) (35.5%)
follow by brucellosis (15.6%) y abscesses (11.6%). Half of malignancy
group was due to lymphoma. Systemic lupus erythematous, polyarteritis
nodosa and temporal arteritis were caused of FUO in 28.8%, 21.6% y 20% of
collagenoses/vasculitis group. In the miscellaneous group emphasized
granulomatous diseases (38.8%) (including sarcoidosis, idiopathic
granulomatous hepatitis and chronic granulomatous disease). The improve of
diagnostic procedures has conditioned a change of spectrum of the
diseases, with a decrease of infectious causes (as brucellosis or
salmonellosis) and increase or neoplasia and collagenoses/vasculitis
Clin Infect Dis 1997 Sep;25(3):551-73
1997 guidelines for the use of antimicrobial agents in neutropenic
patients with unexplained fever. Infectious Diseases Society of America.
Hughes WT, Armstrong D, Bodey GP, Brown AE, Edwards JE, Feld R, Pizzo
P, Rolston KV, Shenep JL, Young LS
Fever and Neutropenia Guideline Panel, Infectious Diseases Society of
America, Alexandria, Virginia, USA.
This is the first in a series of practice guidelines commissioned by the
Infectious Diseases Society of America through its Practice Guidelines
Committee. The purpose of these guidelines is to provide assistance to
clinicians when making decisions on treating the conditions specified in
each guideline. The targeted providers are internists, pediatricians, and
family practitioners. The targeted patients and setting for the fever and
neutropenia guideline are hospitalized individuals with neutropenia
secondary to cancer chemotherapy. Panel members represented experts in
adult and pediatric infectious diseases and oncology. The guidelines are
evidence-based. A standard ranking system was used for the strength of the
recommendations and the quality of the evidence cited in the literature
reviewed. The document has been subjected to external review by peer
reviewers as well as by the Practice Guidelines Committee and was approved
by the IDSA Council. An executive summary, algorithms, and tables
highlight the major recommendations. The guideline will be listed on the
IDSA home page at http://www.idsociety.org.
Lancet 1997 Aug 23;350(9077):575-80 [Texto
Fever of unknown origin.
Arnow PM, Flaherty JP
Department of Medicine, University of Chicago, University of Chicago
Hospitals, IL 60637, USA.
Comment in: Lancet 1997 Nov 8;350(9088);1401-2
Comment in: Lancet 1997 Dec 13;350(9093):1782
Clin Infect Dis 1997 Mar;24(3):291-300; quiz 301-2
Fever of unknown origin in adults.
Seattle Veterans Affairs Medical Center, Washington 98108, USA.
Comment in: Clin Infect Dis 1998 Feb;26(2):534-5
Am Fam Physician 1996 Dec;54(8):2503-12
Fever without source in infants and young children.
University of Kansas Medical Center, Kansas City, Kansas.
Febrile infants and young children pose a challenge to primary care
physicians because the clinical appearance of children who present with
fever without source that is related to a viral illness may be similar to
the appearance of those with occult bacteremia. The evaluation of the
febrile infant and child comprises a comprehensive history, a thorough
physical examination and judicious use of laboratory studies. The
information derived from this evaluation will help clinicians with the two
key management decisions that face physicians caring for this vulnerable
population: the initiation and use of antimicrobial therapy, and inpatient
versus outpatient management. Although no optimal diagnostic and
therapeutic schema exists, physicians should take a structured and
rational approach to these patients, depending on their own clinical
experience and interpretation of the literature on this topic.
Comment in: Am Fam Physician 1996 Dec;54(8):2362-4, 2366
Arch Intern Med 1996 Mar 25;156(6):618-20
Long-term follow-up of patients with undiagnosed fever of unknown
Knockaert DC, Dujardin KS, Bobbaers HJ
Department of General Internal Medicine, Gasthuisberg University Hospital,
BACKGROUND: A casual diagnosis cannot be established in 10% to 25% of the
patients who are studied for fever of unknown origin (FUO). The long-term
clinical outcome of these patients cannot be inferred from the literature.
This study describes the results of a 5-year follow-up of 61 patients
studied for FUO and discharged from the hospital with no causal diagnosis
being established. METHODS: Patients meeting the classic criteria for FUO
who were studied in the 1980s and discharged from the hospital without a
casual diagnosis were followed up for at least 5 years or until death.
Follow-up was performed by review of the patients' medical records or by
consulting the treating physician and occasionally the patients
themselves. The final diagnosis, clinical course (resolution of the fever
and required treatments), and morality rate were studied. RESULTS: Of a
cohort of 199 patients with FUO, 61 individuals (30%) were discharged from
the hospital without a final diagnosis being established. A definite
diagnosis could be established in 12 cases, mostly (eight of 12) within 2
months after discharge. Thirty-one individuals became symptom free during
hospitalization or shortly following discharge. Eighteen patients had
persisting or recurring fever for several months or even years after
discharge, but 10 of them were considered to be finally cured. Four
patients were treated with corticosteroids and six patients required
intermittent therapy with nonsteroidal anti-inflammatory agents. Six
patients died, but the cause of death was considered to be related to the
disease that caused FUO in only two cases. CONCLUSION: No single disease,
particularly not tuberculosis, was found to be a cause of undiagnosed FUO.
Most cases resolved spontaneously, and corticosteroids were seldom
required. Most symptomatic patients could be treated with nonsteroidal
anti-inflammatory drugs. The mortality rate in patients with undiagnosed
FUO who were followed up for 5 years or more was only 3.2%.
Infect Dis Clin North Am 1996 Mar;10(1):93-9
Fever in the elderly.
Norman DC, Yoshikawa TT
West Los Angeles Veterans Affairs Medical Center, California, USA.
Fever in elderly persons is only one clinical presentation that can be
used to assist the clinician at suspecting a serious disease, such as an
infection. Infections, like all other illnesses in the geriatric patient,
may occur with a variety of nonspecific, atypical, nonclassic, and unusual
manifestations. The clinician caring for elderly patients should be aware
of these nonclassical presentations of infections in this age group.
Unexplained change in functional capacity, worsening of mental status,
weight loss or failure to thrive, weakness and fatigue, falls, and
generalized pain are only some of the clues that may aid the clinician in
considering infection in elderly persons. Key concepts of fever in older
adults are: Fever generally indicates presence of serious infection, most
often caused by bacteria. Fever may be absent in 20%-30% of elderly
patients harboring a serious infection. Criteria for fever in elderly
patients should also include an elevation of body temperature of at least
2 degrees F from baseline values. FUO in elderly persons is caused by
infections (30%-35%), CTD (25%-30%), and malignancies (15%-20%) in the
majority of cases.
Infect Dis Clin North Am 1996 Mar;10(1):149-65
Fever in patients with HIV infection.
Sullivan M, Feinberg J, Bartlett JG
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Fever is a common sign during the course of HIV infection, usually
represents a superimposed opportunistic infection, and is almost always a
treatable condition. Proper management generally requires detection of the
underlying cause, and the diagnostic evaluation is largely driven by the
clinical symptoms, associated conditions such as injection drug use, and
stage of disease based largely on the absolute CD4 cell count. This
article provides guidelines for the management of fever in the patient
with HIV infection.
Infect Dis Clin North Am 1996 Mar;10(1):111-27
Fever of unknown origin.
Infectious Disease Division, Winthrop-University Hospital, Mineola, New
Fever of unknown origin (FUO) is defined as a temperature elevation of 101
degrees F (38.3 degrees C) or higher for 3 weeks or longer, the cause of
which is not diagnosed after 1 week of intensive in-hospital
investigation. This article discusses the causes, diagnosis, and treatment
Clin Infect Dis 1995 Dec;21(6):1492-4
Inflammatory pseudotumor presenting as fever of unknown origin.
Fisher RG, Wright PF, Johnson JE
Department of Pediatrics, Vanderbilt University Medical Center, Nashville,
Inflammatory pseudotumor (IPT) is an uncommon benign neoplasm of uncertain
etiology that classically has been associated with the lung, where it is
generally asymptomatic. In recent years, IPT has been increasingly
recognized in other sites. Hepatic, abdominal, and pelvic IPTs produce a
spectrum of nonspecific symptoms including fever, malaise, anemia, and
weight loss. Because prolonged fever is a prominent feature of
extrapulmonary IPT, patients with this condition may first come to the
attention of specialists in infectious diseases. We describe an
illustrative case of pelvic IPT and discuss its presentation, diagnosis,
and treatment; we also suggest that infectious disease specialists should
be familiar with this entity as a possible diagnosis for patients with
fever of unknown origin.
Review of reported cases
Med Clin (Barc) 1995 Nov 11;105(16):615-6
[Fever of unknown origin in HIV infection. New facets of an old
Barbado Hernandez FJ, Pena Sanchez de Rivera JM
Comment in: Med Clin (Barc) 1996 Jun 29;107(5):198
Pediatr Clin North Am 1995 Oct;42(5):999-1015
Fever of unknown origin.
Miller ML, Szer I, Yogev R, Bernstein B
Department of Pediatrics, Northwestern University Medical School, Chicago,
The causes of fever in a child can vary from minor brief illnesses to
life-threatening infectious, malignant, or autoimmune diseases. The
physician often has to evaluate children with fevers of as yet undiagnosed
cause lasting fewer than 2 weeks, in whom it is important to determine
whether localizing findings are present. Fever without localizing signs
and fevers complicating chronic disease and resulting from specific
localized infection are considered in the sections concerning infectious
causes, immunodeficiency diseases, and rheumatic diseases. The diagnostic
and therapeutic approaches to the child with both prolonged fever and
fever of unknown origin are then discussed, with emphasis on rheumatic
Am Fam Physician 1994 Dec;50(8):1717-27
The role of scintigraphy in the evaluation of fever of unknown origin.
Weissman AF, Fig LM, Sisson J, Seow A, Shapiro B
Division of Nuclear Medicine, University of Michigan Medical Center, Ann
Nuclear medicine imaging techniques are an important adjunct to other
currently used modalities in the evaluation of patients with fever of
unknown origin. Bone scanning performed with technetium-labeled
phosphonate agents may identify osteomyelitis when plain radiography fails
and may disclose sites of joint
inflammation or unsuspected osseous tumor metastasis. Indium-labeled
autologous leukocytes localize at sites of inflammation in the same manner
as unlabeled leukocytes. Gallium citrate accumulates in areas of
inflammation and in some tumors, most notably lymphomas. In most cases,
scintigraphy is best used to determine the location of a lesion rather
than to specifically identify the pathologic process.
J Am Geriatr Soc 1993 Nov;41(11):1187-92
Fever of unknown origin in elderly patients.
Knockaert DC, Vanneste LJ, Bobbaers HJ
University Hospital Gasthuisberg, Catholic University of Leuven, Belgium.
OBJECTIVE: To describe the spectrum of diseases that may give rise to
fever of unknown origin in elderly patients and to delineate the
diagnostic approach in these patients. DESIGN: Subgroup analysis of a
prospectively collected case series followed more than 2 years. SETTING:
General Internal Medicine Service based at University hospital, Leuven,
Belgium. PATIENTS: Forty-seven consecutive patients, older than 65 years,
meeting the classic criteria of fever of unknown origin. MEASUREMENTS: The
final diagnosis established and the clinical value of diagnostic
procedures. RESULTS: Infections, tumors and multisystem diseases
(encompassing rheumatic diseases, connective tissue disorders, vasculitis
including temporal arteritis, polymyalgia rheumatica, and sarcoidosis)
were found in 12 (25%), six (12%) and 15 patients (31%), respectively.
Drug-related fever was the cause in three patients (6%), miscellaneous
conditions were found in five patients (10%), and six patients (12%)
remained undiagnosed. Microbiologic investigations were diagnostic in
eight cases (16%), serologic tests yielded one diagnosis, immunologic
investigations had a diagnostic value in four cases, standard X-rays
yielded a diagnostic contribution in 10 cases, ultrasonography and
computed tomography were diagnostic in 11 cases, Gallium scintigraphy had
a diagnostic contribution in 17 cases, and biopsies yielded the final
diagnosis in 18 cases. CONCLUSIONS: Multisystem diseases emerged as the
most frequent cause of fever of unknown origin in the elderly, and
temporal arteritis was the most frequent specific diagnosis. Infections,
particularly tuberculosis, remain an important group. The percentage of
tumors was higher in our elderly patients than in the younger ones but
still clearly lower than in other recent series of FUO in adults. The
number of undiagnosed cases was significantly lower in elderly patients
than in younger individuals (P < or = 0.01). The investigation of
elderly patients with FUO should encompass routine temporal artery biopsy
and extensive search for tuberculosis if the classic tests such as blood
count, chemistry, urinalysis, cultures, chest X-rays, and abdominal
ultrasonography do not yield any clue. Gallium scintigraphy should be
considered as the next step and not as a last-resort procedure.