You are using an outdated browser. Please upgrade your browser to improve your experience.
Become a Fellow
ACP offers a number of resources to help members make sense of the MOC requirements and earn points.
Understanding MOC Requirements
Earn MOC points
The most comprehensive meeting in Internal Medicine.
April 11-13, 2019
Internal Medicine Meeting 2019
Prepare for the Certification and Maintenance of Certification (MOC)
Exam with an ACP review course.
Board Certification Review Courses
MOC Exam Prep Courses
Treating a patient? Researching a topic? Get answers now.
Visit AnnalsLearn More
Visit MKSAP 18Learn More
Visit DynaMed Plus
Ensure payment and avoid policy violations. Plus, new resources to help you navigate the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Access helpful forms developed by a variety of sources for patient charts, logs, information sheets, office signs, and use by practice administration.
ACP advocates on behalf on internists and their patients on a number of timely issues. Learn about where ACP stands on the following areas:
© Copyright 2018 American College of Physicians. All Rights Reserved. 190 North Independence Mall West, Philadelphia, PA 19106-1572
Toll Free: (800) 523.1546 · Local: (215) 351.2400
First Author: Nikhil A. Patel, Mayo Medical School, Class of
Introduction: In adults, fever of unknown
origin (FUO) is primarily infectious, neoplastic, or autoimmune in
etiology. It is characterized by a prolonged febrile illness
without an established etiology despite intensive evaluation and
diagnostic testing. When the history, examination, or imaging
uncovers a possible source, specific testing should be performed.
Biopsy is a specific and critical modality in the directed
evaluation of FUO especially when thrombocytopenia and anemia are
present. Therapeutic trials of antimicrobials or glucocorticoids
are tempting but rarely establish a diagnosis.
Case Description: A 69-year-old South Sudanese
woman presented to outside hospital with fever and productive
cough. She was diagnosed with sepsis secondary to streptococcus
pneumonia by urine antigen. She responded to fluid resuscitation
and was kept on levofloxacin to complete a 7 day course after
dismissal from the hospital.
Two weeks later she presented again with similar symptomology
along with anemia and thrombocytosis. This time she continued to
deteriorate despite multiple IV antibiotics and required ICU level
of care. Extensive infectious disease workup yielded only a
positive QuantiFERON-TB test and a negative HIV antibody assays. CT
of abdomen and pelvis revealed mesenteric lymphadenopathy and
bilateral axillary lymph adenopathy. Right axillary lymph node
aspiration was performed but was nondiagnostic. CT/PET scan again
showed persistent mesenteric and axillary lymphadenopathy as well
as a hypermetabolic spleen. Excisional biopsy pathology of right
inguinal lymph node revealed HHV-8 positive, MCD. She was initiated
on rituximab and ganciclovir therapy. For the history of latent TB
infection, she was started on isoniazid with vitamin B6. She
improved dramatically with this therapy and was discharged to
follow up as an outpatient with hematology and infectious
Discussion: Castleman's disease in its
multicentric form is strongly associated with immunosuppression,
HIV, and HHV-8 infection. Despite many cases associated with HIV
infection, non-HIV, HHV-8 positive MCD can also occur. Diagnosis
should be suspected in patients with fever, splenomegaly, and
peripheral lymphadenopathy. CT imaging should also illustrate
multiple regions of involvement and one irregular node should be
excised for biopsy. First line treatment for HHV-8 positive, MCD is
rituximab (anti-CD 20 antibody) and ganciclovir. With only ten
patients in the literature identified as HIV negative, HHV-8
positive MCD, seven have died, many within several months after
diagnosis. This case highlights the importance of a team-based
approach in evaluating complex FUO cases where the internist plays
a key role not only as a great diagnostician but also as a leader
and care coordinator.
October 2015 Issue of IMpact