Clinicoetiological profile of patients admitted with fever without localization

Abstract

Background: Fever being a common clinical indicator of majority of diseases is one of the most common reasons for seeking healthcare advice worldwide. We aimed to study the clinical profile and etiology of patients who were hospitalized with fever without any localization on history and physical examination at presentation

Objectives:

1 To find out the etiology of fever of the patients admitted in general medicine ward

2 To find out the duration of the fever and day of admission diagnosis established.

3 Follow up of the patients over 6 months period to know their outcome

Participants:  Patients (excluding pediatric group) hospitalized with fever with no focus of infection on history and physical examinations.

Study design: Single-centre  prospective observational study over 18 months.

Methods: Initial investigations included CBC with PBF with ESR,other baseline investigations,sputum examination ,CXR,urine analysis,acute phase reactants, USG,septic screen.Further diagonostic methods included serological testing for salmonella,brucella,viral hepatitis,tubercular profile,vasculitic profile,bone marrow examination and tumour markers.Imaging methodology included CT scan.MRI,echocardiography and PET SCAN.

Results: Fifteen patients in our study (26.3%) received a possible diagnosis in less than 10 days of hospital stay. 24(42.1%) patients received a diagnosis between 10^th to 19^th day of hospital stay and in 18 patients (31.6%) diagnosis was established in more than 20 days of hospital stay. Mean duration of establishing the diagnosis in our study was 14.1 days.Based on 6 months follow up, 16 patients (28.1%) remained febrile, 40 patients were afebrile (70.2%) and mortality was reported in 1 patient (1.8%).In our study a final diagnosis was established in 42 patients (73.7%) and 15 (26.3%) patients were undiagnosed. Infectious etiology of fever was found in 41 patients (71.9%) and Malignancy related fever in 1 patient (1.7%). In a total of 42 patients, most common diagnosis established was  enteric fever 21 patients (36.8%). Second most common diagnosis established was systemic brucellosis in 7 patients (12.3%), then acute dengue fever in 5 patients (8.8%) followed by pulmonary tuberculosis in 2 patients(3.5%), acute viral hepatitis(Hep-A) in 1 patient (1.8%), bacterial endocarditis in 1 patient(1.8%), genitourinary tuberculosis in 1 patient (1.8%), Amoebic liver abscess in 1 patient(1.8%), splenic abscess in 1 patient(1.8%),malaria (plasmodium Falciparum) in 1 patient (1.8%)and malignancy related fever (squamous cell carcinoma of lung) in 1 patient(1.8%).

Conclusion: We conclude that infections are the most common cause of febrile illness without localization of less than one month duration in our population and enteric fever is the commonest, followed by systemic brucellosis and dengue fever. A significant proportion of cases were undiagnosed reflecting the need for improvement in our clinical and diagnostic methodologies, including microbiological methods (improved virus isolation) and availability of more sophisticated investigation tools like PET SCAN. There is a need of further research using a standard definition of fever without localization by evaluating patients clinically and using defined diagnostic methods to determine the various causes of it.