Prolongued "flu"

[Yamar]

3 months ago, I woke up with a flu (headache, malaise, fatigue, night sweats, no nasal congestion or runny nose, fever of 38.2 celcius). The symptoms were much stronger than my usual winter colds, to the point where I was unable to work. A dry cough started a few days later.  After a week of symptoms I saw a doctor who diagnosed a virus. My CXR was normal. A week later I saw another MD who prescribed Biaxin XL x 5 days. The fever dimished and my symptoms started to improve but reached a plateau. On the 5th day of antibiotics I became acutely short of breath, even at rest. I saw a respirologist who did PFT's with ventolin challenge and told me that everything was normal.  After returning to work (I am an ENT surgeon) my symptoms progressively worsened again to the point where I have had to stop working completely. I saw another doctor about 2 weeks after finishing the Biaxin. He prescribed Avelox 400mg qd x 10 days. On the first night of Avelox I had terrible night sweats.  These subsided and I finished the Avelox which led to a minimal improvement. I developped a terrible headache and ended up in the ER. The neurologist diagnosed a post-viral migraine and prescribed Prednisone 50mg qd x 5 days.  The Prednisone made my cough worse.
  I have had multiple tests (CXR's are normal, CT chest without contract done 2 months ago was normal, PPD is nonreactive, CBC, ESR, CRP are normal, EBV, CMV, monospot are negative). I still feel like I still have a flu. I have fatigue, headache, dizziness, dry cough, shortness of breath, hoarse voice, foul breath.  There is a recurrent pattern...activity leads to an increase in fatigue and a sensation of fever (no actual fever). This leads to a worsening of the cough and the shortness of breath. Then I start feeling like an extremely hot fever (as if I am under a hot lamp) and sweating. I will sometimes get night sweats.  It then takes me 2 to 3 days of complete rest to get over it.

I used a CPAP machine prior to all this.

Do you have any ideas on diagnosis/investigations/treatment?

[National Jewish]

This is a very complex illness, one most compatible with a chronic infection or a non-infectious inflammatory process.  The normal lab data are surprising, especially the normal CBC, ESR and CRP.  They should be re-checked.  This disease presentation falls into the category of fever of unknown origin (FUO).  The diagnoses of unexplained fevers fall into six general categories:  infections, non-infectious inflammatory/auto-immune, neoplastic diseases, drug fevers and factitious illnesses.

First a question:  Have you traveled abroad during the preceding six months, especially to tropical countries?  That might give a clue if your symptoms were those associated with a specific disease, one not uncommon in the country you visited but seldom seen where you live.  Tropical diseases fall into the category of disease likely to go undiagnosed, even by skilled diagnosticians, especially if the presentation is atypical.

Some random thoughts:  The headaches, halitosis, cough and fever, along with a partial response to antibiotics raises the question of sinusitis, invasive-fungal and allergic-fungal to be considered.  A CT of the sinuses and brain should be done in the search for unusual sites of infection.

The acute and persistent shortness of breath, in the presence of a clear chest x-ray, clear chest CT and normal PFTs is worrisome.  It raises the question of recurrent pulmonary emboli, possibly even septic emboli.  Emboli might not have been obvious on a conventional CT scan and/or might originate within the heart, as with subacute bacterial endocarditis.

The work-up should be as for any FUO and would best be conducted by an infectious disease specialist, preferably one with experience in tropical medicine.  Your physicians may know of such a specialist.  The work-up will in all likelihood require careful cultures of secretions, blood and even cerebrospinal fluid (CSF).

Good luck.

[starion]

Have you been evaluated for Othostatic Intolerance with a Tilt Table Test (generally in a hospital with a good cardiology department)?  Much of what you're describiing sounds like it c-o-u-l-d be "chronic fatigue immune deficiency syndrome," CFIDS.  One thing that many CFIDS patients also have is orthostatic intolerance, where the fatigue increases when they change positions from lying to sitting and even worse symptoms when standing (especially for prolonged periods of time).

A lot of the symtoms really do sound like those of CFIDS.   Here's some good information from the US Centers for Disease Control about CFIDS (also called "CFS," for Chronic Fatigue Syndrome).

Aloha,
Starion