QD102 - Undulating Fever Save
QD102 - Undulating Fever by Dr. Cush
Transcription
This is QD Clinic. Hi. I'm Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow's coverage of the virtual ACR twenty twenty meeting. Did you know Rheumatology Roundup is now gonna be on RheumNow?
It's not on the ACR program. It's only on room now. Tune in Monday night. Me and Artie Cavanaugh digest the meeting. So today's case, undulant fever.
Spell that one, and then tell me what it is. It happened in a 28 year old fellow who came to me with a eighteen month history of inflammation, fevers, GI problems, and pleuritis. So, it was referred because of Still's disease, and that's because I'm the self declared world's expert in Still's disease. No one will fight me for the title. But he didn't really fit the pattern of Still's disease.
He did not have a quotidian fever, evanescent rash, and whatnot. Almost two years ago, he started out with, he got sick after returning, from a trip to Central America and came back with, diarrhea and fevers, and then actually was found to have pleural effusion, saw, the lung doctors, they did a thoracentesis, he was still having fevers, 101, 102. Work up at that time really didn't disclose anything. He was treated with colchicine, guess what, he got more diarrhea, and then ultimately prednisone, and then he got better. So, he got better, he bounced around, ended up seeing a few rheumatologists, was called a lot of different things including spondyloarthritis.
One rheumatologist did an MRI of his pelvis and showed that he had left inferior sacroiliitis. Although, he didn't really have much in the way of back pain. He's a young fellow who, is very physically active, does a lot of aerobic activity, and running, And, he was treated with nonsteroidals and and whatnot, and the problem was that, again, this ongoing diarrhea, some chest pain after the pleural effusion resolved. And then he kinda went into remission, but was still on prednisone, and while on tapering dose of prednisone was again hospitalized with five days of again high fever, up to a 103. And at that time, he, had very high LFTs, you know, five, six fold elevation of LF of AST and ALT.
Again, was treated with prednisone, got better, was discharged. Work up really was negative for everything, serologies, B27, rheumatoid factor, ANCA, all that stuff was done. Infectious workup was done, nothing was seen. When he came to see me, we did a few more things. We did some gene testing that proved to be negative, and we sent off a Brucella antigen.
Now, why Brucella? Well, I've been trained here in Dallas, Texas, and it didn't take long before I came here that I heard about brucellosis, not from a Warren Zevon song, but instead from patients who would travel to Mexico, eat unpasteurized cheese or dairy products, come back with back pain, uveitis, and fevers, and the fever pattern is an undulating fever, so it's called undulant fever or Malta fever. And you can prove the diagnosis either by tissue biopsy or by doing just a serologic assay for IgM Brucella antibodies, or in this case, in this fellow, he had IgG high titers of brucella antibodies. Now could he have, a spondyloarthritis? He has unilateral sacro sacroiliitis.
He does not have inflammatory back pain. He has had, during that last hospitalization with high fevers, he had a red swollen eye and, was found to have iritis. What else? No other features that would go along with spondyloarthritis, just the sacroiliitis and the iritis, and he's B27 negative. But does brucellosis, do they get uveitis?
Yes, they do. Do they get pleuritis? Yes, they do. Do they get GI symptoms? Yes, they do.
Again, they tend to have chronic SI pain, this guy did not. He said he had some pain there, but he always equated it to his exercise. Anyway, an unusual diagnosis, probable brucellosis, and should be thought of in patients traveling to Mexico or Central America. Again, Brucella is a worldwide disease. The most common, form of Brucella is not from the cow, like we experienced in Mexico, and patients who go there, that's Brucella abortus coming from cow, but the most common is coming from goat worldwide, and that's Brucella militensis.
There's also Brucella suis from pig. Treatment of this diagnosis is serologic, it can be suspected by radiology or by pathology, treatment is going to be four to six weeks of doxycycline, usually with a second agent like rifampin or trimethoprim sulfamethoxazole. Labs are other than the LFT elevations, occasional leukopenia, lymphocytosis, really not that very revealing until you get the serologies. Thought you'd like to hear about an interesting case. You wanna hear about more interesting cases?
Go to ACR. RheumNow is going to do a lot of interesting things. You need to think about whether you're gonna sign up for topic reports. We'll send you an email of all the things that you're interested in. If you're a, you know, lupus guy, we're gonna send you all the lupus reports.
If you're a, you know, spondyloarthritis gal, we're gonna send you all the spondyloarthritis reports in an email. You can sign up for our mid meeting evening recap on Saturday night. That's gonna be fun, or you can sign up for our rheumatology roundup, as I mentioned earlier. Look for our emails on this. Bye.
It's not on the ACR program. It's only on room now. Tune in Monday night. Me and Artie Cavanaugh digest the meeting. So today's case, undulant fever.
Spell that one, and then tell me what it is. It happened in a 28 year old fellow who came to me with a eighteen month history of inflammation, fevers, GI problems, and pleuritis. So, it was referred because of Still's disease, and that's because I'm the self declared world's expert in Still's disease. No one will fight me for the title. But he didn't really fit the pattern of Still's disease.
He did not have a quotidian fever, evanescent rash, and whatnot. Almost two years ago, he started out with, he got sick after returning, from a trip to Central America and came back with, diarrhea and fevers, and then actually was found to have pleural effusion, saw, the lung doctors, they did a thoracentesis, he was still having fevers, 101, 102. Work up at that time really didn't disclose anything. He was treated with colchicine, guess what, he got more diarrhea, and then ultimately prednisone, and then he got better. So, he got better, he bounced around, ended up seeing a few rheumatologists, was called a lot of different things including spondyloarthritis.
One rheumatologist did an MRI of his pelvis and showed that he had left inferior sacroiliitis. Although, he didn't really have much in the way of back pain. He's a young fellow who, is very physically active, does a lot of aerobic activity, and running, And, he was treated with nonsteroidals and and whatnot, and the problem was that, again, this ongoing diarrhea, some chest pain after the pleural effusion resolved. And then he kinda went into remission, but was still on prednisone, and while on tapering dose of prednisone was again hospitalized with five days of again high fever, up to a 103. And at that time, he, had very high LFTs, you know, five, six fold elevation of LF of AST and ALT.
Again, was treated with prednisone, got better, was discharged. Work up really was negative for everything, serologies, B27, rheumatoid factor, ANCA, all that stuff was done. Infectious workup was done, nothing was seen. When he came to see me, we did a few more things. We did some gene testing that proved to be negative, and we sent off a Brucella antigen.
Now, why Brucella? Well, I've been trained here in Dallas, Texas, and it didn't take long before I came here that I heard about brucellosis, not from a Warren Zevon song, but instead from patients who would travel to Mexico, eat unpasteurized cheese or dairy products, come back with back pain, uveitis, and fevers, and the fever pattern is an undulating fever, so it's called undulant fever or Malta fever. And you can prove the diagnosis either by tissue biopsy or by doing just a serologic assay for IgM Brucella antibodies, or in this case, in this fellow, he had IgG high titers of brucella antibodies. Now could he have, a spondyloarthritis? He has unilateral sacro sacroiliitis.
He does not have inflammatory back pain. He has had, during that last hospitalization with high fevers, he had a red swollen eye and, was found to have iritis. What else? No other features that would go along with spondyloarthritis, just the sacroiliitis and the iritis, and he's B27 negative. But does brucellosis, do they get uveitis?
Yes, they do. Do they get pleuritis? Yes, they do. Do they get GI symptoms? Yes, they do.
Again, they tend to have chronic SI pain, this guy did not. He said he had some pain there, but he always equated it to his exercise. Anyway, an unusual diagnosis, probable brucellosis, and should be thought of in patients traveling to Mexico or Central America. Again, Brucella is a worldwide disease. The most common, form of Brucella is not from the cow, like we experienced in Mexico, and patients who go there, that's Brucella abortus coming from cow, but the most common is coming from goat worldwide, and that's Brucella militensis.
There's also Brucella suis from pig. Treatment of this diagnosis is serologic, it can be suspected by radiology or by pathology, treatment is going to be four to six weeks of doxycycline, usually with a second agent like rifampin or trimethoprim sulfamethoxazole. Labs are other than the LFT elevations, occasional leukopenia, lymphocytosis, really not that very revealing until you get the serologies. Thought you'd like to hear about an interesting case. You wanna hear about more interesting cases?
Go to ACR. RheumNow is going to do a lot of interesting things. You need to think about whether you're gonna sign up for topic reports. We'll send you an email of all the things that you're interested in. If you're a, you know, lupus guy, we're gonna send you all the lupus reports.
If you're a, you know, spondyloarthritis gal, we're gonna send you all the spondyloarthritis reports in an email. You can sign up for our mid meeting evening recap on Saturday night. That's gonna be fun, or you can sign up for our rheumatology roundup, as I mentioned earlier. Look for our emails on this. Bye.
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