Pseudo Fever Due to Mucositis
Abstract & Commentary
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine, Section Manager, HIV, is Associate Editor for Infectious Disease Alert.
Dr. Winslow serves as a consultant for Siemens Diagnostics, and is on the speaker's bureau for Boehringer-Ingelheim and GSK.
Synopsis: One hundred consecutive patients receiving cytotoxic chemotherapy were stratified into 4 groups of 25 each (patients with no fever and no mucositis, patients with mucositis, patients with fever and no mucositis, and patients with neutropenia and neither fever nor mucositis). Using simultaneous measurement of oral and tympanic membrane (TM) temperature, patients with mucositis had a mean oral temperature of 38.0 vs. TM temperature of 37.1° C.
Source: Ciuraru NB, et al. The influence of mucositis on oral thermometry: when fever may not reflect infection. Clin Infect Dis. 2008;46:
In this study, 100 consecutive patients, who were receiving several different cytotoxic chemotherapy regimens for a variety of cancers, were self-referred on the basis of perception of mucositis, elevated temperature at home, malaise, or were referred by a nurse based on assessment of potential infection or mucositis. The patients were stratified into the following groups of 25 patients each: group A- patients with neither fever nor mucositis; group B- patients with mucositis; group C- patients with fever and no evidence of mucositis; and group D- patients with neutropenia but without fever or mucositis.
All four groups demonstrated higher mean oral temperatures than TM temperatures: group A, 36.9 vs 36.8; group B, 38.0 vs 37.1; group C, 38.7 vs 38.4; group D, 37.0 vs 36.7. A linear regression model that examined the effect of other variables on the difference in temperature found that only mucositis was a significant factor.
Commentary
This is a fascinating paper that has significant potential clinical implications. Due to the high mortality rate of untreated bacterial sepsis occurring in the setting of fever and neutropenia, it has been "standard of care" since the 1970s to empirically begin broad-spectrum antibiotics in this clinical setting. It has long been recognized that this standard results in many more patients receiving antibiotics than the small number who actually have bacterial sepsis. While the empirical early use of antibiotics in febrile neutropenic patients has clearly resulted in reduction of mortality in patients with cancer and leukemia, it does come with a price tag consisting of all the complications of antibiotics therapy, including C. difficile-associated disease, allergic reactions, including allergic interstitial nephritis, and enhanced predisposition to fungal colonization and infection.
This important observation shows that oral mucositis can result in "pseudo fever" when only oral determinations of temperature are made. Awareness of this phenomenon may result in the reduction of unnecessary empirical use of antibiotics in some patients.
While the results of this study were surprising to me, they probably should not be. When one gets a sunburn, the skin is definitely hot to touch, not just subjectively so. It is always fun these days to occasionally read a paper in the field of infectious diseases which makes use of very simple technology and does not rely on sophisticated molecular techniques to make an important observation.
In this study, 100 consecutive patients, who were receiving several different cytotoxic chemotherapy regimens for a variety of cancers, were self-referred on the basis of perception of mucositis, elevated temperature at home, malaise, or were referred by a nurse based on assessment of potential infection or mucositis.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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