Fever of unknown origin

Fever of unknown origin (FUO), refers to a condition in which the patient has an elevated temperature (fever) but despite investigations by a physician no explanation has been found.[1][2][3][4][5]

Fever of unknown origin
Other namesPyrexia of unknown origin , Febris e causa ignota

If the cause is found it is usually a diagnosis of exclusion, that is, by eliminating all possibilities until only one explanation remains, and taking this as the correct one.


Extrapulmonary tuberculosis is the most frequent cause of FUO.[2] Drug-induced hyperthermia, as the sole symptom of an adverse drug reaction, should always be considered. Disseminated granulomatoses such as tuberculosis, histoplasmosis, coccidioidomycosis, blastomycosis and sarcoidosis are associated with FUO. Lymphomas are the most common cause of FUO in adults. Thromboembolic disease (i.e. pulmonary embolism, deep venous thrombosis) occasionally shows fever. Although infrequent, its potentially lethal consequences warrant evaluation of this cause. Endocarditis, although uncommon, is another important etiology to consider. An underestimated reason is factitious fever. Patients frequently are women that work, or have worked, in the medical field and have complex medical histories.[1][6] Bartonella infections are also known to cause fever of unknown origin.[7]

Here are the known causes of FUO.[8]


Infection cause
Localized pyogenic infections
Intravascular infections
Systemic bacterial infections
Mycobacterial infections
Other bacterial infections
Rickettsial infections
Chlamydial infections
Viral infections
Fungal infections
Parasitic infections


Although most neoplasms can present with fever, malignant lymphoma is by far the most common diagnosis of FUO among the neoplasms.[9] In some cases the fever even precedes lymphadenopathy detectable by physical examination.[9]

Neoplasm causeDisease name
Hematologic malignancies
Solid tumors

Noninfectious inflammatory diseases

Noninfectious inflammatory diseasesDisease name
Systemic rheumatic and autoimmune diseases
Granulomatous diseases

Miscellaneous conditions

Inherited and metabolic diseases

Thermoregulatory disorders

Thermoregulatory disordersLocation

Habitual hyperthermia


  • “Afebrile” FUO [<38.3 °C (100.94 °F)][8]


A comprehensive and meticulous history (i.e. illness of family members, recent visit to the tropics, medication), repeated physical examination (i.e. skin rash, eschar, lymphadenopathy, heart murmur) and myriad laboratory tests (serological, blood culture, immunological) are the cornerstone of finding the cause.[1][3]

Other investigations may be needed. Ultrasound may show cholelithiasis, echocardiography may be needed in suspected endocarditis and a CT-scan may show infection or malignancy of internal organs. Another technique is Gallium-67 scanning which seems to visualize chronic infections more effectively. Invasive techniques (biopsy and laparotomy for pathological and bacteriological examination) may be required before a definite diagnosis is possible.[1][3]

Positron emission tomography using radioactively labelled fluorodeoxyglucose (FDG) has been reported to have a sensitivity of 84% and a specificity of 86% for localizing the source of fever of unknown origin.[10]

Despite all this, diagnosis may only be suggested by the therapy chosen. When a patient recovers after discontinuing medication it likely was drug fever, when antibiotics or antimycotics work it probably was infection. Empirical therapeutic trials should be used in those patients in which other techniques have failed.[1]


In 1961 Petersdorf and Beeson suggested the following criteria:[1][2]

  • Fever higher than 38.3 °C (101 °F) on several occasions
  • Persisting without diagnosis for at least 3 weeks
  • At least 1 week's investigation in hospital

A new definition which includes the outpatient setting (which reflects current medical practice) is broader, stipulating:

  • 3 outpatient visits or
  • 3 days in the hospital without elucidation of a cause or
  • 1 week of "intelligent and invasive" ambulatory investigation.[2]

Presently FUO cases are codified in four subclasses.

Classic FUO

This refers to the original classification by Petersdorf and Beeson. Studies show there are five categories of conditions:


Nosocomial FUO refers to pyrexia in patients that have been admitted to hospital for at least 24 hours. This is commonly related to hospital-associated factors such as surgery, use of a urinary catheter, intravascular devices (i.e. "drip", pulmonary artery catheter), drugs (antibiotic-induced Clostridium difficile colitis, drug fever), and/or immobilization (decubitus ulcers). Sinusitis in the intensive care unit is associated with nasogastric and orotracheal tubes.[1][2][3] Other conditions that should be considered are deep-vein thrombophlebitis, pulmonary embolism, transfusion reactions, acalculous cholecystitis, thyroiditis, alcohol/drug withdrawal, adrenal insufficiency, and pancreatitis.[2]


Immunodeficiency can be seen in patients receiving chemotherapy or in hematologic malignancies. Fever is concomitant with neutropenia (neutrophil <500/uL) or impaired cell-mediated immunity. The lack of immune response masks a potentially dangerous course. Infection is the most common cause.[1][2][3]

Human immunodeficiency virus (HIV)-associated

HIV-infected patients are a subgroup of the immunodeficient FUO, and frequently have fever. The primary phase shows fever since it has a mononucleosis-like illness. In advanced stages of infection fever mostly is the result of a superimposed infections.[1][2][3]

African hantavirus (Sangassou virus)

In 2010, the first indigenous African hantavirus, Sangassou virus (SANGV) was isolated from an African wood mouse in a forest in Guinea, West Africa. A retrospective seroepidemiological analysis revealed the presence of Sangassou virus-specific neutralizing antibodies in the sera of patients suffering from fever of unknown origin.[11][12]


Unless the patient is acutely ill, no therapy should be started before the cause has been found. This is because non-specific therapy is rarely effective and mostly delays diagnosis. An exception is made for neutropenic patients in which delay could lead to serious complications. After blood cultures are taken this condition is aggressively treated with broad-spectrum antibiotics. Antibiotics are adjusted according to the results of the cultures taken.[1][2][3]

HIV-infected persons with pyrexia and hypoxia will be started on medication for possible Pneumocystis jirovecii infection. Therapy is adjusted after a diagnosis is made.[3]


Since there is a wide range of conditions associated with FUO, prognosis depends on the particular cause.[1] If after 6 to 12 months no diagnosis is found, the chances diminish of ever finding a specific cause.[3] However, under those circumstances prognosis is good.[2]


  1. Mandell's Principles and Practices of Infection Diseases 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone
  2. Harrison's Principles of Internal Medicine Archived 2012-08-04 at the Wayback Machine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
  3. The Oxford Textbook of Medicine Archived 2006-09-23 at the Wayback Machine Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
  4. Cecil Textbook of Medicine Archived 2010-06-16 at the Wayback Machine by Lee Goldman, Dennis Ausiello, 22nd Edition (2003), W.B. Saunders Company, ISBN 0-7216-9652-X
  5. Irwin and Rippe's Intensive Care Medicine Archived 2006-04-22 at the Wayback Machine by Irwin and Rippe, Fifth Edition (2003), Lippincott Williams & Wilkins, ISBN 0-7817-3548-3
  6. Fever of Unknown Origin at Mount Sinai Hospital
  7. Florin TA, Zaoutis TE, Zaoutis LB (2008). "Beyond cat scratch disease: widening spectrum of Bartonella henselae infection". Pediatrics. 121 (5): e1413–25. doi:10.1542/peds.2007-1897. PMID 18443019.
  8. al.], ed. Dan L. Longo ... [et (2012). Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 978-0071748896.CS1 maint: extra text: authors list (link)
  9. Harrison'sTM Principles of Internal Medicine (19th ed.). USA: McGraw-Hill Education. 2015-04-17. ISBN 978-0-07-1802161.
  10. Meller J, Altenvoerde G, Munzel U, Jauho A, Behe M, Gratz S, Luig H, Becker W (2000). "Fever of unknown origin: prospective comparison of [18F]FDG imaging with a double-head coincidence camera and gallium-67 citrate SPET". Eur J Nucl Med. 27 (11): 1617–25. doi:10.1007/s002590000341. PMID 11105817.
  11. Klempa B, Koivogui L, Sylla O et al. Serological evidence of human hantavirus infections in Guinea, West Africa. J Infect Dis 2010; 201: 1031–1034.
  12. Strecker, Jan ter Meulen and Detlev H. KrügerAuste, et al. Sangassou virus, the first hantavirus isolate from Africa. Journal of Virology2012, 86(7):3819. doi:10.1128/JVI.05879-11
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