Conlon Peter, Swan Dawn, O'Connell Niamh, Conway Richard
Department of Infectious Diseases, St James's Hospital, Dublin, IRL.
Department of Haematology, St James's Hospital, Dublin, IRL.
Cureus. 2022 Dec 15;14(12):e32546. doi: 10.7759/cureus.32546. eCollection 2022 Dec.
Infection mimics pose a challenge in the world of infectious diseases. Fever of unknown origin (FUO) requires careful consideration for a broad range of diagnoses. The answer often lies in a careful history and dedicated clinical examination. A delay in diagnosis can result in greater morbidity for the patient. We present the diagnostic challenges in a patient with an infection mimic, Behcet's disease (BD), who presented with recurrent venous thromboembolism (VTE) and fever of unknown origin (FUO). We present the case of a 53-year-old male of Irish Caucasian ethnicity who presented with a history of fevers and recurrent VTE at a university hospital in Dublin, Ireland. Past medical history includes schistosomiasis, which was treated following a trip to sub-Saharan Africa. Our patient was previously diagnosed with a provoked deep vein thrombosis (DVT). He went on to experience four subsequent episodes of VTE, including DVT, pulmonary embolism (PE), and cerebral venous sinus thrombosis (CVST) while on different forms of anticoagulation. On each of these occasions, there was a concern for sepsis due to fevers > 38°C and a C-reactive protein (CRP) > 200 mg/L. The infection workup included routine laboratory tests, blood and urine cultures, CT of the abdomen and pelvis (CTAP), echocardiogram, and PET-CT, all of which were unrevealing. However, a focused clinical examination revealed evidence of subtle scrotal and oral ulceration, pustulation, and erythema at several sites in his upper limb following venesection and cannulation. In this context, a diagnosis of Behcet's disease was considered. A diagnosis of Behcet's disease can only be confidently made after the exclusion of other potential etiologies. In this case, we had to consider a broad range of infectious (malaria, schistosomiasis, rickettsial disease, and endocarditis) and noninfectious (malignancy, antiphospholipid syndrome (APS), myeloproliferative disorders, and paroxysmal nocturnal hemoglobinuria (PNH)) diseases. A delay in diagnosis comes at the cost of increased morbidity and mortality for the patient. A detailed history and clinical examination are key, in addition to a high index of suspicion. Following the induction of high-dose steroid, our patient is doing very well on maintenance adalimumab. From an anticoagulation perspective, he is warfarinized and has not had any further episodes of VTE.
感染模仿症在传染病领域构成了一项挑战。不明原因发热（FUO）需要对广泛的诊断进行仔细考虑。答案往往在于详细的病史和专门的临床检查。诊断延迟可能导致患者出现更高的发病率。我们介绍了一名患有感染模仿症——白塞病（BD）的患者所面临的诊断挑战，该患者表现为复发性静脉血栓栓塞（VTE）和不明原因发热（FUO）。我们介绍了一名53岁的爱尔兰白种男性患者的病例，他在爱尔兰都柏林的一家大学医院就诊，有发热和复发性VTE病史。既往病史包括血吸虫病，这是在一次前往撒哈拉以南非洲旅行后患上并接受了治疗。我们的患者此前被诊断为诱因性深静脉血栓形成（DVT）。在接受不同形式的抗凝治疗期间，他又经历了四次VTE发作，包括DVT、肺栓塞（PE）和脑静脉窦血栓形成（CVST）。在每一次发作时，由于体温>38°C且C反应蛋白（CRP）>200mg/L，都担心存在败血症。感染检查包括常规实验室检查、血液和尿液培养、腹部和盆腔CT（CTAP）、超声心动图以及PET-CT，所有这些检查均未发现异常。然而，一次重点临床检查发现，在静脉切开术和插管后，他的阴囊和口腔有细微溃疡、脓疱以及上肢多个部位有红斑。在此背景下，考虑诊断为白塞病。只有在排除其他潜在病因后，才能确诊白塞病。在本病例中，我们必须考虑一系列广泛的感染性疾病（疟疾、血吸虫病、立克次体病和心内膜炎）和非感染性疾病（恶性肿瘤、抗磷脂综合征（APS）、骨髓增殖性疾病和阵发性夜间血红蛋白尿（PNH））。诊断延迟会使患者的发病率和死亡率增加。除了高度的怀疑指数外，详细的病史和临床检查是关键。在使用大剂量类固醇诱导治疗后，我们的患者在接受阿达木单抗维持治疗时情况良好。从抗凝角度来看，他接受了华法林治疗，且未再发生VTE。
