Clinical Review

Grand Rounds—University Hospital of Wales, Cardiff: Pyrexia of unknown origin

BMJ 1997; 314 doi: (Published 22 February 1997) Cite this as: BMJ 1997;314:583

The difficulty of establishing a diagnosis

  1. Richard H EvansCase presented by, registrar in medicine and infectious diseases,
  2. R E Mansel, Chairman, professor of surgery,
  3. L K BorysiewiczDiscussion group, professor of medicine,
  4. B D Williams, professor of rheumatology
  1. Department of medicine, University hospital of Wales, Heath park, Cardiff Cf4 4XW

    Pyrexia of unknown origin is a common problem in medical practice and encompasses a broad spectrum of diagnostic possibilities. The clinical phenomenon of pyrexia of unknown origin was defined in 1961 as an illness persisting for three weeks or longer, with episodes of fever greater than 38.3°C and with no diagnosis reached after one week of hospital investigation.1 This case highlights the difficulty that can be encountered in establishing a diagnosis in a patient presenting with pyrexia of unknown origin.

    Case history

    A 34 year old man developed a mild sore throat on 29 October 1995. This became more severe during the following week, when he consulted his general practitioner and was given a seven day course of penicillin V. The patient discontinued the antibiotics after two days because of nausea. During the subsequent fortnight he developed myalgia and arthralgia, followed by drenching night sweats and rigors.

    After four weeks he was unable to get out of bed without help because of the severity of the myalgia and arthralgia, and he had lost over 10 kg. He was admitted to his district general hospital in November 1995. He appeared pale and unwell with a fever of 40°C. He complained of weakness and intense myalgia of his shoulder and pelvic girdle muscles, arthralgia of his left knee and right elbow, and left sided pleuritic chest pain. He had no medical history of note and no history of recent foreign travel. Physical examination was unremarkable: there was no palpable lymphadenopathy; no organomegaly; and no stigmata of infective endocarditis.

    Laboratory data on admission showed a blood haemoglobin concentration of 81 g/l with normochromic normocytic indices, a raised leucocyte count of 21.85x109/l with a neutrophil count of 19.65x109/l and a raised platelet count of 648x109/l. His erythrocyte sedimentation rate …

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