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Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 218-220

Disseminated tuberculosis in a kidney transplant patient: Diagnostic significance of reversed circadian temperature rhythm

Infectious Diseases Department, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashad, Iran

Date of Web Publication1-Mar-2017

Correspondence Address:
Ali Akbar Heydari
Infectious Diseases Department, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashad
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.ijmyco.2012.10.002

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Presently, clinicians often forget important aspects of fever patterns. This study presents the case of disseminated tuberculosis in a 64-year-old man whose chief complaint was morning fever. He was a kidney transplant patient and presented with productive cough, reverse fever pattern and a nodular pattern in chest radiograph. Clinicians should suspect disseminated tuberculosis in patients who present with reverse fever pattern, especially with compatible radiographic findings.

Keywords: Reversed circadian temperature rhythm, Disseminated tuberculosis, Kidney transplantation, Morning fever

How to cite this article:
Heydari AA, Sarvghad MR. Disseminated tuberculosis in a kidney transplant patient: Diagnostic significance of reversed circadian temperature rhythm. Int J Mycobacteriol 2012;1:218-20

How to cite this URL:
Heydari AA, Sarvghad MR. Disseminated tuberculosis in a kidney transplant patient: Diagnostic significance of reversed circadian temperature rhythm. Int J Mycobacteriol [serial online] 2012 [cited 2021 Sep 23];1:218-20. Available from: https://www.ijmyco.org/text.asp?2012/1/4/218/201256

  Introduction Top

Miliary tuberculosis (TB) is a progressive, disseminated hematogenous form of TB. Miliary or disseminated TB remains a diagnostic challenge. Clinical signs of miliary TB and its presentations are protean. When miliary TB is presented by nodular pattern on the chest X-ray, the differential diagnosis is extensive and includes infectious, inflammatory and neoplastic diseases.

Although the fever pattern is a useful diagnostic tool in a few cases of infectious diseases, it is more useful in obscure diagnoses or in conditions that differential diagnosis is extensive [1]. The case reported herein is unusual, in particular the reversed circadian temperature rhythm in disseminated TB in which an appreciation of temperature recordings is essential for the TB diagnosis.

  Case report Top

The patient is a 64-year-old man who presented with a chief complaint of morning fever and sweating. The patient reported that the disease started 20 days before admission with a productive cough; 10 days after the productive cough started, he developed fever and chills. The fever was worse in the morning accompanied by chills, followed by sweating. He had no fever at night.

His past history was significant for Type 2 diabetes mellitus, chronic renal failure and kidney transplantation 9 months before admission. The patient denied the use of alcohol, tobacco, or illicit and intravenous drugs.

Except for the recent use of cyclosporine, prednisolon, vitamin B1, and co-trimoxazole, he took no other medications.

Upon admission (in the afternoon), his temperature was 37 °C, his pulse was 88 beats per minute, his respiratory rate was 18 breaths per minute and his blood pressure was 126/78mmHg. Upon physical examination, there was no altered mental status, no neck stiffness and no scleral icterus. There was also no lymphadenopathy present. Heart sounds were normal and no murmurs were auscultated. There were rale sounds heard at the base of the lungs. Abdominal examination revealed normoactive bowel sounds, but there was no rebound, and no hepatosplenomegaly or masses. No adenopathy was present. Rectal examination revealed a normal-sized prostate. Extremity and neurologic examinations revealed normal motor and sensation in all 4 extremities with no gross neurologic abnormalities present.

Laboratory data revealed a white blood cell count of 13,000 cells per mm3 (89% neutrophils, 10% lymphocytes and 1% monocytes), platelet count of 300,000 per mm3, hemoglobin of 12.2 g/dl, and hematocrit of 37%. Serum sodium, potassium, chloride, bicarbonate, blood urea nitrogen, and glucose were all normal. Erythrocyte sedimentation rate was 88 at 1 h, and CRP was strongly positive. Blood cultures and purified protein derivative were negative. Chest X-ray [Figure 1] revealed the bilateral nodular pattern. Owing to repeated negative sputum smear, bronchoalveolar lavage was performed and reported positive for acid-fast bacilli. Sputum culture was not performed owing to regional health policy.
Figure 1: Chest X-ray showing bilateral nodular pattern in the patient with miliary tuberculosis.

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Anti-tuberculosis treatment was started upon admission. The patient's fever decreased after 3 days.

The key symptoms presented to properly diagnosing this patient were pulmonary nodular pattern and a reverse circadian temperature rhythm. With anti-tuberculosis treatment, the patient made an uneventful recovery.

  Discussion Top

After initial inhalation of TB bacilli, miliary TB may occur as primary TB or it may occur years after the initial infection.

The clinical presentation of disseminated TB is highly variable and may present as failure to thrive without fever, fever of unknown origin [2], malfunction of one organ or multi-organ system failure [3],[4], septic shock [5], and acute respiratory distress syndrome [6],[7]. The most common symptoms are nonspecific and include fever, wasting, and weakness or malaise. Night sweats are frequent. Rigors have been described although this is unusual in disseminated TB [8],[9].

Studies of TB in organ transplant recipients consistently show a high proportion of patients, up to 63%, with non-pulmonary or disseminated TB. Some patients may be asymptomatic, and the infection may be diagnosed incidentally.

This patient presented with chronic onset of cough accompanied by fever and sweating. The most efficient diagnostic approach to fever of unexplained origin involves the analysis of clues obtained from a careful history and physical examination, the fever pattern, and selected tests. Fever patterns may help in exploring the diagnosis in the absence of other clinical clues. Important information can be obtained at the patient's bedside, including fever patterns that should not be overlooked. For example, a morning temperature spike instead of the usual afternoon spike may suggest TB, periarteritis nodosa, or Salmonella bacteremia [10].

Chronic onset of cough accompanied by fever and sweating is typical of TB infection. Consistent with disseminated mycobacterial infection in this study's patient was the miliary pattern of chest X-ray. Vital signs provided the most important clues to TB and included reverse circadian temperature rhythm. This constellation of findings in an immunocompromised patient suggested the diagnosis, which led to microbiologic search and confirmation of the miliary TB by positive smear of a bronchoalveolar lavage specimen.

Currently, clinicians often forget important aspects of fever patterns. So much concentration is fixed on laboratory testing, and patient's fever curves or patterns are easily overlooked. Of course fever patterns are not diagnostic in many infectious diseases, but they may be helpful in situations when the diagnosis is doubtful or the list of differential diagnoses is broad [1].

Clinicians should suspect disseminated TB in the patients who present with fever and chills accompanied by sweating. The findings of a reverse pattern of fever and nodularity in chest X-rays should further suggest the possibility of TB. Physicians should evaluate fever patterns that may offer important diagnostic clues so that timely investigations may be started to reach a definitive diagnosis.

  Conflict of interest Top

These authors confirm that there is no conflict of interest.

  References Top

B.A. Cunha, J. Krakakis, B.P. McDermott, Fever of unknown origin (FUO) caused by miliary tuberculosis: diagnostic significance of morning temperature spikes, Heart Lung 38 (2009) 77–82.  Back to cited text no. 1
J.H. Kim, A.A. Langston, H.A. Gallis, Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis and outcome, Rev. Infect. Dis. 12 (1990) 583.  Back to cited text no. 2
Y. Asada, T. Hayashi, A. Sumiyoshi, M. Aburaya, E. Shishime, Miliary tuberculosis presenting as fever and jaundice with hepatic failure, Hum. Pathol. 22 (1991) 92.  Back to cited text no. 3
M. Sydow, A. Schauer, T.A. Crozier, H. Burchardi, Multiple organ failure in generalized disseminated tuberculosis, Respir. Med. 86 (1992) 517.  Back to cited text no. 4
S.S. Ahuja, S.K. Ahuja, K.R. Phelps, W. Thelmo, A.R. Hill, Hemodynamic confirmation of septic shock in disseminated tuberculosis, Crit. Care Med. 20 (1992) 901.  Back to cited text no. 5
A.R. Piqueras, L. Marruecos, A. Artigas, C. Rodriguez, Miliary tuberculosis and adult respiratory distress syndrome, Intensive Care Med. 13 (1987) 175.  Back to cited text no. 6
A. Mohan, S.K. Sharma, J.N. Pande, Acute respiratory distress syndrome (ARDS) in miliary tuberculosis: a twelve year experience, Indian J. Chest Dis. Allied Sci. 8 (1996) 157.  Back to cited text no. 7
C. Harvey, S. Eykyn, C. Davidson, Rigors in tuberculosis, Postgrad. Med. J. 69 (1993) 724.  Back to cited text no. 8
K.J. Lowry, K.T. Stephan, C.E. Davis, Miliary tuberculosis presenting with rigors and developing unusual cutaneous manifestations, Cutis 64 (1999) 23–28.  Back to cited text no. 9
B.A. Cunha, Fever of unknown origin in the elderly, Geriatrics 37 (1982) 30–36. 39–40, 44.  Back to cited text no. 10


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