Chest xray

2. Bone scan. Useful with localized tenderness.

3. CT scan. May be useful, especially when there are localized findings in areas such as chest, abdomen, bones, and CNS. Routine use of CT scan in all patients without localizing findings is not useful and may give misleading information.

4. Leukocyte tagged scans. Occasionally useful to localize infection, but there are reports of false-negative results.

5. MRI scan. Rapidly becoming the most useful test to evaluate certain areas (eg, bone, spine, and CNS).

V. Plan. Treatment is based on whether or not patient has an identifiable condition. Inflammatory markers help clinician to decide whether further extensive testing is necessary. Even when present, at times there must be a period of watchful waiting and repeat examination, seeking additional information from history or physical exam.

A. Pursue Clues, Only. Most clinicians approach patients with FUO by random testing (x-rays, CT scans, etc) without any clear information as to a possible diagnosis.

B. Seek Additional Information From History and Exam. This is clinician's strength: New data may lead to the correct diagnosis. Examples may be new exposures, hearing a new murmur, a new skin rash.

C. Use Laboratory Wisely. Repeat cultures may be helpful. Blood may be sent for additional titers or for "vasculitis" screens (eg, ANCA).

VI. Problem Case Diagnosis. Patient had an increased ESR, low albumin, and negative throat, blood, urine, and stool cultures as an outpatient. He had mild abdominal pain at onset, which was improving. Additional history revealed exposure to a neighbor's new kitten. Physical exam uncovered several resolving old papules on the right arm where he had been scratched, as well as axillary adenopathy. Sonogram and abdominal CT scan, performed because of initial abdominal pain, showed typical granulomatous lesions in the liver. Titers for Bartonella henselae were strongly positive, confirming a diagnosis of systemic cat-scratch disease.

VII. Teaching Pearl: Question. A patient presents with generalized adenopathy and fever of 8 days' duration. The patient had periorbital edema early in the illness and now has splenomegaly and mild hepatitis. What diagnosis should be considered?

VIII. Teaching Pearl: Answer. Periorbital edema is seen occasionally in infectious mononucleosis and is known as Hoagland sign. Mild hepatitis is seen almost universally in the 2nd week of illness.

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