Let us assume we have a patient with this history and let us try to explain his/her normal CRP values on the end of this post given the fact of commorbid high fever and neutrophilia.
The questions to intrigue are here
- If it is bacterial, how come CRP is not elevated?
- If it is viral, how come there is neutrophilia?
- If it is autoimmune, how come it is not autoimmune (ruled out by hematology and clinic)?
The patient wrote this:
Here are some fact about my fever of unknown origin, the diagnosis is apparently unknown, I am waiting now for some more serology, blood tests, urine cultivation and throat culture results.
The illness had 4 onsets, connected by a "feeling well" periods, 3 of them were cured by ATB, the four is being left untreated for diagnostic purposes.
First onset
before seeing a doctor:
duration:
- one week
symptoms:
- high fever on first day (39 Celsius)
- elevated temperature the rest of the week (37.7 Celsius)
- violent unproductive cough
- conjunctivitis (bloody eyes)
- congested nose (not runny, just swelled)
- sore throat
therapy:
- rest, hot tea, sore throat and cough off-the-counter medicine
- w/o medical attention
after seeing a doctor:
diagnostics:
- CRP elevated to 33
- stethoscope test found "something" on the lungs
therapy:
- clarithromycin 500mg 2 times a day
- some otc mucolytics and antitusics (not codeine like)
duration:
- four days
symtoms:
- resolved after 4 days, but on the 7th day on ATB, the sore throat returned
Second onset
duration:
- three days
therapy:
- azithromycin 500mg for 3 days once a day
symtoms:
- resolved after 3 days
Third onset
After another 4 days being ok, I went to sauna to strengthen my immunity. The next day...
symptoms:
- high fever, used antipyretics when reached 39 Celsius
- vomitting (due to fever)
- violent unproductive cough
diagnostics:
- referred to pneumologist
- CRP elevated to 48
- RTG of the lungs and hearth OK
- stethoscope, lymph nodes, abdomine ok
- the "pulse oximetry and arterial blood gas test" showed high pulse
- blood: true left shift
- leukocytes 18 (<10)
- neutrophils 0.856 (<0.7)
- lymphocytes 0.091 (>0.2)
- neutrophils# 15 (<7)
therapy:
- cefurixim (cephalosporines 2nd gen) 500mg twice a day for 2 weeks
duration:
- resolved completely in a day or two
Fourth onset
After three weeks feeling healthy and one alright blood test (cell count+diff, antigens, CRP and biochemistry), I went into a hot shower after a train trip and ended it with a very short cold shower to strengthen immunity. The next day...
symptoms:
- high fever (39 Celsius)
- vomiting (due to fever)
- mild unproductive cough
diagnostics:
- RTG of the lungs OK
- lymphnodes OK
- sthetoscope OK
- blood: true left shift
- bilirubin 24 (<21)
- ALT 1.04 (<0.83)
- leukocytes 19 (<10)
- neutrophiles 0.92 (<0.8)
- lymphocytes 0.038 (>0.2)
- neutrophiles# 17 (<7)
- lymphocytes# 0.72 (>0.8)
- sedimentation 1 (>2)
- BUT CRP NOT (much) ELEVATED 6.2 (<5)
At this point, the pneumologist was kind of stunned by these results and referred me to the hemmatology the same day. The test there were pretty much the same, except a bit elevated CRP (~20). Hematologist ruled out malignity and referred me to the infections diseases. They ruled out some viruses Eppstein-Barr, HIV, heppatitis and perhaps boreliosis and referred me to USG of abdomen and RTG of sinuses, which were ok.
