Fever of unknown origin physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: febris continua e causa ignota; febris e causa ignota; febris E.C.I.; fever/pyrexia of obscured/undetermined/uncertain/unidentifiable/unknown focus/origin/source; fever/pyrexia without a focus/origin/source; FUO; PUO

Physical findings may be subtle and merit close scrutiny in the investigation of fever of unknown origin.

Physical findings with diagnostic significance are as follows:^[1][2][3][4]

• A fever is often present. The periodicity of fever may have clinical significance in selected contexts.

• Weak or absent pulse may be present in Takayasu’s arteritis.

• Physiologically, fever is accompanied by tachycardia.
• Relative bradycardia (Faget’s sign) may be present in legionellosis, brucellosis, psittacosis, leptospirosis, drug fever, or factitious fever.

• Janeway lesions may be present in infective endocarditis.
• Petechiae may be present in Rocky Mountain spotted fever.
• maculopapular, vesicular, or petechial rash may be present in typhus.
• An eschar at the site of the tick bite may be present in tick-borne diseases.
• Swollen lymph nodes may be present. Lymphadenopathy may represent reactive lymphoid hyperplasia (suggestive of inflammation or infection) or underlying malignant processes such as lymphoma.
• Rose spots (blanching pink papules 2-3 mm in diameter) may be present on the trunk in salmonellosis.
• Macules, papules, and nodules may be present on the trunk and extremities in meningococcemia.
• Macules or petechiae evolving into vesicles and pustules on a hemorrhagic base may be present in disseminated gonococcal infection.
• Diffuse hyperpigmentation may be present in Whipple’s disease.
• Papules and nodules evolving into crusted, verrucous growths may be present in blastomycosis.
• Warty nodules and subcutaneous abscesses may be present in coccidioidomycosis
• Erythematous papules, pustules, subcutaneous nodules, or cellulitis may be present in cryptococcosis.
• Sister Mary Joseph nodule (palpable nodule bulging into the umbilicus) may be present in metastasis of a malignant tumor in the pelvis or abdomen.
• Multiple purplish papules, nodules, and plaques may be present on the scalp, face, and neck in lymphoma.
• Multiple erythematous, painful plaques with small bumps, pustules, and vesicles may be present in Sweet’s syndrome.
• Palpable purpura may be present on the lower extremities and other areas of dependency in cutaneous vasculitis.

• Temporal artery tenderness with weak pulse may be present in temporal arteritis.
• Sinus tenderness may be present in sinusitis.

• Roth’s spots or conjunctival hemorrhage may be present in infective endocarditis.
• Photophobia or ocular pain on palpation suggestive of uveitis may be present in Wegener’s granulomatosis, Behcet syndrome, Vogt-Koyanagi-Harada syndrome, or infections.

• Oral thrush caused by candidiasis may be present in patients with HIV/AIDS.
• Oral ulcers may be present in systemic lupus erythematosis, disseminated histoplasmosis, and Behcet syndrome.
• Tenderness with a palpable abscess may be present in periodontal disease.
• Petechiae on the palate may be present in infective endocarditis.
• Parotid gland enlargement and tenderness may be present in infections (e.g., Staphylococcus aureus, tuberculosis, mumps, HIV), Sjogren’s syndrome, or sarcoidosis.

• Cervical lymph nodes may be present in inflammation, infection, lymphoma, or Kikuchi disease.
• Enlargement of the thyroid gland may be present in thyroiditis.

• Rales or rhonchi may be present in pneumonia.
• Fremitus with diminished breath sounds may be present in pneumonia.

• Heart murmurs may be present in endocarditis secondary to infections (infective endocarditis), systemic lupus erythematosus (Libman-Sacks endocarditis), or chronic diseases (marantic endocarditis)..

• Abdominal tenderness may be present in intra-abdominal infections.
• Rebound tenderness may be present in intra-abdominal infections.
• An acute abdomen may be present in intra-abdominal infections.
• Guarding may be present in intra-abdominal infections.
• Flank pain may be present in psoas muscle abscess, perinephric abscess, or pyelonephritis.
• An inguinal mass may be present in psoas muscle abscess.
• Splenomegaly may be present in infectious mononucleosis, splenic abscess, or hepatitis.

• Prostatic enlargement may be present in prostatic abscess.
• Epididymal nodule may be present in epididymitis.
• Testicular nodule may be present in polyarteritis nodosa.

• Osler’s nodes may be present in infective endocarditis.
• Swollen joints with effusion may be present in infectious arthritis or rheumatic diseases.
• Splinter hemorrhage in the nail beds may be present in infective endocarditis.
• Limb tenderness along deep veins may be present in deep vein thrombosis or thrombophlebitis.

• Altered mental status may be present.
• Cranial nerve deficits may be present in cerebral vasculitis associated with systemic lupus erythematosus.