Moffitt Pearls 6.12.17 – Pulm Report

Today in Pulmonary report Saate presented an amazing case of a middle age man w/ no past medical history found down with initial broad w/u notable for elevated Alk-Phos and recurring fevers of unknown origin!! In this case we discussed refractory acidosis, granulomatous hepatitis and finally the definition, evaluation and workup for fever of unknown origin. After broad w/u this patient was found to have miliary TB and infiltrative granulomatous hepatitis!! WOW and big thank you Saate for a truly amazing case!



  1. Remember, whenever a patient is not getting better as expected, to come back to the problem representation and consider reframing à it can be difficult to separate out noise from signal, but that’s also what’s fun about clinical problem solving!
  2. An isolated elevated alkaline phosphatase is highly suggestive of infiltrative disease.
  3. The differential for an FUO can be guided by sub-classifying the FUO into 1 of 4 different subtypes: Check out this review for more details.
    1. Classic FUO
    2. Nosocomial FUO
    3. Immune-deficient FUO
    4. HIV-related FUO

Differential for Lactic Acidosis:

lactic acidosis.png

Granulomatous Hepatitis Ddx


  • TB
  • Fungal
  • Syphillis


  • Sarcoid
  • Drugs
  • Malignancy
  • Idiopathic

Great review:

Fever of Unknown Origin


  • Fever > 38.3ºC on several occasions
  • Duration of fever for at least three weeks
  • Uncertain diagnosis after one week of study in the hospital (exact duration of inpatient work-up varies by source from 3-7days of inpatient work-up)FUO can be subclassified into 4 different subtypes:


  1. Classic FUO
  2. Nosocomial FUO
  3. Immune-deficient FUO
  4. HIV-related FUO

Etiologies for FUO often Three Broad Categories:

  • Infectious – endocarditis, fungal infections
  • Inflammatory including connective tissue disease
  • Malignancy

Initial Work-Up:

  • Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
  • Serum lactate dehydrogenase
  • TB skin test or Quanta gold
  • HIV antibody assay and HIV viral load for patients at high risk
  • Three routine blood cultures drawn from different sites over a period of at least several hours without administering antibiotics, if not already performed
  • Rheumatoid factor
  • Creatine phosphokinase
  • Heterophile antibody test in children and young adults
  • Antinuclear antibodies
  • Serum protein electrophoresis
  • Computed tomography (CT) scan of abdomen
  • CT scan of chest

Great review on FUOs:


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