Fever of unknown origin and pericardial effusion in a haemodialysis patient

• Autor(a) principal: Pereira,Tiago Assis
• Data de Publicação: 2016
• Outros Autores: Gonçalves,Margarida, Torres,João, Rodrigues,Ilídio, Pires,Ana, Boquinhas,Helena, Barata,José
• Tipo de documento: Relatório
• Idioma: eng
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692016000300008
• topic: Fever of unknown origin; hemodialysis; idiopathic retroperitoneal fibrosis

Introduction: Retroperitoneal fibrosis is a rare disorder. The idiopathic (IRF) form of the disease accounts for most of cases. Renal failure is a common finding, and some patients present with non-functioning kidneys, as a result of long-lasting obstructive uropathy. The symptoms and signs associated with IRF are non-specific and, thus, its diagnosis requires a high degree of suspicion. Case Report: A 71-year-old man with multifactorial chronic kidney disease required initiation of haemodialysis on February 2014, due to disease progression to end-stage renal disease (ESRD). His past medical history included the diagnosis of optic neuritis, seronegative arthritis and biopsy-proven retroperitoneal fibrosis. The patient had been treated with glucocorticoids for 13 years, stopping this treatment at the time of haemodialysis (HD) initiation. Two months after initiation of HD, in April 2014, the patient complained of malaise and presented with recurrent fever. A thorough clinical and laboratory evaluation was unremarkable. An echocardiogram showed a minor to moderate pericardial effusion that led to prescription of HD intensification. Five months later, he was admitted to the Hospital due to worsening of the pericardial effusion, requiring pericardiocentesis. Pericardial fluid analysis showed exudative changes. A thorough laboratory evaluation was performed and only interferon gamma release assay (IGRA) was positive. Empirical anti-bacillary therapy was initiated, waiting for definite mycobacterial cultures. One month later, as the patient maintained complains of malaise and fatigue, and had recurrent fever, he was readmitted to the Hospital. Mycobacterial cultures ultimately became negative. Further work-up was performed, including positron emission tomography/computed tomography (PET/CT) scan, which detected recurrence of IRF along with aortic, pericardial and pleural involvement. Following initiation of glucocorticoid treatment, a clinical and laboratoryl improvement was documented, that persisted at 11 months of follow-up. Conclusion: IRF is characterized by a relapsing nature, and clinical presentation includes local and systemic symptoms and complications, making it difficult to diagnose. Treatment of IRF is often delayed because of difficulties in reaching the correct diagnosis