Discussions By Condition: I cannot get a diagnosis.

I challeng you to figure out my wife's bizarre, high-grade fever:

Posted In: I cannot get a diagnosis. 0 Replies
  • Posted By: Anonymous
  • October 10, 2010
  • 00:40 AM

Summary:
- 35-year-old white female
- Thyroidectomy a few years back
- 4-weeks of persistent fever between 101.5 and 104-degrees that does not respond to medication of any kind (steroids, tyelnol, aleve, etc.)
- Diagnosed with Nodular Schlerosing Hodgkin’s Lymphoma (stage 2-B) 1.5-weeks ago, first dose of chemo (ABVD) 1-week ago
- Fever became worse, and has been accompanied by some neuropathy, which led to hospitalization 6-days ago
- Neurologist, Infectious Disease Specialist and Oncologist all working together and are completely stumped!


Story:
My wife gave birth to our daughter on May 25th, 2010 and all was well for awhile. After about two months she began having trouble controlling her temperature (felt too cold or too hot), had general fatigue that gradually got worse, some dizziness, as well as significant weight loss. All of these were attributed to her recently giving birth as it takes the body awhile to adjust post-partum and weight loss is common in the months after delivery.


Around 4-weeks ago she began feeling bad, so she took her temperature on a Saturday and it was around 101-degrees. Sunday it was over 102, so on the following Monday we went to our family doctor. They ran all the obvious tests (flu, strep, etc.) and all came back negative. The diagnosis was “fever of unknown origin” and the doctor said to come back in two days. The fever never subsided and did not react to over the counter drugs, so we went back on Wednesday. The doctor sent her for a chest x-ray to look for pneumonia, and while the lungs were clear, a “mass” was noticed in the chest. He sent her for a CT Scan which revealed a mediastinal mass about 3.9cm x 2.5cm. He immediately suspected Hodgkin’s Lymphoma, so she was sent for a biopsy which confirmed this suspicion. A bone marrow biopsy was also done that came back clear.
Next we went to an oncologist and got her scheduled to start chemo on Friday, 10/01. In the meantime, the oncologist prescribed a steroid to help with the fever, but it did nothing. The only way to cool her is with physical methods (cold baths, etc.). Since fever (usually low grade) is a Hodgkin’s symptom, the oncologist figured that the fever would go away once chemo began.


She had her first dose of chemo (ABVD) and was ok that day, but the next morning (10/02) she was running a fever of 104.7, so we got her into a cold bath and cooled down to around 102. Later that day she also developed some neuropathy (hands shaking, shaky voice, etc.). Sunday the temperature was not as high (103), but the shaking was no better, so we called the oncologist and she said this sounded strange and we should visit the ER to see a neurologist, so that’ what we did, and she has been in the hospital ever since.


The first thing they did was an MRI of the brain which came back clear and normal. Later was an MRI of the spine and an EEG, both normal. A lumbar puncture was performed and came back “unremarkable”, with the only thing found being a single white blood cell, which they said was fine. Next came a full-body CT Scan, which was completely clean, and it actually showed that the mediastinal mass had already SHRUNK just from the first dose of chemo, so the cancer seemed to be responding very well to treatment.


The oncologist was confused by the fact that the disease was reducing but the fever was getting worse, so an infectious disease specialist was brought on board to start trying to find a hidden infection that was maybe unrelated to the cancer entirely. Many blood tests were performed, and performed again, and there was no sign of infection at all…. No elevated white blood counts, no problems really with the blood at all except for low potassium which was corrected with a supplement. Also, the platelet count was low, so a platelet infusion was done and they have been fine since.


This brought the doctors back to thinking that the fever was associated with the cancer only, so they tried a high dose of a heavy duty steroid called Solu-Medrol. They were convinced that this would work, but it did absolutely nothing. In fact, later that night her fever had spiked to 104.4 so they took her down to intermediate care. When they took her temp there, it was at 105.6! They immediately put a cooling blanket under her and her temp went down slowly over a period of hours. She became nauseous as well and was vomiting mainly bile.


The next morning (10/07) she was still in very bad shape, so they took her to the ICU for even closer monitoring. She was still vomiting so they put a tube down to her stomach to keep her from aspirating anything. She was very unresponsive for the rest of the day. That night they started her on intravenous immunoglobulin (IVIG) as well as antibiotics (just in case there was some crazy infection that was not showing up in the tests). There are four antibiotics: gram positive, gram negative, viral and fungal. They also switched her from Demerol to Delotid, which worked better and seemed to eliminate the nausea issues. They also left the cooling blanket machine setup to where it would turn on if her temp hit 102, and turn off once it was down to 99. The machine ran way more often than not for the rest of that night.


The morning after that (10/08) there was marked improvement. She was still having fever issues, but could go longer without the cooling blanket and she was much more lucid and more like herself again. Today (10/09) she seemed to improve a little more, even getting her appetite back and eating a bowl of chicken broth. Still, she cannot stay off the cooling blanket for very long as her temperature will slowly rise throughout the day.


So, after reading this, what in the world could possibly be wrong? How can she have such a strong fever that rises so quickly and does not seem to respond to medication? Why was she so much better after the IVIG and the antibiotics, even with no signs of infection? Was it either of those treatments or has the chemo helped somehow?


This fever has all her doctors baffled and they don’t know what to do except “wait and see”. While everyone is glad she is getting better, I am still not satisfied that nobody has a clue what is wrong with her. There MUST be a logical explanation for a fever that behaves this way and does not respond to anything except physically cooling the body.

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