Pyrexia of Unknown Origin in Non-Small Cell Lung Cancer: A Fatal Diagnostic Dilemma Between Infectious and Neoplastic Fever

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

INTRODUCTION: Fever has been well established as a paraneoplastic phenomena in hematologic malignancy's and renal cell carcinoma. Paraneoplastic syndrome are also with establish with small cell lung cancers. However, a few case records have described neoplastic fever associated with non-small cell lung cancer. (1) diagnostic criteria for neoplastic fever includes temperature of 37.8 Celsius for greater than two weeks in the absence of infectious or allergic etiology, no response to empiric antibiotics and prompt lysis with NSAIDS. (2) Medical or surgical management of the neoplasm leading to lysis of fever is also consistent with neoplastic fever. The pathophysiology of neoplastic fever, enclosed interleukin 1 interleukin 6 and TNF alpha released due to body's immune response to chemotherapy. (3) CASE PRESENTATION: A 55-year-old male with stage four squamous cell carcinoma of the left upper lobe of lung presented with high-grade fever upto 102°F for a week He had undergone two cycles of chemotherapy with cisplatin and gemcitabine along with one cycle of immunotherapy with tremelimumab and durvalumab in the last four months; he was due for his next cycle at the time of presentation. On presentation, he was febrile up to 102F, with normal leukocyte count. Initial infectious work up including blood cultures, respiratory virus, panel, and urine cultures was negative. Patient developed neutrophilic leukocytosis on day 2; both fever and leukocytosis persisted despite five days of empiric antibiotic therapy. Work up for viral myocarditis with coksackie A virus antibody was mildly elevated (1:16). EBV early antigen was mildly positive. ESR CRP, ANA titles and ferritin were elevated but workup for HLH was negative. Patient developed hemoptysis around day three. Chest x-ray showed stable left-sided pleural effusion with pleural catheter in place. Pleural fluid analysis was unremarkable for infection but showed possibility of intra-nuclear organisms. Workup for atypical pneumonia (Mycoplasma and Clamydophila pneumonia PCR) was negative. Workup for fungal ideology was negative. CT angiography of the chest ruled out pulmonary embolism. Repeat CT scan of the chest abdomen pelvis ruled out infectious foci. RUQ abdominal ultrasound showed my CBD dilation which was redemonstrated on MRCP. Patient underwent ERCP with stent placement without any change in fevers. He continued to require 650 mg paracetamol every 4 hours. Subsequently, he developed worsening respiratory failure with new onset right sided pleural effusion. He also developed acute liver injury. HIV, CMV and acute hepatitis panel were negative Despite initial improvement with thoracentesis, patient's condition continue to decline with worsening fevers, hypotension and hypoxemia. He was transitioned to comfort care and passed away a few days later. DISCUSSION: It is essential to differentiate between neoplastic fever and infectious fever in malignancy as treatment for the former can worsen the latter. In our case a diagnosis of neoplastic fever could not be made as the patient several soft indicators of infection like leukocytosis, hyperferritinemia and positive EBV antigen. A trial of chemotherapy could not be done due to concern for infection CONCLUSIONS: Naproxen trial should be incorporated early in management if chemotherapy is contraindicated due to concerns for infection in pyrexia of unknown origin in malignancy.

Volume

166

Issue

4 Suppl

First Page

A4394

Comments

Chest Annual Meeting, October 6-9, 2024, Boston, MA

Last Page

A4395

DOI

10.1016/j.chest.2024.06.2668

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