Fever of unknown origin in a 58 year old man

A 58 year old man from Kolkata presented with high grade fever since 4 months with weight loss of 20 kilograms. There was no history of cough, diarrhea, abdominal pain, GI bleeding, skin rashes, joint pains or neurological symptoms. Physical examination was normal. The complete blood count, renal function tests and liver function tests were normal. The erythrocyte sedimentation rate was 98 mm at 1 hour.

Multiple blood cultures were sterile. A CT scan of the chest and abdomen showed no abnormalities. A transesophageal echocardiogram revealed no valvular vegetations. Brucella serologies were negative. Serum TSH was 0.4 IU/ml. Basal cortisol levels were 14 ug/dl. Ten days prior to presentation in our hospital, the patient had been started on empirical anti tuberculous therapy, following which he was admitted to the hospital with fever, hypotension and leucocytosis, and recovered after treatment with broad-spectrum antibiotics. A PET-CT done in this hospital showed no abnormalities.

A cosyntrophin stimulation test showed suboptimal cortisol response. Repeat thyroid function tests revealed low TSH and fT3/fT4 levels. The serum FSH, LH, and testosterone levels were low. A MRI brain revealed an empty sella.

The patient was diagnosed to hypopituitarism secondary to empty sella syndrome. The patient's symptoms resolved after institution of hormonal replacement therapy.

Hypopituitarism secondary to empty sella syndrome presenting as fever of unknown origin

A 37 year old HIV+ woman with fever and respiratory distress

A 37 year old woman from Nellore presented with low grade fever and malaise since 3 weeks. She developed non bloody diarrhea, dry cough and dyspnea at rest since 1 week. At presentation, she was hypoxemic (oxygen saturation ambient air 85%) with a respiratory rate of 35/min. Investigations revealed leucopenia (TC 2000 cells/ul), mild thrombocytopenia (platelet count 100000/ul) and mild transaminitis. Chest XRay revealed bilateral symmetrical infiltrates.

ELISA for HIV-I was positive, the CD4 count was 6 copies / ul, and viral load 320,000. Empirical treatment with TMP-SMX and prednisolone was initiated for Pneumocystis jirovecii pneumonia. After 8 days of treatment, the patient showed little clinical improvement. Diarrhea persisted through the hospital stay.

The CMV viral load in peripheral blood was 2 million copies/ml. A colonoscopy revealed diffuse erythema without ulcerations and colonic biopsy samples revealed intranuclear inclusions.

The patient was started on IV ganciclovir. She made steady improvement over the next 10 days and was discharged with advise to complete oral ganciclovir. Antiretroviral therapy with TDF/FTC/EFV was initiated.

CMV pneumonia and CMV colitis in advanced HIV/AIDS