Chest Infections |

An Unusual Case of Fever of Unknown Origin FREE TO VIEW

Omar Al Dhaybi, MD; Pallavi Bellamkonda, MBBS
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Creighton University, Omaha, NE

Chest. 2013;144(4_MeetingAbstracts):235A. doi:10.1378/chest.1685721
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Fever of unknown origin has an extensive etiologic list. The cause remains unidentified in up to 20% of patients.

CASE PRESENTATION: A 51 year-old Native American female was admitted for an episode of atypical chest pain. Her past medical history included a recent hospitalization for community-acquired pneumonia. Following admission, she started developing high grade fever. No focus of infection was identified after a preliminary assessment & workup. CT scan of chest revealed bibasilar consolidations that were improving compared to previously. Blood cultures were consistently negative. Procalcitonin was low (0.38). CT scan of abdomen was negative. Vasculitis workup was negative. Serum protein electrophoresis (SPEP) was negative for monoclonal gammopathy. Patient remained febrile despite receiving broad spectrum antibiotics. Her hospital stay was complicated by hemodynamic instability that responded to intravenous fluids. Fungal, viral and atypical bacterial serologies were negative. Fungal cultures were also negative. The infectious diseases consultant deemed her fever to be of noninfectious origin, and antibiotics were discontinued. Patient remained febrile. Furthermore, she developed anemia and workup was suggestive of hemolysis, with a positive direct Coombs test. Patient was started on prednisone for her warm-antibody hemolytic anemia. She improved subsequently and her fever resolved. Bone marrow biopsy revealed foci containing more than 30% of plasma cells, which was consistent with the diagnosis of multiple myeloma. She was discharged soon afterwards on oral prednisone.

DISCUSSION: Fever is a rare presentation of multiple myeloma, occurring in less than 1% of patients. Multiple myeloma is not listed as an etiology of fever of unknown origin (FUO). Nevertheless, it was previously reported to be a cause of FUO in a case series of 9 patients. SPEP can be negative in in up to 40% of multiple myeloma patients. Those would be diagnosed with immunofixation. The latter was not performed in our patient. Her fever responded promptly to corticosteroids.

CONCLUSIONS: Multiple myeloma should be included in the differential diagnosis of FUO. That may reduce unnecessary testing as well as prolonged hospital stay (three weeks in our case). It would also allow to quickly establish diagnosis and initiate effective therapies.

Reference #1: Fever of unknown origin caused by multiple myeloma : a report of 9 cases. Arch Intern Med. 2002;162(11):1305-9.

DISCLOSURE: The following authors have nothing to disclose: Omar Al Dhaybi, Pallavi Bellamkonda

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