It is well established that the presence of malignancy itself can cause fever. Classical malignancy causing fever include lymphoma, leukaemia, renal carcinoma and so on. However, on occasion infection and hence the resulting fever, can occur because of the presence of cancer and the investigation of fever can lead to finding a sometimes unexpected malignancy.
In the following case supplied from another hospital and fully anonymised, it shows how history and physical examination gave a bedside diagnosis.
A 70 year old female was admitted with fever. The fever had started 2 days previously and was associated with appetite loss and headache. There was no associated chills, mylagia, nausea or vomiting. The headache was frontal in nature and there were no other associated symptoms of meningitis and no visual disturbance. She complained of no chest problems i.e. no dyspnoea, no cough or sputum. She had no skin or joint problems. She had no urinary symptoms. However, on direct questioning, she admitted to a long history of diarrhoea that was not painful. She denied night sweats and weight loss.
Previous medical history included hypertension and ovarian cancer that had been operated 6 years ago with chemotherapy as additional treatment, although the patient was no longer under active follow up.
She was taking no regular medication.
There was no family history of note and she lived alone and was independent.
On physical examination, she appeared relatively well. Hydration state seemed adequate although she felt hot to touch. Dentition was extremely poor.
CVS: There were no peripheral stigmata of endocarditis. Pulse 80/min and regular. BP 140/70. JVP not raised. Heart Sounds were normal with no murmurs. No peripheral oedema or evidence of DVT.
RESP: Respiratory rate 20/min. Expansion was normal and percussion was resonant. Chest sounds were normal.
ABDO: Slightly obese abdomen and soft. However, in the Right Iliac Fossa there was a smooth, tender mass arising from the pelvis. Percussion revealed dullness, but not stony dullness, making this consistent with a solid or at least a semi-solid structure. Auscultation of the mass revealed no bowel sounds. The mass was at least the size of a grapefruit from what could be elucidated from the surface examination. There was no hepatosplenomegally or ascites and bowel sounds were otherwise normal.
CNS: No evidence of meningeal signs. Neurological examination was otherwise unremarkable.
In view of the previous history of ovarian cancer and no regular follow up, a new fever and a tender, smooth abdominal mass, recurrent ovarian cancer had to be high on the list. However, this could have also been sepsis related to formation of an abscess although it was considered too large to be an abscess especially as the history of fever was only 2 days. In view of the poor dentition and despite the absence of a cardiac murmur and peripheral stigmata, endocarditis was also considered although this would not have accounted for the pelvic mass.
Bloods revealed a raised white cell count of 20, and high CRP of almost 30, haemoglobin was normal. Renal blood result revealed mild renal failure with normal sodium and potassium. Liver tests were normal. Urine revealed blood, a high white cell count, protein 2+, bacteria 2+ and casts. Chest Xray and ECG were unremarkable. Echocardiogram revealed no vegetation.
Abdominal CT scan was grossly abnormal. The Left kidney was almost completely destroyed due to hydronephrosis and the right kidney was mildly hydronephrotic. The pelvic region revealed a very large, well circumscribed mass with internal septations and dense fluid. The mass was compressing the sigmoid colon and displacing it to the right.
The diagnosis was likely to be recurrent ovarian cancer and compression of pelvic structures had resulted in renal failure from hydronephrosis and as a result, bacterial infection had occurred due to urine stagnation, and probable overflow diarrhoea from colonic compression and / or invasion.
Once again, from taking a thorough and detailed history by asking questions in respect of causes of fever, it was possible to work out the likely diagnosis. In this case, the patient only had fever and few other symptoms. In such a case, the physician has to consider infective and non infective causes of fever. Direct questioning involves asking about symptoms from ALL of the body regions e.g. cardiovascular, respiratory, abdominal, genitourinary, musculoskeletal, skin, central nervous system. This is in fact part of the Review of Systems that is normally done at the end of a history taking session but when few symptoms are evident, the Review of Systems is the safety net for the physician to try and squeeze out innocuous symptoms from the patient which in this case was the diarrhoea and which the patient had not initially offered up as a worrisome symptom. Hence, the Review of Systems came in to use at the beginning of the history taking !
The shorter the history of fever, the more likely it is to be infective and yes, infection was indeed found. However, the presence of the infection led to the diagnosis of a recurrent tumour which seems to have by itself, not caused a fever at all, and only few symptoms such as diarrhoea and mild abdominal discomfort on examination. When there is a situation when one finds an obstructed and hydronephrotic kidney with fever and evidence of infection, the infection could well exist in the kidney itself and in such situations, it is necessary to insert a nephrostomy tube to try and save the kidney and drain the infection. Sometimes, a double J stent can also be inserted to drain the kidney.
In this case, the history made the physician concentrate the physical examination on the pelvic region and indeed the recurrent tumour was identified. Hence, history and examination can provide a bedside diagnosis and in this case, CT scan CONFIRMED the diagnosis rather than making the diagnosis.
Please consider.... :)