Content area
Full Text
ABSTRACT
The presence of fever in malignancy usually indicates infection, though transfusion, thrombosis and drugs are also culprits. However, particularly in some tumour types, fever can also be a paraneoplastic syndrome, caused by the malignancy itself. This can be a difficult diagnosis to establish and presents a therapeutic challenge to the physician when the underlying malignancy is not easily treated.
KEYWORDS: Neoplastic fever, fever, FUO, malignancy *
Introduction
The mechanisms by which malignancies induce fever are not fully understood. The release of pyrogenic cytokines either directly from tumour cells or from macrophages responding to tumour are likely to play a major role, particularly interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)α. Cytokines induce prostaglandin E2 which acts on the hypothalamus, causing a change in the thermostatic set point. Although cancer is often a concern in fever of unknown origin (FUO), malignancy appears to account for a decreasing proportion of those investigated.1 In 1961, 19% of FUO were attributed to cancer and by 2007 this had fallen to 7%. Neoplastic fevers are now most commonly encountered in the setting of febrile patients with a known malignancy and presents a diagnostic challenge in differentiating whether fever is attributable to infection, therapy or disease.
Unfortunately there is no fever pattern pathognomonic of cancer. Classically, neoplastic fever may be less associated with rigors, tachycardia and hypotensive episodes than other causes. Fevers may be only partially relieved by paracetamol and may respond better to nonsteroidal anti-inflammatory drug (NSAIDs). Cyclical fever patterns may occur. The most well known of these is Pel-Ebstein fever associated with Hodgkin's lymphoma.2 However, the pattern of a week of high fevers, followed by an afebrile period of similar duration, is rare, and both its specificity for Hodgkin's lymphoma and its existence as an entity at all are contentious.2
Naproxen test
An interesting series of small studies published by Chang and Gross3 in 1984 observed that neoplastic fever was suppressed by naproxen. Defervescence occurred in 14 of 15 patients with neoplastic fever in contrast to none of the 5 patients with fever due to infection. Two patients with connective tissue disease had partial lysis of fever. In patients with neoplastic fever, the fevers resolved within 24 hours and patients remained afebrile as long as they...