When the diagnosis is generally unknown. Let’s talk a little about the “difficult” diagnosis

Sometimes even a full and comprehensive examination does not reveal the cause of poor health, and then it comes to a “difficult” diagnosis. If you find yourself in a similar situation, do not despair, let’s discuss how to act in such cases. As a rule, chronic problems that plague patients without a specific diagnosis can be divided into four groups: fever (fever) of unknown origin, long-lasting inflammation from an unknown source, chronic pain or constant fatigue without a specific cause. It is very important to emphasize that if you feel bad and at the same time there are problems in the emotional sphere (pronounced stress, anxiety, obsessive thoughts, low mood or apathy), and a comprehensive medical examination has not revealed any abnormalities, you should first contact a psychotherapist or psychiatrist. If the treatment prescribed by this specialist is ineffective or the state of health begins to deteriorate, you need to continue the diagnostic search without abandoning the current treatment.

Fever of unknown origin. Under this term, doctors understand an increase in body temperature above 38.3 °C for more than three weeks; at the same time, the patient underwent a full examination (including at least a week in a hospital), and the cause of the fever is still unclear. In normal life, patients are much more likely to encounter subfebrility of unknown origin, when the body temperature for many months fluctuates between 37.1-37.5 °C and sometimes even rises to 38 °C. As a rule, even if long-term, but a small increase in body temperature for the absolute majority of cases is not something terrible and occurs as a result of a violation of heat exchange (thermoregulation) after infections, some chronic diseases, chronic stress. The temperature of 37.1-37.3 °C does not require treatment and constant monitoring, if you have already been examined and you do not have significantly enlarged lymph nodes, there are normal indicators of ESR and C-reactive protein, and hyperfunction of the thyroid gland is excluded (that is, thyroid-stimulating hormone is normal).

Patients with persistent subfebrility should avoid stress and anxiety, exercise, study any meditative and breathing techniques, and leave treatment to doctors only in case of obvious deterioration of well-being.

When we talk about a classic fever of unclear origin with a persistently high and incomprehensible increase in body temperature, then we need to approach this issue with all seriousness. The examination program should at least include a general blood and urine test, ESR, C-reactive protein, blood cultures for infection, chest X-rays and abdominal ultrasound. If necessary, doctors perform additional examinations of the paranasal sinuses, thyroid gland, breast (for women), heart valves, pelvic organs, perform gastro-and colonoscopy. The main search for the cause is conducted in three large areas: infectious, oncological, and rheumatic diseases. After standard examinations, special additional tests can be taken for infection (among them, HIV and tuberculosis are mandatory), for numerous rheumatic diseases, studies of organs with the help of computed tomography and magnetic resonance imaging, ultrasound and radiopaque studies of blood vessels. In some cases, an organ or tissue biopsy may be required if there are any structural abnormalities that the doctor wants to further examine. If even a more detailed examination did not explain the cause of the fever, the next step in most cases, experts recommend positron emission tomography with 18F-fluorodeoxyglucose, this study allows you to detect many (but not all!) malignancies, and also find the source of inflammation as the cause of fever.

Inflammation very often goes hand in hand with a fever of unknown origin, but sometimes it happens that we see in the blood of patients significantly increased levels of ESR and/or C-reactive protein (these are laboratory markers of inflammation) at normal body temperature. For example, this often happens with Takayasu arteritis. Inflammation of unknown origin is examined according to the same rules as fever of unspecified origin, but it is with prolonged and persistent inflammation that the diagnostic significance of positron emission tomography with 18F-fluorodeoxyglucose is significantly higher. This is why we use this study more often among patients with chronic unclear inflammation than with isolated fever.

Both for fever and for inflammation of unspecified origin, doctors use broad-spectrum antibacterial drugs in parallel with the examination for the trial treatment of a possible infection. In the absence of their effect, they resort to glucocorticoid drugs as drugs that can reduce inflammation, regardless of its cause.

Please note that even in the most famous medical centers in the world, there are patients with unspecified causes of fever and inflammation, in such situations, the patient is discharged from the hospital, is under dynamic outpatient control and receives treatment that helps to reduce body temperature and inflammation (most often these are glucocorticoids).

What exactly you SHOULD NOT do if you have a fever and / or inflammation of unknown origin.

  • Panic and look for somewhere else to be hospitalized.
  • Take all existing tests for infections and cancer markers.
  • Treat “chronic” herpes infection, that is, in the absence of acute infection, you do not need to take drugs from the herpes simplex virus, cytomegalovirus, Epstein–Barr virus!
  • Independently prescribe positron emission tomography.
  • To experiment on yourself and take dozens of dietary supplements, interferon preparations, various immunomodulators and immunostimulants.
  • Take prednisone or its analogues independently.

What to do if you have a fever and / or inflammation of unknown origin.

  • Choose a doctor-curator who will observe you in the dynamics.
  • Keep a well-being diary, where you can record the days of increased body temperature and other symptoms. If you or your doctor use this diary to track any frequency of fever, that is, days of poor health with fever are replaced by acceptable health with normal body temperature, and this alternation is followed regularly (months or even years), then you should consult with medical geneticists for auto-inflammatory diseases. As we said above, this is a whole group of diseases where the key role of the occurrence of fever and inflammation belongs to the genetic breakdown of genes responsible for the regulation of inflammation. In most cases, such diseases require treatment with special biological drugs, which are selected by doctors depending on the type of auto-inflammatory disease.
  • Take dynamic tests prescribed by your doctor. The minimum list is a clinical blood test, ESR, C-reactive protein.
  • Follow medical prescriptions and do not change the dosage regimen of medicines without notifying the attending physician.

Two more common factors that make the patient look for the causes of their poor health are generalized pain and chronic fatigue syndrome. Often they are present together in the same person.

If you have pain in the muscles and joints throughout the body, then without thinking twice, you need to consult a doctor, preferably a rheumatologist. In such situations, we exclude metabolic disorders (and, in particular, hormones), inflammatory joint diseases, and various systemic autoimmune diseases. If, as a result of a full-scale study, the doctor throws up his hands and says that you are healthy, but you still feel bad, you should think about whether fibromyalgia is hiding here. This is a disease of disturbed pain perception, when the system of anesthesia in the body breaks down (or rather, in the central nervous system!) and even ordinary movements and everyday activities lead to a feeling of constant and widespread pain. Once again, I want to emphasize: with fibromyalgia, the patient does not invent pain, but really suffers from it, and the reason for this common pain lies not in inflammatory diseases of the joints and muscles, but in a violation of the pain recognition system in the body. Most often, fibromyalgia affects young women aged 20 to 40 years, especially those who have suffered stress. Often, fibromyalgia is accompanied by general weakness, increased fatigue, and sleep disorders. Often, doctors diagnose many functional diseases in such patients: frequent episodes of low blood pressure, pain in the heart (cardialgia), irritable bowel syndrome, interstitial cystitis and other diseases that occur without changing the structure of organs and tissues. The treatment of fibromyalgia is based on psychotherapy, massage and SPA treatments (this is really true!), taking antidepressants (amitriptyline, duloxetine, milnacipran) or anticonvulsants (pregabalin). Patients with fibromyalgia in our country are most often seen by a neurologist, psychotherapist or psychiatrist.

Chronic fatigue often accompanies fibromyalgia, although it may be present on its own. The examination is mainly aimed at excluding anemia (a decrease in the level of hemoglobin), impaired thyroid or adrenal function, chronic inflammation, and severe metabolic disorders. As we wrote earlier, the syndrome of chronic fatigue without an obvious cause after a comprehensive examination most often occurs as a result of disorders in the emotional sphere and requires treatment by specialists of the appropriate profile (neurologist, psychotherapist or psychiatrist).

What exactly you SHOULD NOT do if you have common pain and / or chronic fatigue syndrome.

  • Endlessly take tests for herpes simplex, cytomegalovirus, or Epstein–Barr viruses, and be treated for these infections (except in acute cases of infection!)
  • Make a diagnosis and treat yourself (and even more repeatedly!) antibiotics for chronic tick-borne borreliosis (Lyme disease) only based on the detection of IgG to borrelia. Contact specialists, avoid unnecessary appointments.
  • Repeatedly take immunograms and try to increase your immunity with immunomodulators and stimulants.
  • Take painkillers or anti-inflammatory drugs independently and without supervision.

What to do if you have common pain and / or chronic fatigue syndrome.

  • Check with your doctor the rules for taking nonsteroidal anti-inflammatory drugs (NSAIDs). Discuss which of the many NSAIDs is right for you. For more information about these medicines, see the corresponding chapter.
  • Consult a doctor (neurologist, rheumatologist, pain specialist) about how to relieve chronic pain, what medications and how long to take it. Do not be afraid to use prescribed antidepressants and anticonvulsants, they really help many patients with chronic pain.
  • In the case of chronic fatigue/weakness syndrome and the absence of contraindications, try to increase physical activity, connect the study of meditative and breathing practices.

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