Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin

OBJECTIVES: The ability of endosonography to diagnose a variety of gastrointestinal pathology has been significantly advanced with the introduction of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. EUS-FNA technology can also be applied to the evaluation of non-GI disorders. The role of EUS-FNA to establish the diagnosis of unexplained mediastinal masses has not been previously described. The aim of this study was to determine the diagnostic accuracy, impact on subsequent workup, and role of EUS-FNA in treating mediastinal masses of unknown cause. METHODS: A total of 26 patients (15 men and 11 women, mean age 61 yr, range 39-77 yr) underwent EUS-FNA in patients presenting with unexplained mediastinal masses at four tertiary referral centers. Presenting symptoms included: chest pain (10 patients), dysphagia (eight), cough (seven), fever (six), night sweats (three), and no symptoms/abnormal x-ray (five patients). Five of 26 patients had prior history of cancer (three lung, one tracheal, and one esophageal). RESULTS: Final diagnosis using EUS-FNA, surgery, autopsy, other diagnostic study, or long-term follow-up was available in all patients. EUS-FNA results were classified under three disease categories: 1) infectious, 2) benign/ inflammatory, and 3) malignant. Final diagnosis included infectious in five patents, benign/inflammatory in nine, and malignant in 12. EUS-FNA was successful in 21 of 26 patients (81%) for all disease categories (infectious 60%, benign/inflammatory 78%, and malignant 92%). EUS-FNA was successful in directing subsequent workup in 77% (20 of 26) and therapy in 73% (19 of 26). Mean EUS-FNA passes for adequate tissue sampling was lower of nonmalignant disease categories (3.0 and 3.4) versus malignant disease (4.4). No complications were seen during the course of this study. CONCLUSIONS: EUS-FNA in patients presenting with idiopathic mediastinal masses establishes the diagnosis in the vast majority of cases, particularly for those with malignant disease. The emergence of transesophageal EUS-FNA of the mediastinum provides the ability to alter subsequent workup and therapy, obviating the need for more invasive diagnostic studies such as thoracotomy.     

Isolated splenic tuberculosis presenting with pyrexia of unknown origin

We report a case of a 62-y-old man who presented with fever, malaise and weight loss. He was diagnosed with pyrexia of unknown origin due to tuberculosis of the spleen. Combination anti-tuberculous therapy was administered and fever gradually subsided after 6 weeks. A 12-month course of anti-tuberculous treatment would appear to be appropriate for the treatment of most patients with splenic tuberculosis.     

Angiomyolipoma presenting as fever of unknown origin

A case of renal angiomyolipoma presenting as fever of unknown origin unassociated with tuberous sclerosis is described. Important features include (1) infrequent occurrence in absence of tuberous sclerosis, (2) angiographic appearance suggesting neoplasm, (3) absence of documented malignant tissue transformation, and (4) presenting symptoms most frequently included abdominal pains, palpable flank mass and hematuria. Surgical removal of the lesion in this instance was associated with cessation of fever.     

Lethal cytomegalovirus ischemic colitis presenting with fever of unknown origin

We report a fatal case of cytomegalovirus (CMV) ischemic colitis in a renal transplant recipient. The disease was manifested with fever of unknown origin for 27 days followed by progressive right lower abdominal pain. The clinical condition deteriorated rapidly with development of disseminated intravascular coagulopathy and internal bleeding despite right hemicolectomy and antiviral therapy. The patient died 11 days after the onset of abdominal pain. We conclude that the possibility of CMV ischemic colitis should be suspected if a patient presents with fever and abdominal pain in the early months after transplantation, and that early viral detection by CMV polymerase chain reaction can be lifesaving.     

以不明原因发热为首发表现的恶性肿瘤69例临床分析

目的探讨以不明原因发热（FUO）为首发表现的恶性肿瘤患者的病因及临床特征。方法回顾性分析我院2000年1月～2007年12月间以FUO为首发表现的69例恶性肿瘤患者的病因、诊断方法和临床表现。结果69例恶性肿瘤患者男女比例为3．06：1,淋巴瘤最多见（占56．5％）,肺癌次之（占24．6％）。多部位穿刺活检有助于淋巴瘤明确诊断,淋巴瘤患者PPD试验阳性率低于结核病,但差异无显著性;89．7％（35／39）的患者有血象下降改变,其中三系细胞均下降比例最高,占36．4％（14／39）,83．9％（26／31）的患者乳酸脱氢酶（LDH）增高。所有肺癌患者均合并有阻塞性肺炎。结论以不明原因发热为首发表现的恶性肿瘤患者中淋巴瘤居首位,肺癌其次,仔细寻找线索有助于明确诊断。     

Aortic dissection presenting as fever of unknown origin

Acute aortic dissection may have variable presentations, making the diagnosis clinically challenging. Although fever is a common accompanying feature, it rarely dominates the clinical setting. We report the case of a patient who sustained a prolonged spiking fever with unknown origin following acute aortic dissection. The case serves as a reminder that prolonged fever may be the principal residual sequelae after acute aortic dissection or one of the protean clinical manifestations of painless aortic dissection.     

Pituitary lymphoma presenting as fever of unknown origin

An 86-yr-old woman presented with fever of unknown origin. When laboratory evaluation revealed partial hypopituitarism, a magnetic resonance imaging scan of the head was performed and revealed a sellar mass consistent with a pituitary adenoma. Only after other possible etiologies for fever were excluded did she undergo transsphenoidal resection of the sellar mass, which proved to be a B-cell lymphoma. Primary central nervous system lymphoma of the pituitary region is a rare cause of a sellar mass, and this is the first reported case of pituitary lymphoma whose presenting manifestation was fever of unknown origin. Several disease processes can manifest themselves as fever and a sellar mass, including lymphomas. In our case, only surgical biopsy could make a diagnosis and distinguish this process from the more common pituitary adenoma.     

Vancomycin allergy presenting as fever of unknown origin

A 37-year-old woman receiving long-term hemodialysis was admitted to the hospital with a fever of unknown origin (6 weeks of unexplained, persistent, low-grade fever). Although she had received vancomycin hydrochloride 5 days before the onset of fever, the drug was not suspected as the cause because of the duration of fever, the administration of vancomycin on prior occasions without incident, and the lack of allergic stigmata. After hospitalization, vancomycin and gentamicin sulfate were administered empirically. Immediately thereafter, her temperature rose to 40 degrees C, and over the ensuing 24 hours, eosinophilia and a maculopapular rash developed that resolved entirely when antibiotic therapy was stopped and low-dose steroid therapy was instituted. The prolonged hypersensitivity reaction after a single dose of vancomycin is consistent with the greatly extended half-life of this drug in the population with end-stage renal disease and should alert physicians to the possibility of such persistent idiosyncratic reactions in this group.     

Multiple myeloma presenting as fever of unknown origin

BACKGROUND: Multiple myeloma (MM) itself is not considered to be responsible for fever and is not usually listed among the causes of fever of unknown origin (FUO). METHODS: We report three cases of MM presenting with specific fever that we analyze in combination with the three previously published cases. RESULTS: MM could easily be suspected in most, but not all, cases, emphasizing that bone marrow aspiration should be a part of 'standard' FUO investigations. All patients underwent extensive, sometimes potentially harmful, investigations. Conventional treatment of MM produced a sustained improvement in the temperature curve and inflammatory syndrome in all cases within a few months. Fever recurred during nearly all relapses. Six patients died, one after a disease course of more than 8 years. CONCLUSIONS: This series shows that MM may present as a FUO and that useless and hazardous investigations may be avoided given the possibility of specific fever in this disease. Chemotherapy must be considered without much delay after a reasonable work-up to eliminate any associated process, especially infections.     

Differential diagnosis in fever of unknown origin

Fever is one of the most frequent and important symptoms in pediatrics. Most cases are caused by self-limiting viral or easily treatable bacterial infections. If after 5-7 days no cause of the ongoing fever has been found, the condition is termed fever of unknown origin, a working diagnosis which often poses a diagnostic challenge. The ultimate cause may be an infectious disease, a chronic inflammatory disorder, a malignancy, or another rare disease. The cause may also remain obscure or the fever can finally disappear. Here we elaborate the diagnostic work-up and symptomatic treatment.     

Iodine-induced subacute thyroiditis with thyrotoxicosis presenting as fever of unknown origin

A 26-year-old woman with features of bulimia nervosa presented with fever of unknown origin, hepatomegaly, marked leukocytosis, and increased erythrocyte sedimentation rate. Following prolonged observation, slight tenderness over the thyroid gland and signs of thyrotoxicosis occurred. A thyroid scan demonstrated no isotope uptake and the patient admitted abusing an organic iodine preparation in order to control her weight. The diagnosis of iodine-induced subacute thyroiditis with thyrotoxicosis was, therefore, considered. A brief course of low-dose steroids normalized both thyroid function and hematological parameters. On followup evaluation, urinary iodine excretion and thyroid function tests were normal.     

经胃腹腔内镜检查对原因不明腹水的诊断价值

目的探讨经自然腔道进行腹腔内镜检查对渗出性腹水病因的诊断价值。方法23例不明原因渗出性腹水患者经口腔穿胃壁行腹腔内镜检查及病理活检。结果23例中22例获得明确诊断,确诊率95．7％。明确病因诊断22例中,腹腔恶性肿瘤12例（54．6％）,结核性腹膜炎8例（36．4％）,肝硬化合并自发性腹膜炎1例（4．5％）,嗜酸性小肠炎1例（4．5％）。结论经自然腔道腹腔内镜检查及病理活检对原因不明渗出性腹水患者是一种安全、确诊率高的诊断方法。     

以不明原因发热为主要症状的成人恶性肿瘤48例分析

目的探讨成人恶性肿瘤患者中以不明原因发热(FUO)为主要症状者的病因构成及诊断难点。方法回顾性分析1989年～2002年以FUO入院、且最终诊断为恶性肿瘤的48例成人患者的临床资料。结果48例患者中淋巴／造血组织肿瘤35例，占72．9％，其中淋巴瘤18例，恶性组织细胞病13例；实体瘤13例，占27．1％，其中12例位于腹腔，7例为原发性肝癌。初诊与确诊相符者仅5例，占10．4％；有39例被误诊为感染性疾病，占90．7％，其中结核病最多。误诊的主要原因有：(1)症状和体症不典型；(2)人院初的影像学和活组织检查结果不支持；(3)使用肾上腺皮质激素和多种抗生素，一度掩盖病情。结论警惕FUO病人中恶性肿瘤的可能性，尤其是淋巴瘤、恶性组织细胞病和腹腔实体瘤，尽量寻找诊断线索，同时合理使用退热药。     

Carcinoma of colon presenting as fever of unknown origin

Fever of unknown origin (FUO) is defined as fever of more than 38.3 degrees C, the cause of which remains elusive after 1 week of intensive investigation. Most cases of FUO are restricted to infections, malignancies, and inflammatory diseases. FUO was previously reported as the presenting symptom of a few solid tumors such as lymphoma, renal cell carcinoma, and hepatocellular carcinoma. Colon carcinoma manifesting as FUO has been rarely reported. We describe three female patients who presented with classical FUO and microcytic anemia. As a control, we retrospectively evaluated 28 matched patients with carcinoma of colon and no fever. The evaluation included review of patient files, clinical and laboratory data, and pathologic specimens. In the three patients (mean age, 58 years) who presented with FUO and had left-sided colon carcinoma and microcytic anemia, pathologic evaluation of the tumor tissues demonstrated a severe organized inflammatory process forming abscesses in the pericolic fat. The 28 control matched patients showed no such histopathologic changes. In patients presenting with FUO, especially those who present with microcytic anemia, even with no bowel disturbances or elevated carcinoembryonic antigen levels, diagnostic workup should include a search for occult colorectal carcinoma. In our three cases, it appears that microabscesses in the pericolic fat are the cause of fever.