Trop Doct 2008;38:221-222
doi:10.1258/td.2007.070293
© 2008 Royal Society of Medicine Press
Fever of unknown origin in the elderly: nine years experience in China
Minghua Zheng MD *
Hailong Lin MD 
Sheng Luo MD 
Lihua Xu MD 
Yanjun Zeng PhD ¶
Yongping Chen MD *
* Department of Infection and Department of Liver Diseases;
Department of Rehabilitation, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou 325000;
Department of Pediatric Infection, The Second Affiliated Hospital of Wenzhou Medical College, Wenzhou 325000;
Department of Hematology;
¶ Biomedical Engineering Center, Beijing University of Technology, Beijing 100124, China
Correspondence to: Yanjun Zeng, Biomedical Engineering Center, Beijing University of Technology, Beijing 100124, China Email: yjzeng{at}bjut.edu.cn
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SUMMARY
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This is a retrospective study of older patients admitted to
the First and Second Affiliated Hospitals of Wenzhou Medical
College, China, with a diagnosis of fever of unknown origin.
The study took place from January 1998 to December 2006 among
102 patients who fulfilled the criteria. Infections were responsible
for 50 cases (49.1%), followed by no diagnosis in 27 (26.5%),
miscellaneous in nine (8.8%), neoplasms in eight (7.8%) and
connective tissue disease in another eight (7.8%). Mycobacterium
TB was the most frequent type of infection diagnosed.
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Introduction
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Difficultly diagnosed and prolonged fever was first described
and termed as ‘fever of unknown origin’ (FUO) by
Petersdorf
et al. in 1961.
1 Past studies have revealed that
FUO in the elderly differs from that in young people.
2 The spectrum
of symptoms is different, the manifestations of distress are
more subtle, the implications for the maintenance of functions
are more important and improvement is sometimes less dramatic
and slower. There is a lack of epidemiological data in Wenzhou
and our study aimed to examine the causes of classic FUO in
the elderly in Wenzhou and to see if it differed from those
seen in other parts of the world.
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Methods
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Between January 1998 and December 2006, we studied 102 patients
who were hospitalized in the First and Second Affiliated Hospitals
of Wenzhou Medical College because of prolonged, community-acquired
fever and who met the criteria of FUO. The files, including
demographic information and a detailed medical history, were
reviewed retrospectively. All information was collected in a
standardized form.
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Results
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During the nine-year study period, 102 patients admitted to
the hospitals met the criteria of FUO. The average age of the
patients was 73 years (range 60–94 years); 58 (56.9%)
men and 44 (43.1%) women. The median duration of the fever before
hospitalization was 34 days (range 8–398 days). The median
duration from admission of fever to final diagnosis was 18 days
(range 8–46 days). In 27 (26.5%) patients no diagnosis
could be made. In this group, fever resolved spontaneously in
five (18.5%) and the remaining 22 were not followed up.
Causes were classified as infections (50, 49.1%), which was the most common cause, followed by no diagnosis (27, 26.5%), miscellaneous in (9, 8.8%), neoplasms in (8, 7.8%), and connective tissue disease (8, 7.8%) (Table 1). Two patients with miliary pulmonary TB – one with abdominal malignant tumour and extensive metastasis and one with pancreatic cancer – died of multiple organ failure. Mycobacterium TB was the most frequent infection diagnosed and included patients with pulmonary (6) and extrapulmonary infections (9). TB was diagnosed based on the findings of microbial cultures, tissue pathology, radiographic evidence or anti-TB trials. One case of TB meningitis was diagnosed by testing the cerebrospinal fluid. Two cases were diagnosed as TB peritonitis by peritoneal biopsy. Two cases of spinal TB were diagnosed using computed tomography. In the remaining cases, all investigations were inconclusive, but the patients responded to anti-TB therapy.
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Discussion
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Despite the wealth of literature on FUO in the elderly, even
in recent studies from Europe and USA, the most common diagnosis
was infectious disease followed by no diagnosis, neoplasms,
connective tissue diseases and miscellaneous conditions.
3,4
Unlike other FUO series from western countries, in this series TB was the most common infectious aetiology (14.7%): either disseminated disease without the characteristic pulmonary radiographic pattern or extrapulmonary disease without clear localizing features. In the series of FUO reported from Europe and USA after the 1980s, the frequency of TB was below 5%.5,6 This difference can be attributed to the relatively low socioeconomical status in China and the high endemicity of TB in this region. Recent studies7,8 suggest that acquired immunodeficiency syndrome has become another important cause of FUO in the elderly. It is important for clinicians to remain vigilant so as to not delay the diagnosis of AIDS.
Our findings suggest that the spectrum of diseases causing FUO in the elderly continues to change. Infection remains the most common cause, and the high percentage of cases with TB and AIDS suggest the need to be aware of these likely causes of FUO. Because of the wide spectrum of causes, and often atypical illness manifestations, an accurate diagnosis of the cause of FUO in the elderly requires careful history taking, physical examinations, an aggressive laboratory work up and image studies.
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Acknowledgements
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We thank Dr Martin Braddock, Discovery Bioscience, AstraZeneca
R&D, UK, for his critical reading of the report.
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References
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- Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine (Baltimore) 1961;40:1–30[Medline]
- Knockaert DC, Vanneste LJ, Bobbaers HJ. Fever of unknown origin in elderly patients. J Am Geriatr Soc 1993;41:1187–92[Medline]
- Schneider T, Loddenkemper C, Rudwaleit M, et al. Fever of unknown origin in the 21st century. 2. Non-infectious diseases (autoimmune diseases). Dtsch Med Wochenschr 2005;130:2774–8[Medline]
- Schneider T, Loddenkemper C, Rudwaleit M, et al. Fever of unknown origin in the 21st century: infectious diseases. Dtsch Med Wochenschr 2005;130:2708–12[Medline]
- De Kleijn EM, Vandenbroucke JP, van der Meer JW. Fever of unknown origin (FUO). I A. prospective multicenter study of 167 patients with FUO, using fixed epidemiologic entry criteria. The Netherlands FUO Study Group. Medicine (Baltimore) 1997;76:392–400[Medline]
- Kazanjian PH. Fever of unknown origin: review of 86 patients treated in community hospitals. Clin Infect Dis 1992;15:968–73[Medline]
- Sepkowitz KA. FUO and AIDS. Curr Clin Top Infect Dis 1999;19:1–15[Medline]
- Mathurin SA, Lupo S, Alonso HO. Fever of unknown origin in patients infected with the human immunodeficiency virus (HIV). Medicina (B Aires) 2000;60:623–30[Medline]
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SUMMARY
Introduction
