1. Fever of Unknown Cause Presenting with Multiorgan Failure

V Kumar, M Matta, A Datta, A Bhagra
INHS Kalyani, Visakhapatnam, Andhra Pradesh – 530 005.

Background : Seasonal epidemics of fever occur frequently in India. Most are improperly described and no cause is found due lack of health infrastructure. Subsets of cases end fatally producing concern for the physician and community. Data on mortality are imprecise.

Aim : To describe a subset of cases with fever of unknown cause presenting with multiorgan failure and ending fatally during an epidemic.

Material and Method : Retrospective analysis of 11 subjects presenting with fever of < 1 week without an obvious primary cause with features of multiorgan failure during an epidemic of fever cases clinically labeled as Chikungunya (May-July 06).

Results : One thousand and thirty nine cases of fever with polyarthralgia presented at our hospital. 11/1039 also gave h/o respiratory distress within 5 days of onset. 7/11 were male, age range 45-67 years, none had co morbid illness. All had tachypnea, tachycardia, hypotension, fever, clear lungs and sensorium, soft abdomen, normal CVS, SpO2 < 90%, CVP 6-8 cms, ABG : metabolic acidosis with respiratory alkalosis and PaO2 < 60 mm,
elevated aminotransferases (1-2 ULN) and azotaemia (non oliguric) at admission. Hemogram, Urinanalysis, widal titers, cultures (blood x 3 and urine), serum amylase and lipase, CXR and USG abdomen: normal; ICT and QBC for Malaria, serology for Dengue, Leptospira, ELISA for HIV and plasma D-dimers: negative. ECG: sinus tachycardia. 2D Echo: poor LV contractility, normal RV. All required mechanical ventilation and vasopressors, were exhibited empirical broad spectrum antibiotics and antimalarials. 4/11 developed ileus in first week; diagnostic laparoscopy done in 2 cases; not contributory. Further course: all afebrile < 1 week, gradual resolution of ileus, slow withdrawal of pressor support (> 2 weeks), but inability to wean (repeated failed SBT due respiratory muscle fatigue) resulting in prolonged ventilation (4-6 weeks) in all cases; all patients finally succumbed to nosocomial sepsis (VAP 4, CRBSI 3, aspiration pneumonia 1, unknown primary 3).

Conclusion : Physicians should be aware of and identify early cases of fever with MOF where standard diagnostic workup is noncontributory, shift them to tertiary care centers, inform prognosis to relatives, and try to establish a diagnosis at all costs (we could not send samples for virological studies due outstation centers). High hospital costs and mortality are anticipated in this subset. Further studies are needed and data should be pooled from several centers to study this subset.