Virginia Research Day 2025

Medical Resident Research Case Reports

24 Fever of Unknown Origin with Multiple New Diagnoses

Katelyn Gudyka-Massie DO; Cynthia Pie, MD Corresponding author: katelyn.gudyka-massie@lpnt.net

Sovah Health Family Medicine Residency, Danville, VA

to persistent fevers despite broad spectrum antibiotic coverage. CTs of the abdomen, pelvis, maxillofacial, and neck were performed and found dental caries, enlarged lymph nodes, and proctitis. IV doxycycline was transitioned to cefepime, and the patient was started on IV fluconazole. HIV and Hepatitis C testing came back positive, with a CD4 count of 200. Infectious disease specialists believed source of infection was likely dental but recommended further STD testing: gonorrhea and chlamydia tests were negative, but syphilis antibody then RPR testing was positive, and patient was also started on penicillin G. Patient continued to receive IV antibiotics and had a course of doxycycline added on, however, had persistent fevers, leukopenia, and thrombocytopenia leading to a hematology consult. CMV and Parvo IgG testing were positive as well and the patient was also started on valganciclovir. Due to persistent fevers, dental caries, concern for lymphoma granuloma

venereum the patient was transferred to a facility with Infectious disease, gastrointestinal, cardiac, and ENT specialists. At this facility, the patient was placed on Unasyn, vancomycin, penicillin G, and fluconazole. After his extensive workup and evaluation at another facility his symptoms resolved, and he was diagnosed with a Jarisch Herxheimer reaction as the cause of his recurrent fevers; He was discharged on HAART for new HIV and metronidazole for colitis and to empirically treat for giardia. Conclusion: This case illustrates the need for an open mind and a thorough differential in cases of fever of unknown origin, even when possible causes have already been identified. Jarish herxheimer reactions occur rarely, in 10-35% of spirochetal infection treatment. Although rare, it is important to keep in a good differential.

Background: Fevers of unknown origin typically involve an in depth work up due to the spread of possible causes. The full differential is difficult to keep in mind due to the great number of possibilities. Case Presentation: A 36-year-old male with a past medical history of schizoaffective disorder and methamphetamine use disorder presented from a mental institution due to a fever and body aches after being treated with amoxicillin for hand cellulitis. On examination the patient was febrile and hypotensive. As cellulitis had been adequately treated blood and urine cultures and a pneumonia panel were obtained, but all were negative. A transthoracic and transesophageal ECHO was ordered to evaluate for endocarditis due to a history of IV drug use but was negative. Empiric IV antibiotics (doxycycline, vancomycin, and clindamycin) were started due to unknown cause. Infectious Disease was consulted due

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