Vancouver IM LMR

Slides from today’s noon report

Fever of unknown origin NEJM review 2022

Teaching pearls

Consider a wide differential including infectious (25%), inflammatory (25%), malignant (15%), misc (35%) etiologies

FUO workup is done in tiers

1. First tier
   • Thorough history and physical
   • CBC, CRP, ferritin, TSH, RF, ANA, HIV/Hep serology, blood cultures x 3 +/- EBV/monospot/Q-fever serology
   • Urinalysis and culture
   • TB skin test or IGRA
   • CT chest abdo pelvis
   • TTE
2. Second tier
   • Repeat thorough history and physical
   • Discontinue non-essential medications (esp those associated with drug fever)
   • Leg Doppler for DVT
   • 18-FDG PET/CT scan vs WBC scan
3. Third tier
   • Repeat thorough history and physical
   • Chase any findings with investigations
   • Consideration of empiric use of NSAIDs, steroids

Intravascular lymphoma

• Rare subtype of large cell lymphoma in which malignant cells (CD20 expressing) proliferate within the lumina of small blood vessels – no circulating lymphoma cells in peripheral blood (90-95% cases), no obvious extravascular tumor mass
• Quite rare – annual incidence <0.5 cases per 1,000,000. Usually affects elderly (avg age at diagnosis approx 70), M = F
• Highly variable presentation:
  • Pain, organ-specific local symptoms, multiorgan failure, FUO
  • >50% have systemic symptoms (fever, B symptoms)
  • Cutaneous involvement in 40% (heterogenous range of lesions, commonly in the chest/lower abdomen/extremities)
  • Highly variable neurological involvement in 35%
• Diagnosed by biopsy – skin lesion if present, or affected organ. If there is no clear focus, random skin biopsies described in the literature.
• Treated by chemotherapy (eg R-CHOP)
  • Limited data around prognosis, although a case series (n=10, single institution in Taiwan) showed improved survival in those who were caught in time and completed chemotherapy.