Search

Objective: Chest and sinus CT imaging among cancer patients undergoing chemotherapy and bone marrow transplant in the setting of neutropenic fever is not uncommon, yet the utility of routine imaging surveillance remains unclear. We aim to compare the rates of acute infection detected on CT chest and CT sinus exams performed in this clinical setting., Methods: Reports of 1059 consecutive CT chest and sinus examinations for the clinical indication of neutropenic fever on 262 patients performed between January through June 2017 were retrospectively reviewed. Infection as reported was characterized as acute or worsening, improving, stable, indeterminate or negative. Results were tabulated and Pearson's chi-square test was used for comparison analysis., Results: Absence of infection on CT sinus was significantly higher than CT chest (86.1% vs. 58.5%; P<0.001). Conversely, CT chest had significantly higher incidence of acute or worsening infection than CT sinus (28.7% vs. 11.6%; P<0.001). CT chest also showed significantly higher incidence of improving infection compared to CT sinus (6.2% vs. 1.1%; P<0.001). There was no significant difference between incidence of stable infection on CT chest and CT sinus (1.1% vs. 0.2%; P=0.059). Infection was indeterminate in 5.5% of CT chest vs. 1% on CT sinus (P<0.001)., Conclusions: CT chest showed significantly higher diagnostic yield for acute infection than CT sinus, suggesting that sinusitis is less likely to be the source of fever than chest infections in febrile neutropenic patients. The majority of CT studies showed absence of infection, raising the question of the overall utility of routine surveillance CT imaging among this subset of patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Post fever retinitis is a heterogenous entity that is seen 2-4 weeks after a systemic febrile illness in an immunocompetent individual. It may occur following bacterial, viruses, or protozoal infection. Optical coherence angiography (OCTA) is a newer non-invasive modality that is an alternative to fundus fluorescein angiography to image the retinal microvasculature. We hereby describe the vascular changes during the acute phase of post fever retinitis on OCTA. Imaging on OCTA was done for all patients with post fever retinitis at presentation with 3 × 3 mm and 8 × 8 mm scans centred on the macula and corresponding enface optical coherence tomography (OCT) scans obtained. A qualitative and quantitative analysis was done for all images. 46 eyes of 33 patients were included in the study. Salient features noted were changes in the superficial (SCP) and deep capillary plexus (DCP) with capillary rarefaction and irregularity of larger vessels in the SCP. The DCP had more capillary rarefaction when compared to the SCP. The foveal avascular zone (FAZ) was altered with an irregular perifoveal network. Our series of post fever retinitis describes the salient vascular features on OCTA. Although the presumed aetiology was different in all our patients, they developed similar changes on OCTA. While OCTA is not useful if there is gross macular oedema, the altered FAZ can be indicative of macular ischemia., (© 2021. The Author(s).)

Purpose: To verify that physicians' presumptive diagnosis is the most significant factor for finding any signs related to the cause of fever on computed tomography (CT) images., Materials and Methods: This single-center retrospective cohort study included patients (age ≥ 16 years) who underwent CT to investigate the cause of fever between January 1, 2014, and August 31, 2016. Patients who underwent surgical procedures were excluded. The primary outcome was the presence of suspicious CT findings related to the cause of fever. We performed univariate and multivariate logistic regression analyses, adjusted for CT contrast agent use, quick sequential organ failure assessment score > 1, and C-reactive protein level., Results: We enrolled 171 patients, of which 57 had CT findings, and 114 did not. Multivariate logistic regression analyses demonstrated a significant difference for the presence of a presumptive diagnosis by the attending physician (odds ratio, 4.99; 95% confidence interval 2.31-10.76; p < 0.01), but not for other covariates, including C-reactive protein., Conclusions: In hospitalized patients with fever, an attending physicians' presumptive diagnosis is associated with the presence of fever-related CT findings. Improving the quality of the diagnostic assessment before the CT scan may lead to more appropriate CT imaging use., (© 2021. The Author(s).)

Rationale: Neurogenic fever is a non-infectious source of fever in a patient with brain injury, especially hypothalamic injury. We report on a stroke patient with neurogenic fever due to injury of hypothalamus, demonstrated by using diffusion tensor imaging (DTI)., Patient Concerns: A 28-year-old male patient was admitted to the rehabilitation department of university hospital at 30 months after onset. Brain MRI showed leukomalactic lesions in hypothalamus, bilateral medial temporal lobe, and bilateral basal ganglia. He showed intermittent high body temperature (maximum:39.5°C, range:38.5-39.2°C), but did not show any infection signs upon physical examination or after assessing his white blood cell count and inflammatory enzyme levels such as erythrocyte sedimentation rate and C-reactive protein. In addition, 8 age-matched normal (control) subjects (4 male, mean age: 26.6 years, range: 21-29years) were enrolled in the study., Diagnosis: Intraventricular hemorrhage and intracerebral hemorrhage in the left basal ganglia., Interventions: He underwent extraventricular drainage and ventriculoperitoneal shunting for hydrocephalus., Outcomes: DTI was performed at 30 months after onset, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were obtained for hypothalamus. The FA and ADC values of patient were lower and higher, respectively, by more than two standard deviations from control values. Injury of hypothalamus was demonstrated in a stroke patient with neurogenic fever., Lessions: Our results suggest that evaluation of hypothalamus using DTI would be helpful in patients show unexplained fever following brain injury., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Kawasaki disease is a common childhood vasculitis. Fever and lymphadenopathy, at times, are the only clinical presentation of Kawasaki disease, which mimics infectious lymphadenitis, especially, when other features are yet to evolve. In such a scenario, ultrasonography of cervical lymph nodes can help to differentiate Kawasaki disease lymphadenitis from infectious lymphadenitis. We present one such patient who was initially diagnosed as having bacterial lymphadenitis; however, ultrasonography of the neck lymph nodes showed typical imaging features described with Kawasaki disease lymphadenitis.

With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to summarize the clinical profile, investigations, and radiological findings among patients with SARS-CoV-2-associated meningoencephalitis in the form of a systemic review. This review was carried out based on the existing PRISMA (Preferred Report for Systematic Review and Meta analyses) consensus statement. The data for this review was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase, and Cochrane library and Preprint servers up till 30 June 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes "SARS-COV-2," "COVID-19," and "meningoencephalitis." All peer reviewed, case-control, case report, pre print articles satisfying our inclusion criteria were involved in the study. Quantitative data was expressed in mean ± SD, while the qualitative date in percentages. Paired t test was used for analysing the data based on differences between mean and respective values with a p < 0.05 considered to be statistically significant. A total of 61 cases were included from 25 studies after screening from databases and preprint servers, out of which 54 of them had completed investigation profile and were included in the final analysis. Clinical, laboratory findings, neuroimaging abnormalities, and EEG findings were analyzed in detail. This present review summarizes the available evidences related to the occurrence of meningoencephalitis in COVID-19.

Objective: As dairy herds increase in size, close monitoring of health becomes a necessity, but this is expensive and labour-intensive. Early detection of febrile diseases is essential for economical and welfare reasons and to prevent the spread of disease. The goal of this study was therefore to evaluate a mobile, non-invasive technique for measuring the body temperature of cows that precludes the need for restraint of the animals., Materials and Methods: An infrared thermographic imaging camera installed on a smart phone was used to measure the surface temperature of cows. In experiment 1, a metal block heated to defined temperatures was used to obtain infrared thermographic measurements (THM). The accuracy of THM made at different distances from the block and at 2 different ambient temperatures was determined. In experiment 2, non-febrile cows underwent infrared thermographic imaging, and the body regions with the highest correlations between thermographic and rectal temperature were identified. In experiment 3, THM were made in febrile and neighbouring non-febrile cows., Results: In experiment 1, the thermographic and true temperatures of the block had the strongest relationships at 0.5 and 1.0 m (r = 0.98). The ambient temperature had a significant effect on the THM, which had larger variations and greater deviations from the block temperature at 14.8 °C than at 23.8 °C. In experiment 2, the maximum temperature at the eye (r = 0.37), THM at the muzzle (r = 0.28) and the medial canthus (r = 0.27) showed the strongest relationships with the rectal temperature. After correcting the THM with the mean difference between thermographic and rectal temperatures of the non-febrile cows, sensitivities of 88, 90 and 82 %, respectively, were calculated for THM at the muzzle, eye and medial canthus in febrile cows in experiment 3. The corresponding specificities were 6, 23 and 32 %., Conclusion and Clinical Relevance: Based on the low specificities of the infrared THM, the thermographic imaging camera has limited usefulness for the mass screening of dairy cows for febrile conditions. Cattle falsely identified as febrile need to be separated, caught and re-examined, which causes unnecessary stress to the animal and increases labour input., Competing Interests: The authors declare that they have no competing interests., (Thieme. All rights reserved.)

Opsoclonus-myoclonus-ataxia syndrome is a heterogeneous constellation of symptoms ranging from full combination of these three neurological findings to varying degrees of isolated individual sign. Since the emergence of coronavirus disease 2019 (COVID-19), neurological symptoms, syndromes, and complications associated with this multi-organ viral infection have been reported and the various aspects of neurological involvement are increasingly uncovered. As a neuro-inflammatory disorder, one would expect to observe opsoclonus-myoclonus syndrome after a prevalent viral infection in a pandemic scale, as it has been the case for many other neuro-inflammatory syndromes. We report seven cases of opsoclonus-myoclonus syndrome presumably parainfectious in nature and discuss their phenomenology, their possible pathophysiological relationship to COVID-19, and diagnostic and treatment strategy in each case. Finally, we review the relevant data in the literature regarding the opsoclonus-myoclonus syndrome and possible similar cases associated with COVID-19 and its diagnostic importance for clinicians in various fields of medicine encountering COVID-19 patients and its complications.

Background: The viral persistence in patients with Coronavirus Disease 2019 (COVID-19) remains to be investigated., Methods: We investigated the viral loads, therapies, clinical features, and immune responses in a 70-year patient tested positive for SARS-CoV-2 for 3 months., Findings: The patient exhibited the highest prevalence of abnormal indices of clinical features and immune responses at the first admission, including fever (38.3 ℃), decreased lymphocytes (0.83 × 10 9 /L) and serum potassium (3.1 mmol/L), as well as elevated serum creatinine (115 µmol/L), urea (8.6 mmol/L), and C-reactive protein (80 mg/L). By contrast, at the second and the third admission, these indices were all normal. Through three admissions, IL-2 increased from 0.14 pg/mL, 0.69 pg/mL, to 0.91 pg/mL, while IL-6 decreased from 11.78 pg/mL, 1.52 pg/mL, to 0.69 pg/mL, so did IL-10 from 5.13 pg/mL, 1.85 pg/mL, to 1.75 pg/mL. The steady declining trend was also found in TNF-α (1.49, 1.15, and 0.85 pg/mL) and IFN-γ (0.64, 0.42, and 0.27 pg/mL). The threshold cycle values of RT-PCR were 26.1, 30.5, and 23.5 for ORFlab gene, and 26.2, 30.6, and 22.7 for N gene, showing the patient had higher viral loads at the first and the third admission than during the middle term of the disease. The patient also showed substantially improved acute exudative lesions on the chest CT scanning images., Conclusions: The patient displayed declining immune responses in spite of the viral shedding for 3 months. We inferred the declining immune responses might result from the segregation of the virus from the immune system.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: None

Objectives: To compare CT findings of early (within 3 weeks post-onset)- and later (within 1 month before or after diagnostic criteria were satisfied, and later than 3 weeks post-onset) stage thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome., Methods: Between 2014 and 2019, 13 patients with TAFRO syndrome (8 men and 5 women; mean age, 54.9 years) from nine hospitals were enrolled. The number of the following CT findings (CT factors) was recorded: the presence of anasarca, organomegaly, adrenal ischaemia, anterior mediastinal lesion, bony lesion, and lymphadenopathy. Records of adrenal disorders (adrenomegaly, ischaemia, and haemorrhage) throughout the disease course were also collected. Differences in CT factors at each stage were statistically compared between remission and deceased groups., Results: Para-aortic oedema and mild lymphadenopathy were observed in all patients, whereas pleural effusion, ascites, and subcutaneous oedema were found in 5/13, 7/13, and 7/13 cases, respectively, at the early stage. CT factors at the early stage were significantly higher in the deceased than in the remission group (mean, 11 vs 6.5; p = 0.04), while they were nonsignificant at the later stage. Adrenal disorders were present in 7/13 cases throughout the course including 6 of adrenomegaly and 4 of ischaemia at the early stage., Conclusions: Para-aortic oedema and mild lymphadenopathy are most common at the early stage. Anasarca, organomegaly, lymphadenopathy, and adrenal disorders on early-stage CT are useful for unfavourable prognosis prediction. Moreover, adrenal disorders are frequent even at the early stage and are useful for early diagnosis of TAFRO syndrome., Key Points: • CT findings facilitate early diagnosis and prognosis prediction in TAFRO syndrome. • Adrenal disorders are frequently observed in TAFRO syndrome. • Adrenal disorders are useful for differential diagnosis of TAFRO syndrome.

Introduction: Giant cell arteritis (GCA) is a large vessel (LV) vasculitis, mainly affecting elder patients. Monitoring GCA activity during tocilizumab (TCZ) treatment is an unmet need, since low serum levels of C-reactive protein (CRP) during treatment may underestimate disease activity. To date, few data are available on the role of different imaging techniques in monitoring GCA activity and response to treatment. We report herein a cohort of GCA patients treated with TCZ and followed up with multimodal imaging. Patients and Methods . We collected clinical, laboratory, and imaging data of 11 GCA patients treated with TCZ 162 mg subcutaneously every week. Disease activity was assessed at baseline and within 12 months from the start of treatment using different imaging techniques such as color Doppler ultrasonography (CDUS), magnetic resonance imaging/angiography (MRI/MRA), computed tomography angiography (CTA), and/or positron emission tomography (PET)., Results: Four patients were affected by cranial and 7 by LV-GCA. All patients were treated with oral glucocorticoids (GCs) (mean dose 55.68 mg ± 8.19 of prednisone or equivalent) in combination with TCZ. Treatment was preceded in 5 cases by 3 intravenous boluses of 1000 mg methylprednisolone. A significant decrease of the mean dose of oral GCs was observed between baseline and the last follow-up visit (4.65 ± 3.69 mg) ( p = 0.003). TCZ treatment significantly decreased erythrocyte sedimentation rate ( p < 0.01) and CRP levels ( p < 0.01). At follow-up (mean 8.18 ± 3.63 months), all patients were in clinical and serological remission. Moreover, PET, CDUS, MRI/MRA, and CTA did not show any LVV finding., Conclusions: Our study highlights TCZ efficacy in inducing GCA remission and its steroid-sparing effect. We highlighted a reliability of imaging procedures in the evaluation of disease activity and treatment response. A close disease monitoring with imaging techniques should be taken into account in GCA patients during TCZ treatment., Competing Interests: The authors declare that the research was carried out in the absence of any personal, professional, or financial relationships that could potentially be construed as a conflict of interest., (Copyright © 2020 Edoardo Conticini et al.)

Purpose: Elevated body temperature might change glucose metabolism in human organs. The purpose of this study is to explore 18 F-FDG distribution in febrile patients on the day of 18 F-FDG PET/CT scanning and compare it with patients with a normal temperature., Procedures: 18 F-FDG PET/CT was performed on 69 febrile patients and 82 patients with a normal temperature. Patient sociodemographic data, blood glucose levels before PET/CT, body temperature on the day of the exam, and laboratory test results were collected. Maximal standard uptake values (SUV max ) in the brain, mediastinal blood pool, liver, spleen, and the bone marrow were compared., Results: Compared with the controls, SUV max of the febrile patients was significantly lower in the brain, mediastinal blood pool, and the liver (p < 0.01), and higher in the spleen and bone marrow (p < 0.01). In the febrile group, SUV max was not significantly different between the FDG burden and non-FDG burden patients (p > 0.05). Body temperature was found negatively correlated with SUV max in the brain (r = - 0.646), mediastinal blood pool (r = - 0.530), and the liver (r = - 0.384), and positively correlated with the SUV max in the spleen (r = 0.592) and bone marrow (r = 0.651). Multivariate linear regression established body temperature on the day of PET/CT as an independent affecting factor (p < 0.01) for the SUV max in the brain, mediastinal blood pool, liver, spleen, and bone marrow. The SUV in the brain, liver, and mediastinal blood pool remained different (p < 0.05) after corrected with the SUV max in the blood pool or liver., Conclusions: Fever influences 18 F-FDG distribution in multiple human tissues and organs. Altered 18 F-FDG distribution in vivo might affect results of disease lesion detection and tumor therapy response assessment. Correction with blood pool or liver SUV fails to cancel the effects of fever. The day of fever should be avoided for PET/CT scan, especially in assessing tumor therapy response.

Purpose: To evaluate the diagnostic accuracy and the imaging features of routine admission chest X-ray in patients suspected for novel Coronavirus 2019 (SARS-CoV-2) infection., Method: We retrospectively evaluated clinical and X-ray features in all patients referred to the emergency department for suspected SARS-CoV-2 infection between March 1st and March 13th. A single radiologist with more than 15 years of experience in chest-imaging evaluated the presence and extent of alveolar opacities, reticulations, and/or pleural effusion. The percentage of lung involvement (range <25 % to 75-100 %) was also calculated. We stratified patients in groups according to the time interval between symptoms onset and X-ray imaging (≤ 5 and > 5 days) and according to age (≤ 50 and > 50 years old)., Results: A total of 518 patients were enrolled. Overall 314 patients had negative and 204 had positive RT-PCR results. Lung lesions in patients with SARS-Cov2 pneumonia primarily manifested as alveolar and interstitial opacities and were mainly bilateral (60.8 %). Lung abnormalities were more frequent and more severe by symptom duration and by increasing age. The sensitivity and specificity of chest X-ray at admission in the overall cohort were 57 % (95 % CI = 47-67) and 89 % (83-94), respectively. Sensitivity was higher for patients with symptom onset > 5 days compared to ≤ 5 days (76 % [62-87] vs 37 % [24-52]) and in patients > 50 years old compared to ≤ 50 years (59 % [48-69] vs 47 % [23-72]), at the expense of a slightly lower specificity (68 % [45-86] and 82 % [73-89], respectively)., Conclusions: Overall chest X-ray sensitivity for SARS-CoV-2 pneumonia was 57 %. Sensitivity was higher when symptoms had started more than 5 days before, at the expense of lesser specificity, while slightly higher in older patients in comparison to younger ones., Competing Interests: Declaration of Competing Interest All authors declare no conflicts-of-interest related to this article., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aims and Background: The COVID-19 outbreak spread in China and is a threat to the world. We reported on the epidemiological, clinical, laboratory, and radiological characteristics of children cases to help health workers better understand and provide timely diagnosis and treatment., Methods: Retrospectively, two research centers' case series of 67 consecutive hospitalized cases including 53 adult and 14 children cases with COVID-19 between 23 Jan 2020 and 15 Feb 2020 from Jinan and Rizhao were enrolled in this study. Epidemiological, clinical, laboratory, and radiological characteristics of children and adults were analyzed and compared., Results: Most cases in children were mild (21.4%) and conventional cases (78.6%), with mild clinical signs and symptoms, and all cases were of family clusters. Fever (35.7%) and dry cough (21.4%) were described as clinical manifestations in children cases. Dry cough and phlegm were not the most common symptoms in children compared with adults (p = 0.03). In the early stages of the disease, lymphocyte counts did not significantly decline but neutrophils count did in children compared with adults (p = 0.02). There was a lower level of CRP (p = 0.00) in children compared with adults. There were 8 (57.1%) asymptomatic cases and 6 (42.9%) symptomatic cases among the 14 children cases. The age of asymptomatic patients was younger than that of symptomatic patients (p = 0.03). Even among asymptomatic patients, 5 (62.5%) cases had lung injuries including 3 (60%) cases with bilateral involvement, which was not different compared with that of symptomatic cases (p = 0.58, p = 0.74)., Conclusions: The clinical symptoms of children are mild, there is substantial lung injury even among children, but that there is less clinical disease, perhaps because of a less pronounced inflammatory response, and that the occurrence of this pattern appears to inversely correlate with age.

A 19-year-old woman presented with a productive cough, fever and chest pain. Clinical and chest X-ray findings prompted us to do a CT-scan, which revealed a mediastinal mass extending in the left thoracic cavity, suggestive of a teratoma with an obstructive pneumonia. The patient was successfully treated with intravenous antibiotics and surgical removal of the tumour.

In general, in digital infrared thermographic imaging (DITI) of patients with unilateral spinal radicular pain, the thermal pattern of the extremities of the side of lesion shows hypothermia compared to the opposite, intact side. However, sometimes, DITI shows hyperthermia on the side of the lesion, and this variation can cause confusion. We compared the data of both hypothermia and hyperthermia patients to clarify the factors determining different thermal characteristics in spinal radiculopathy.We retrospectively collected data from patients who underwent DITI at a single center. The final cohort (n = 224) was allocated into 2 groups, a hypothermia group (n = 180) or a hyperthermia group (n = 44). We compared the various factors, including demographic factors and symptom-related factors, that might affect the results of DITI.Except the presence of trauma history (13.9% vs 31.8%, odds ratio 2.893, P = .008), no significant intergroup difference was found in baseline demographic factors, including age, gender, diabetes mellitus, spinal level of pathology, and intervention history. Among symptom-related factors, in the hyperthermia group, the symptom duration was shorter (10.64 weeks [95% confidence interval (CI) 8.36-13.04] vs 2.10 weeks [95% CI 1.05-3.53], P < .001) and Visual Analogue Scale (VAS) of radicular pain was higher (4.23 ± 1.29 vs 5.18 ± 1.40, P < .001) than in the hypothermia group. Also, in the regression analysis, significant factors for hyperthermia include the presence of trauma history, shorter symptom duration (cut-off value 2.50 weeks or less) and higher VAS of radicular pain (cut-off value 4.50 or more).In patients with trauma history, acute phase, and severe radicular pain, hyperthermia in DITI is not unusual and careful interpretation of the DITI results is necessary for proper diagnosis and treatment decisions in spinal radiculopathy.

Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use. Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of ≥3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation. Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn't find any significant risk factors associated with treatment change following the CT scan. Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.

Case Presentation: A 22-year-old woman was admitted to our department for fever of unknown origin. The patient reported intermittent fever and nonspecific abdominal pain for several years. Six months before admission she started complaining of palpitations and exertional dyspnea. She had no weight loss, chest pain, headache, or joint complaints. Medical history was unremarkable. She did not consume tobacco, alcohol, or illicit drugs. The patient was from Malia. She had lived in France for 4 years and did not report recent travel., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: Periportal hyperechogenicity has been recorded in many inflammatory and infectious diseases, including viral hepatitis, inflammatory bowel diseases, toxic shock syndrome of staphylococcus infection, typhoid fever, and schistosomiasis. We aimed to evaluate the echogenicity of the portal tracts of the liver by abdominal ultrasound imaging in patients with fever irrespective of the cause., Methods: Abdominal ultrasound examination was performed in 277 consecutive patients presented with fever at their first visit and repeated 2 weeks later after their recovery., Results: Transient periportal hyperechogenicity was present in 39% (108 patients) of the feverish patients studied irrespective of the cause of the fever., Conclusion: Transient periportal hyperechogenicity is a frequent ultrasonographic finding in feverish patients irrespective of the cause of fever, and hence should not be misdiagnosed as liver disease or chronic periportal fibrosis unless the hyperechogenicity persists after recovery from the febrile or inflammatory condition.

Objective: The purpose of this study is to determine the characteristic findings of contrast-enhanced CT (CECT) of the neck in patients with Kawasaki disease (KD) and to develop a diagnostic scoring system to facilitate the diagnosis of KD versus other causes of fever and cervical lymphadenopathy., Materials and Methods: Two blinded radiologists evaluated CECT images of 37 patients with KD and 92 patients without KD who had febrile cervical lymphadenopathy, first independently and then in consensus. Significant findings in CECT images were evaluated through cervical edema and lymph node scores. CT attenuation of the nodal low-attenuation area and its ratio to the CT attenuation of the trapezius muscle were measured. On the basis of these indexes, a diagnostic scoring system was developed to differentiate between patients with and without KD. Its diagnostic performance was determined using ROC curve analysis., Results: Retropharyngeal edema, lateral cervical edema, nasopharyngeal wall edema, level IIA lymphadenopathy, and retropharyngeal lymphadenopathy were more common in patients with KD than in patients without KD (p < 0.001, < 0.001, < 0.001, 0.003, and 0.028, respectively). Level VB lymphadenopathy was more common in patients without KD (p = 0.013), and the presence of nodal low-attenuation areas with lower attenuation indexes (attenuation of nodal low-attenuation area ≤ 50 HU, or ratio of attenuation of nodal low-attenuation area to trapezius muscle attenuation ≤ 0.7) was specific to patients without KD. In cases of higher attenuation indexes and cervical edema and lymph node scores of 4 or higher, sensitivity, specificity, and accuracy of the diagnostic scoring system were 86% (32/37), 86% (79/92), and 86% (111/129), respectively, for diagnosing KD., Conclusion: The proposed diagnostic scoring system was useful in differentiating between patients with and without KD.

Objective: The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage., Methods: We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis., Results: Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2-5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (β = 13.5; 95% CI, 0.83-8.79, P = 0.01), posthemorrhage day (β = 20.1; 95% CI, 2.14-7.52; P < 0.001), and (posthemorrhage day) 2 (β = -0.72; 95% CI, -0.26 to -0.11; P < 0.001)., Conclusions: Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This study aimed to analyze the clinical characteristics and prognosis of pediatric idiopathic pulmonary hemosiderosis (IPH)., Methods: Pediatric IPH cases that were diagnosed at West China Second University Hospital, Sichuan University between 1996 and 2017 were reviewed. Follow-up data from 34 patients were collected., Results: A total of 107 patients were included (42 boys and 65 girls). The median age was 6 years at diagnosis. The main manifestations of the patients were as follows: anemia (n = 100, 93.45%), cough (n = 68, 63.55%), hemoptysis (n = 61, 57%), fever (n = 23, 21.5%), and dyspnea (n = 23, 21.5%). There were relatively few pulmonary signs. The positive rates of hemosiderin-laden macrophages in sputum, gastric lavage fluid, and bronchoalveolar lavage fluid were 91.66%, 98.21%, and 100%, respectively. Seventy-nine patients were misdiagnosed. A total of 105 patients were initially treated with glucocorticoids, among whom 102 survived and three died. Among the followed up patients, two died and 32 survived, among whom 10 presented with recurrent episodes., Conclusions: The classic triad of pediatric IPH is not always present. The rates of misdiagnosis and recurrence of IPH are high. Early recognition and adequate immunosuppressive therapy are imperative for improving prognosis of IPH.

Competing Interests: We have read and understood BMJ policy on declaration of interests and declare no competing interests.

A 14-year-old boy presented to our institution with a 1-month history of neurocognitive decline and intermittent fevers. His history was significant for fevers, headaches, and a 10-lb weight loss. Previous examinations by multiple medical providers were significant only for bilateral cervical lymphadenopathy. Previous laboratory workup revealed leukopenia, neutropenia, and elevated inflammatory markers. Despite improvement in his laboratory values after his initial presentation, his fevers persisted, and he developed slowed and "jerky" movements, increased sleep, slurred speech, delusions, visual hallucinations, and deterioration in his school performance. A brain MRI performed at an outside hospital before admission at our institution was concerning for patchy, increased T2 and fluid-attenuated inversion recovery signal intensity in multiple areas, including the basal ganglia. After transfer to our institution and admission to the pediatric hospital medicine team, the patient had an acute decompensation. Our subspecialists will discuss the initial evaluation, workup, differential diagnosis, definitive diagnosis, and subsequent management of this patient., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

The neural responses during hyperthermia, once thought of as simple physiological processes (e.g. thermal sensation and regulation), have now been recognised involving more cognitive processes, which would be of high importance to the management of those occupations during heavy heat exposure. Previous studies have demonstrated altered activity in localised subcortical clusters for thermal sensation and regulation, as well as cortical-cortical activity for behavioural tasks during hyperthermia. However, the involvement of cortical-subcortical activity during hyperthermia has not been investigated. In this study, we performed exploratory analyses comparing thalamocortical functional connectivity during whole body hyperthermic condition for an hour at 50 °C and normothermic condition at 25 °C. We found weakened functional connectivity of cortical fronto-polar/anterior cingulate cortex and prefrontal areas with the corresponding thalamic nuclei during hyperthermic versus normothermic comparisons. On the contrary, the motor/premotor, somatosensory and temporal cortical subdivisions showed increased connectivity with thalamic nuclei during hyperthermia. Thalamocortical connectivity changes in the prefrontal were identified to be correlated with the behavioural reaction time during psychomotor vigilance test after controlling for physiological variables. These distinct thalamocortical pathway alterations might reflect physiologically thermal sensation and regulation, as well as psychologically neural behaviour changes underlying cortical-subcortical activity during hyperthermia.

Importance: Powassan virus is a rare but increasingly recognized cause of severe neurological disease., Objective: To highlight the diagnostic challenges and neuropathological findings in a fatal case of Powassan encephalitis caused by deer tick virus (lineage II) in a patient with follicular lymphoma receiving rituximab, with nonspecific anti-GAD65 antibodies, who was initially seen with fever and orchiepididymitis., Design, Setting, and Participants: Comparison of clinical, radiological, histological, and laboratory findings, including immunohistochemistry, real-time polymerase chain reaction, antibody detection, and unbiased sequencing assays, in a single case report (first seen in December 2016) at an academic medical center., Exposure: Infection with Powassan virus., Main Outcomes and Measures: Results of individual assays compared retrospectively., Results: In a 63-year-old man with fatal Powassan encephalitis, serum and cerebrospinal fluid IgM antibodies were not detected via standard methods, likely because of rituximab exposure. Neuropathological findings were extensive, including diffuse leptomeningeal and parenchymal lymphohistiocytic infiltration, microglial proliferation, marked neuronal loss, and white matter microinfarctions most severely involving the cerebellum, thalamus, and basal ganglia. Diagnosis was made after death by 3 independent methods, including demonstration of Powassan virus antigen in brain biopsy and autopsy tissue, detection of viral RNA in serum and cerebrospinal fluid by targeted real-time polymerase chain reaction, and detection of viral RNA in cerebrospinal fluid by unbiased sequencing. Extensive testing for other etiologies yielded negative results, including mumps virus owing to prodromal orchiepididymitis. Low-titer anti-GAD65 antibodies identified in serum, suggestive of limbic encephalitis, were not detected in cerebrospinal fluid., Conclusions and Relevance: Owing to the rarity of Powassan encephalitis, a high degree of suspicion is required to make the diagnosis, particularly in an immunocompromised patient, in whom antibody-based assays may be falsely negative. Unbiased sequencing assays have the potential to detect uncommon infectious agents and may prove useful in similar scenarios.

Background: Routine chest X-ray (CXR) is recommended for neutropenic fever (NF) management however its role is relatively understudied in haematology patients., Aim: To investigate the utility of CXR in the diagnosis and management of patients with haematological conditions complicated by NF., Methods: Retrospective, single-centre analysis of haematology patients admitted with NF between January 2011 and December 2015. Baseline demographics, treatment details and outcomes were collected from electronic patient records. CXR underwent independent radiology review. Primary endpoints were a proportion of NF episodes in which CXR detected a probable chest infection in the absence of respiratory symptoms/signs and/or resulted in a change in antibiotic management., Results: Four hundred and thirty-five episodes were identified; CXR was performed in 75% of patients (65% within 2 days of NF). In 4 of 164 (2.4%) asymptomatic patients, CXR was consistent with infection, in contrast to 19 of 119 (16%) patients with clinical signs of respiratory infection. Only 3 of 283 (1.1%) CXR resulted in a change to antibiotics. CXR consistent with infection was not associated with increased mortality or increased admission length, although there was an association with intensive care unit admission (odds ratios: 7.61, 95% confidence interval: 2.04-28.31)., Conclusion: In haematology patients with NF, CXR rarely detected chest infection or changed management in patients with no respiratory symptoms or signs. CXR in our institution is no longer part of routine assessment of NF in the absence of these features., (© 2017 Royal Australasian College of Physicians.)

Passive hyperthermia would impair wide-domain cognitive performances (e.g. attention, working memory), which may involve abnormal regional and long-range neural activity. Combining the regional homogeneity (ReHo) and seed-based functional connectivity analysis, this study investigated the regional and long-range neural synchronization abnormality during passive hyperthermia. We acquired the resting-state blood oxygenation level dependent (BOLD) data from twenty-three healthy male participants in two simulated thermal conditions: normothermic condition (NC) with temperature at 25°C for 1 h and hyperthermic condition (HC) with temperature at 50°C for 1 h. After scanning, participants were asked to perform an attention network test (ANT). Relative to NC participants, the participants in HC group exhibited decreased regional neural synchronization in the frontal-occipital cortex, specifically in the left opercular part of inferior frontal gyrus/insula, bilateral middle occipital gyrus, and posterior cingulate cortex/precuneus, but increased one in the left dorsal superior/middle frontal gyrus. Using these significantly differed ReHo clusters as seeds, we further performed functional connectivity analysis and found aberrant long-range neural synchronization in the orbital medial frontal cortex, temporal-parietal junction areas. Further neurobehavioral correlation analysis showed significant positive correlation between the regional ReHo alteration in left dorsolateral superior/middle frontal gyrus and executive control effect. Additionally, the functional connectivity of the orbital medial frontal cortex with the seeds "left superior/middle frontal gyrus" and "posterior cingulate cortex/precuneus" were negatively correlated with the increase of rectal temperature. In current study, the participants showed hyperthermia-induced brain activity disruptions, appearing as altered local ReHo and long-range functional connectivity, which might help understand the relationship between neuronal and circuit activities and physiological thermal sensation and regulation as well as behavioral changes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Ultrasound contrast agent microbubbles were combined with magnetic resonance imaging (MRI)-guided focused ultrasound (MRgFUS) as a means to achieve mild hyperthermia at reduced power levels., Methods: MRgFUS hyperthermia (42°C for 20 min) was evaluated in rabbit thigh muscle or Vx2 tumors using infusions of microbubbles (Definity, 20 µL/kg) or saline (sham) administered over 5 min. The impact of treatments on drug uptake was assessed with liposomal doxorubicin (Caelyx, 2.5 mg/kg). Applied power levels before and after the injection of microbubbles or saline were compared, and drug uptake was evaluated with fluorometry of tissues harvested 24 hr post-treatment., Results: MRgFUS hyperthermia in muscle and tumors resulted in accurate temperature control (mean =42.0°C, root mean square error (RMSE) = 0.3°C). The power dropped significantly following the injection of microbubbles in muscle and tumors compared to exposures without microbubbles (-21.9% ± 12.5% vs -5.9% ± 7.8%, p = .009 in muscle; -33.8% ± 9.9% vs -3.0% ± 7.2%, p < .001 in tumors). Cavitation monitoring indicated emission of subharmonic, ultraharmonic, and elevated levels of fourth to sixth harmonic frequencies following microbubble injection. The drug delivery was elevated significantly in muscle with the use of microbubble-assisted relative to conventional heating (0.5 ± 0.5 ng/mg vs 0.20 ± 0.04 ng/mg, p = .05), whereas in tumors similar levels were found (11 ± 3 ng/mg vs 16 ± 4 ng/mg, p = .13)., Conclusions: The finding that microbubbles reduce the applied power requirements for hyperthermia has considerable clinical implications. The elevated levels of drug found in muscle but not tumor tissue suggest a complex interplay between the heating effects of microbubbles with those of enhanced permeabilization and possible vascular damage.

This was a study of a 33-year-old man with bipolar disorder treated with lithium who developed cerebellar atrophy after an event of extreme hyperthermia. Unlike previously reported cases of acute cerebellar atrophy after heat stroke, neuroleptic syndrome or lithium toxicity, this case was characterized by a chronic cerebellar atrophy that developed after sepsis-induced hyperthermia in the setting of non-toxic lithium levels. Unique to this case also was the early finding of cerebellar atrophy on MRI 2 weeks after the episode of hyperthermia, long-term neurotoxicity after the novo lithium therapy, and longest follow-up case of chronic cerebellar syndrome after hyperthermia with non-toxic lithium levels.