Daniel Knockaert

Clinical Value of [18F]fluoro-Deoxyglucose Positron Emission Tomography for Patients with Fever of Unknown Origin

We describe the diagnostic contribution of [ 18 F]fluoro-deoxyglucose (FDG) positron emission tomography (PET) scan in 58 consecutive cases of fever of unknown origin (FUO) and compare this new approach with gallium scintigraphy. This investigation was performed from March 1996 through October 1998 at Gasthuisberg University Hospital in Leuven, Belgium. A final diagnosis was established for 38 patients (64%). Forty-six FDG-PET scans (79%) were abnormal; 24 of these abnormal scans (41% of the total number of scans) were considered helpful in diagnosis, and 22 (38% of the total number) were considered noncontributory to the diagnosis. In a subgroup of 40 patients (69%), both FDG-PET and gallium scintigraphy were performed. FDG-PET scan and gallium scintigraphy were normal in 23% and 33% of these cases, respectively; helpful in diagnosis in 35% and 25%, respectively; and noncontributory in 42% each. All foci of abnormal gallium accumulation were also detected by use of an FDG-PET scan. We conclude that FDG-PET is a valuable second-step technique in patients with FUO because it yielded diagnostic information in 41% of the patients in whom the probability of a definite diagnosis was only 64%. FDG-PET scan compares favorably with gallium scintigraphy for this indication. Because of the quick results (within hours instead of days), FDG-PET scan may replace gallium scintigraphy as a radiopharmaceutical for the evaluation of patients with FUO.

Fever of unknown origin in adults: 40 years on

Abstract.  Knockaert DC, Vanderschueren S, Blockmans D. (Gasthuisberg University Hospital, Leuven, Belgium). Fever of unknown origin in adults: 40 years on (Review). J Intern Med 2003; 253: 263–275.

Fever of Unknown Origin in Elderly Patients

Objective: To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients.

Comparison of Premortem Clinical Diagnoses in Critically Ill Patients and Subsequent Autopsy Findings

OBJECTIVE To determine whether our practice of requesting an autopsy for patients who die in the medical intensive care unit (MICU) continues to be a valid approach to obtain clinically and educationally relevant findings. METHODS In this retrospective study conducted in an adult MICU population of a university hospital, the clinical diagnoses and postmortem major diagnoses of 100 patients who died in 1996 (autopsy rate of 93%) were compared. RESULTS Eighty-one percent of the clinical diagnoses were confirmed at autopsy. In 16%, autopsy findings revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival (class I missed major diagnoses). The most frequent class I missed major diagnoses were fungal infection, cardiac tamponade, abdominal hemorrhage, and myocardial infarction. Another 10% of autopsies revealed a diagnosis that, if known before death, would probably not have led to a change in therapy (class II error). CONCLUSIONS Autopsy remains an important tool for education and quality control. In contrast with historical series of 1 to 2 decades ago, there is a clear shift in the type of class I missed major diagnoses toward opportunistic infections. Bedside-applicable techniques such as electrocardiography with supplemental posterior leads, echocardiography, and meticulous abdominal ultrasonography might improve the outcome in selected MICU patients.

Temporal arteritis: the silent presentation and delay in diagnosis

Abstract. To determine the frequency of the so‐called silent or occult presentation of temporal arteritis (presentation with mere constitutional symptoms) and the resulting delay in diagnosis in this particular group, the medical records of all patients (n = 82) with temporal arteritis or polymyalgia rheumatica, presenting between 1982 and 1988 at the Department of General Internal Medicine of the University Hospital, were retrospectively analysed. Only biopsy‐proven cases (n = 34) were studied further.

Chest pain in the emergency department: the broad spectrum of causes.

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively. Cardiac diseases were statistically significantly less common in self-referred patients (p <0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.

Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance

BACKGROUND Involuntary weight loss frequently poses a diagnostic challenge. Patient and physician alike want to exclude malignant and other major organic illness. The present study aimed to evaluate whether a negative baseline evaluation (consisting of clinical examination, standard laboratory examination, chest X-ray, and abdominal ultrasound) lowers the probability of evolving organic illness in patients with significant unexplained weight loss. METHODS Prospective observational study of 101 consecutive patients presenting to a general internal medicine department of a university hospital with an unexplained unintentional weight loss of at least 5% within 6-12 months. Laboratory tests of interest included C-reactive protein, albumin, haemoglobin, and liver function tests. RESULTS Weight loss of the 101 patients [age (mean, interquartile range): 64 (51-71) years, 46% male] averaged 10 (7-15) kg. Organic causes were found in 57 patients (56%), including malignancy in 22 (22%). In 44 patients without obvious organic cause for the weight loss (44%), a psychiatric disorder was implicated in 16 (16%) and no cause was established in 28 (28%), despite vigorous effort and follow-up of at least 6 months. Baseline evaluation was entirely normal in none of the 22 patients (0%) with malignancy, in 2 of the 35 (5.7%) with non-malignant organic disease, and in 23 of the 44 (52%) without physical diagnosis. Additional testing, oftentimes extensive, after a normal baseline evaluation led to one additional physical diagnosis (lactose intolerance). CONCLUSION In patients presenting with substantial unintentional weight loss, major organic and especially malignant diseases seem highly unlikely when a baseline evaluation is completely normal. In this setting, a watchful waiting approach may be preferable to undirected and invasive testing.

Electromyographic findings in ilioinguinal-iliohypogastric nerve entrapment syndrome.

The ilioinguinal-iliohypogastric nerve entrapment syndrome is a recognised cause of, usually chronic, lower abdominal pain. Diagnosis is based upon a typical clinical triad and relief of pain by injection of a local anaesthetic. In the present study we assessed the value of abdominal muscle electromyography in 41 patients with a clinical syndrome suggestive of ilioinguinal-iliohypogastric nerve entrapment. Electromyographic abnormalities were detected in 15 of 25 cases (60%) with definite diagnosis and in 6 of 16 (37%) of those with probable diagnosis of ilioinguinal-iliohypogastric nerve entrapment syndrome. The rather low sensitivity and the clinical value of this technique are discussed.

Imported malaria in the 1990s: a review of 101 patients.

Imported malaria remains a difficult problem in nonendemic areas of the world. We describe the clinical presentation of 101 cases of malaria diagnosed at the Leuven University Hospital between 1 January 1990 and 31 December 1999. Ninety‐three patients (92%) presented initially at the emergency department. Diagnosis was initially not suspected by the referring physician in 48 patients (47%). Plasmodium falciparum was the commonest species, accounting for 67% of the cases. All but three patients had fever as the presenting symptom, but only 10 had a typical tertian fever pattern. Haemolytic anaemia, thrombocytopenia and hyponatraemia represented a typical triad in 20% of the cases. Only 13% of the malaria patients had taken correct chemoprophylaxis according to WHO recommendations. Eighty‐three per cent of the patients were admitted to the hospital with a median duration of hospitalization of 4 days. All complications occurred in cases with P. falciparum. All patients were cured.

Osteopathia striata and focal dermal hypoplasia

A 43-year old female, presenting with pain in the left knee, attributed to a stress fracture of the tibia, was found to have osteopathia striata and numerous other congenital anomalies, not only of the skeleton, but also of other tissue systems. Of the latter the most important was the presence of focal dermal hypoplasia, a disorder of the skin. Review of the radiological and dermatological literature has shown this to be the fourteenth case in which these excessively rare entities have been associated. Such an association is considered to be more than a coincidence. A radiological diagnosis of osteopathia striata, therefore, should be followed by a careful dematological examination for focal dermal hypoplasia. Conversely, diagnosis of this rare dermatological disease should indicate the necessity for radiological survey of the skeleton.