Another Test to Consider in Evaluating Fever of Unknown Origin?
April 1, 2003 2 minutes read
Another Test to Consider in Evaluating Fever of Unknown Origin?
Abstract & Commentary
Synopsis: Random skin biopsies may be helpful in establishing an etiology of fever of unknown origin.
Source: Gill S, et al. Use of random skin biopsy to diagnose intravascular lymphoma presenting as fever of unknown origin. Am J Med. 2003;114:56-58.
Gill and associates report using random skin biopsies to establish a diagnosis of intravascular lymphoma in 2 patients with fever of unknown origin (FUO).
In the first case, a 63-year-old woman had fever, night sweats, malaise, and weight loss for 6 weeks. A leukoerythroblastic peripheral blood smear accompanied an increased leukocyte count and anemia (hemoglobin 7.8 g/dL). The erythrocyte sedimentation rate was increased to 88 mm/hr. An extensive diagnostic work-up was unrevealing. Finally, because of a suspected medication-associated erythematous macular rash, a skin biopsy was performed. In addition to a perivascular inflammatory infiltrate that confirmed the probability of a drug rash, the biopsy revealed intravascular malignant B lymphocytes.
The second case was that of a 60-year-old man with a 3-month history of fever, night sweats, weight loss, and lethargy. Physical examination was unremarkable. Anemia (hemoglobin 10.3 g/dL) was the only significant laboratory abnormality. Cerebrospinal fluid analysis, gallium radionuclide scanning, echocardiography, and biopsies of temporal artery, liver, and bone marrow were nondiagnostic. Random skin biopsies from normal-appearing skin yielded the diagnosis of intravascular lymphoma, and the patient completely recovered after intensive chemotherapy.
Comment by Jerry D. Smilack, MD
Gill et al emphasize that the diagnosis of intravascular lymphoma—a rare form of extranodal non-Hodgkin’s lymphoma—can be exceedingly difficult and is usually not made before autopsy. The histology is that of an intravascular proliferation of monoclonal B-cell lymphocytes, although occasionally T-cell lymphocytic disease occurs. Neurologic and cutaneous involvement predominates. Generalized or localized symptoms can herald neurologic involvement. Cutaneous disease can result in tender nodules, indurated plaques, or ulceration. Involvement of seemingly unaffected skin has been rarely reported, but this paper suggests the possibility that the disease may be more common than presently realized.
Will I consider obtaining random skin biopsies in my patients with FUO? Gill et al advocate doing so, especially when one factors in the simplicity of the procedure. It remains to be seen how useful skin biopsies will be in the evaluation of patients with FUO.
Dr. Smilack is Infectious Disease Consultant Mayo Clinic Scottsdale Scottsdale, AZ
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