Prolonged fever since 6 weeks, no diagnosis yet

Patient

Q: The patient is Female, 50yrs old.

She was diagnosed with Cervical Spondylitis and Frozen shoulder, around 2 years back, we did physiotherapy and some anti-inflammant medications. As that wasn’t helping, we went for alternate medicine (Ayurvedic hot oil massage and physical traction, with some herbal medicines) - and this is still ongoing with little benefit (there is some benefit, but very less)

She started getting Gastro-ulcer, for which herbal medicines were prescribed by the Ayurvedic doctor, and there was relief to an extent.

Slowly she started getting mouth-ulcers on the inside of her mouth, and burning sensation in the mouth on eating any kind of spices. Nothing was really done for this, and was suspected an extension of the stomach ulcers.

Around 6 weeks ago, she started getting high fever and chills every evening 6/7pm onwards till morning. Our family doctor suspected a urinary tract infection, and recommended a Urologist, so we did a urine test and it had high amount of pus cells, for which the urologist gave antibiotic injections and tablets.

The urologist also recommended to do Liver Function Test (LFT III), which we did, results are attached.

After the antibiotics, the evening fever subsided, and she started getting all-day fever every day (3 weeks now).

During the treatment of urologist, she had excessive mouth pain (nervous - more on the right side) and slight blood in her cough. It was suspected as part of stomach ulcers, but a Ear-Nost-Throat (ENT) specialist was recommended.

The ENT specialist said that the upper jaw had an infection due to less space for the tooth, and gave antibiotics to treat that, the nervous mouth pain has subsided after that and there has not been any kind of bleeding since.

For the fever, the ENT suspected typhoid fever, and suggested a Widal test. The test was found negative, she does not have typhoid fever.

In one of the test results, the ESR = 44, which is considered high, and hence there is some infection or inflation somewhere, unidentified.
The urologist also asked to do an ultrasound, in which there were some abnormalities (results are attached), and hence he recommended to consult a Gynecologist.

The Gynecologist concluded that no treatment is needed despite multiple fibroids, as it could go away after menopause phase (which is due).

The current situation is: Fever is still present throughout and does not subside with Panadol, loss of appetite, nausea-feeling, mouth ulcers are still present, fever is still present. There is no diagnosis yet for the prolonged fever (around 6 weeks now).

All attachments: http://ritenv.com/jyoti-test-reports.zip

Symptoms:  Prolonged fever, nausea, loss of appetite, general weakness, pain in random body areas
Doctor

A:   Hello. Welcome to Ask The Doctor. We are here to help you.

I have read your query in detail and have studied the all reports.
First of all she never had any Urinary Tract Infections as per her urine report.
Moreover, persistent fever even after the many course of different antibiotics from different doctors represents that probably there is no bacterial Infection.

Looking at the history and high ESR I would recommend evaluating for following diseases:
1. Rheumatoid arthritis
2. Systemic Lupus Erythematosus (SLE)
3. Tuberculosis.
I would advice following tests for this purpose:
1. R-Factor, Anti CCP Antibody.
2. ANA
3. Chest Xray
4. Fasting blood sugar.
5. Thyroid function tests.

The diagnosis of her fever and all the presenting symptoms you would get in these investigations.
Stop treating her with antibiotics.
Probably she has some Autoimmune disease.
You should see an Internal Medicine Specialist (MD Medicine) for this purpose and share my opinion.

He would agree to my opinion and would get her the above-mentioned tests done.
I hope it helps you.
If you have any further query, please ask me.
Stay Healthy.

Comments / Follow Ups

Patient: Thank you very much for your prompt response, please check attached the reports of tests we did. Could you kindly let us know your conclusion from them?
Thank you very much.
Doctor: Hello. As per her reports the few Autoimmune disorders have been ruled out. However fever with high ESR would require further evaluation.
In case her fever has subsided then just get a repeat ESR. It should be settelling down.
But if fever is not responding to any treatment as discussed, I would advice further workup that should include a Chest Xray and Ultrasound Abdomen.
As per your reports you have been seeing a Gastro.
I would advice you to see a good renowned Physician of your city.
Good luck
Patient: Hello,
Yes we are showing to Gastro, will go for a physician next. However, one of the tests show positive for ANA, could you kindly let us know what that means?
Also, we did a chest X-ray as well, and also a CT scan. Chest X-ray shows dark patch in lower left lungs area, so they said it could be due to infection, and they prescribed antibiotic for that: Genlox 400mg.

Do you still recommend a physician still?
Doctor: Hello. Positive ANA signifies an Autoimmune diseases. So a workup would be required to rule out the cause. SLE becomes less likely when your anti Ds DNA is negative.
I suppose you should be get a complete Autoimmune Antibody panel that would show up which Autoimmune condition you have.
Make sure you get tested before you are started on steroids.
Good luck.
Patient: Thank you, which specialist would you recommend in that case? Sorry for many questions, we are confused.
Doctor: Hello, You should see an Internal Medicine Specialist or a Rheumatologist for the purpose.
Good Luck.

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