الفهرس 
Records And MethodsOnly 14 pages are availabe for public view
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Abstract
Fever of unknown origin is one of the most challenging diagnostic dilemmas in the field of infectious diseases and tropical medicine. Fever is a cardinal manifestation of many diseases, including both infectious and non-infectious diseases.(1)
Petersdorf and Beeson defined Fever of unknown origin (FUO) in 1961 as a temperature higher than 38.3°C on several occasions and lasting longer than 3 weeks, with a diagnosis that remains uncertain after one week of investigation.(2)
Duracket alhave argued for a more comprehensive definition of FUO that takes into account medical advances and changes in disease states, such as the emergence of human immunodeficiency virus (HIV) infection and an increasing number of patients with neutropenia.(3) The new definition proposed in addition to the old definition criteria, to include patients who are undiagnosed after two outpatient visits within one week or three days in hospital.(6)
This study aimed to analyze the demographic criteria, diagnosis and medical prognosis of cases of fever of unknown origin admitted to Alexandria Fever Hospital during the years 2009 and 2010 through review of the medical records to evaluate various diagnostic approaches, identify the extent of fulfillment of the basic diagnostic workup done for each patient, to the required diagnostic workup to reach a diagnosis for Fever of Unknown Origin cases. Also, the study aimed toidentify the distribution of the etiological categories and prognosis of Fever of Unknown Origin during the studied period.
To accomplish this aim, a descriptive cross sectional study was conducted on all cases satisfying the old definition of FUO, admitted to Alexandria fever hospital, Egypt in the years 2009 and 2010 were included in the study (n = 979). A data collection tool was developed covering most of the epidemiological and medical data available in the medical records. This tool was evaluated regarding the phrasing, the order, the need for adding or omitting items included in the data collection sheet. Also, to estimate the time needed to complete the data collection andto determine what kinds of difficulties were likely to arise and how to deal with them.
In this study, the two definitions were put to test. A comparison between the different final diagnoses when applying the 2 definitions to the study population clearly showed that using the new definition, a large number of the patients (49.54%) were diagnosed as bronchitis.
This would affect the distribution of final diagnosesin favor of infectious diseases and distorts the results of this study. In light of these results; we selected to focus only on the cases that are compliant with the old definition throughout the rest of the study results (n=555).
Only 3 fever patterns were detected in the study population; as 47.9% of cases had continuous fever, 45.2% had continuous fever with abrupt onset and remission and 6.8% of cases had remittent fever pattern. Intermittent, undulant and relapsing fever patterns were not detected in the study population.
Regarding lab workup done for cases of FUO, all 100% of patients in the study population had 4 basic investigations which are Complete blood Picture (CBC), Erythrocyte Sedimentation Rate (ESR), C Reactive Protein (CRP), and measure of Blood Sugar. Around 88% of cases were tested for urine examination, Elisa for Brucella and Widal for Typhoid fever. from 50-67% of cases had chest x-ray,Abdominal Ultrasound, Kidney Function Tests, Serum Bilirubin, , ASOT, Blood Culture and Liver Functions. from 24-34% of patients were tested for ANA, Rheumatoid Factor (RF), Serology for HAV, HBV, HCV and HIV. Only 10 – 17% of cases had ECG, Stool Examination, ABG, and Sputum Culture. Less than 10% of case had Lumbar Puncture for Cerebrospinal Fluid (CSF) examination and Tuberculin Test. Only 2.3% of cases had other miscellaneous investigations.
A final diagnosis was reached in 537 cases (96.8%), while 18 cases (3.2%) defied diagnosis. Diagnoses were grouped into 5 major categories;infectious disease (63.4%), autoimmune disease (30.3%), malignancy (0.9% of cases - 5 cases), 12 cases were diagnosed with miscellaneous conditions.
Infectious diseases commonly diagnosed were urinary tract infection (18.2%), Bronchitis (11.7%) and Brucellosis (7.6%). commonly diagnosed autoimmune conditions were Systemic Lupus (11.4%), Rheumatoid Arthritis (8.1%) and Rheumatic fever (7.6). Other Miscellaneous conditions included Hyperthyroidism and glomerulonephritis.
In pregnant females, as in non-pregnant females, infectious diseases were the highest diagnostic category with 76.9% followed by autoimmune diseases with 23.1%, malignancy and other causes of Fever of Unknown Origin were not diagnosed.
50 cases were reported to be drug abusers. 78% of drug abusers were diagnosed with infectious disease versus 62% of non-abusers.
57.3% of cases were discharged as cured cases. 26.8% of cases were transferred to more specialized health care facility. 13.78% of cases (76 patients) were discharged at the request of the patient. 2.2% (12 cases) died in the hospital. 90% of patients required less than 2 weeks of hospitalization to reach a final outcome.
Regarding outcome of different diagnostic categories; infectious disease had the highest improvement rate (80.8%), compared to only 18.6% in autoimmune diseases and 0.3% in malignant diseases. Of 12 cases died in the hospital, 16.7% had infectious disease, 41.7% had autoimmune diseases, and 16.7% had other causes. No patients died from malignant diseases in the study population. 25% of dead cases were undiagnosed before death.
Risk estimation shows that it is more likely for cases of Fever of Unknown origin to be diagnosed with an infectious disease if the patient was a smoker, had contact with animals or birds, a drug addict or HIV positive. It is more likely for cases of Fever of Unknown origin to be diagnosed with an autoimmune disease if the patient was a female.
To increase the diagnostic capabilities of the physicians, more sophisticated lab and imaging tests should be provided with suitable cost. Training of the physicians on using the most recent diagnostic tools, which are introduced to the medical community on a rapid pace, is highly recommended.
The quality of the data available in the medical records considered as a major limitation to reach higher accuracy in the results of this study.
Although this study involved a large number of patients (979 patients), it had some limitations.It relied on available medical records; thus it was not possible to acquire any additional information outside the available data in the medical records. Also, it was not possible to follow up with the patients after they have been discharged from the hospital. These aspects are worthy of further investigation.
Based on the results of this study, a three stages diagnostic approach is proposed and is recommended to help guide the physician towards a definitive diagnosis.