FEVER   76A

A 28-year-old woman presents to her primary care clinician because of intermittent fevers for the past 3 days, reaching 39°C. She reports a sore throat, myalgias, and stomach upset. She had unprotected sex with a new partner 2 weeks prior. On physical examination, there is diffuse, nontender lymphadenopathy in the axillary, cervical, and occipital regions and an erythematous throat without tonsillar exudates. HIV enzyme-linked immunosorbent assay (ELISA) test results negative, but HIV viral load shows 150,000 copies/mL.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Young woman; fever; myalgias; sore throat without tonsillar exudates; unprotected sex; lymphadenopathy; negative HIV ELISA result but positive viral load indicating acute HIV infection

How to think through: Although most acute febrile illnesses are self-limiting, many serious illnesses present with fever. What broad categories of disease could account for the initial presentation of—fever, this patient’s pharyngitis, myalgias, gastrointestinal upset, and lymphadenopathy? (Infection, such as infectious mononucleosis, cytomegalovirus, streptococcal pharyngitis, or acute HIV infections; malignancy, such as lymphoma; inflammatory disease, such as lupus or sarcoidosis.) Most patients with acute fever can be managed with supportive care but only after assessment of risk factors and “red flag” symptoms. What exposures and social risk factors should be assessed? (High-risk sexual activity; injection drug use; substance use; new medications; travel; occupational exposures; contact with ill persons.) Physical examination is important for localizing the source of fever and for refining the differential diagnosis. What examination elements should be included? (Mental status; neck range of motion; cardiac, lung, abdominal, skin, and joint examinations.) At this patient’s initial presentation, what diagnostic testing would be appropriate in addition to the HIV antibody test? (Complete blood count [CBC], rapid strep test, heterophile test. Blood cultures and liver tests should also be considered in febrile patients.) Here, the diagnosis is acute HIV infection. What initial testing is needed to begin planning her care? (CBC, CD4 T-cell lymphocyte count, HIV genotype, serum creatinine, liver tests, hepatitis B serologies, hepatitis C antibody, toxoplasmosis IgG, G6PD level, and tuberculin skin test.)

FEVER   76B

What are the essentials of diagnosis and general considerations regarding fever?

Essentials of Diagnosis

Age, localizing symptoms, weight loss, joint pain, injection drug use, immunosuppression, history of cancer, medications, and travel history

General Considerations

Most febrile illnesses are caused by common infections, are short-lived, and are relatively easy to diagnose.

The term FUO (“fever of undetermined origin”) refers to cases of unexplained fever exceeding 38.3°C on several occasions for at least 3 weeks in patients without neutropenia or immunosuppression.

In HIV-infected individuals, fever may be caused by lymphoma or infections such as disseminated Mycobacterium avium, Pneumocystis jiroveci, cytomegalovirus, or disseminated histoplasmosis.

In a returned traveler, consider malaria, dysentery, hepatitis, or dengue fever.

Stay updated, free articles. Join our Telegram channel

Join