Childhood fever of unknown origin (FUO) – A Pandora box

Sabarinath M, Balameena S, Mythili S, Ramesh R, Aravindan A

Pdf Page Numbers :- 117-121

Sabarinath M^1,*, Balameena S¹, Mythili S¹, Ramesh R¹ and Aravindan A¹

¹Institute of Rheumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, India

*Corresponding author: Dr. Sabarinath Mahadevan, Institute of Rheumatology, Madras Medical College (MMC) & Rajiv Gandhi Government General Hospital (RGGGH), Chennai, India. Mobile: +91 8072634837; Email: Msabari1987@gmail.com

Received 2 August 2018; Revised 4 September 2018; Accepted 20 September 2018; Published 29 September 2018

Citation: Sabarinath M, Balameena S, Mythili S, Ramesh R, Aravindan A. Childhood fever of unknown origin (FUO) – A Pandora box. J Med Sci Res. 2018; 6(4):117-121. DOI: http://dx.doi.org/10.17727/JMSR.2018/6-19

Copyright: © 2018 Sabarinath M et al. Published by KIMS Foundation and Research Center. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Rheumatological illnesses are common differential diagnosis in the evaluation of childhood fever of unknown origin (FUO). We report an 11-year-old female child referred as FUO for eight months, possibly sarcoidosis. Her past records showed treatment for UTI, enteric fever in initial two months of fever. She was referred to tertiary institute due to recurrence of fever, multiple joint pain, right eye pain where she underwent evaluation for FUO. Investigation showed positive anti-nuclear antibody (ANA), elevated ESR. She was diagnosed as a case of juvenile idiopathic arthritis (JIA) with uveitis and treated with steroids, disease-modifying anti-rheumatic drugs (DMARDs). Two months later, she developed fever, multiple joint pain and worsening right eye visual acuity. Ophthalmic reevaluation revealed panuveitis and periphlebitis. CT chest showed mediastinal lymphadenopathy. With the above features, childhood sarcoidosis was suspected and treated with T. Azathioprine. Child was referred to our institute due to return of fever spikes. On examination, she had intermittent fever, plaque like lesion in cheeks? Lupus pernio, but skin biopsy was suggestive of SLE. Investigations showed positive ANA by indirect immunofluorescence (IIF), positive anti dsDNA (IIF), low complement (C3), positive immunoblot for SmD1, U1RNP, SSA/Ro60. Diagnosis was revised as childhood SLE with one clinical and three immunological criteria. She responded to steroids and immunosuppression. We report this case of childhood lupus presenting as FUO, multiple joint pain, uveitis, periphlebitis, without specific skin lesions, renal and hematological manifestations. We emphasize the need for meticulous evaluation and long term follow up for children with FUO diagnosed as rheumatological illness. The slow evolution of disease process and atypical presentation of common illnesses may lead to diagnostic dilemma.

Keywords: juvenile idiopathic arthritis; sarcoidosis; lupus pernio; childhood lupus; childhood FUO