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🌡️ Case Report: Atopic Cytokine-Mediated Fever in a 13-Year-Old Boy (A Hidden Cause of FUO)
MasterPediatrics.com | Clinical Case Series
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📝 Introduction
Fever of Unknown Origin (FUO) is one of the most challenging clinical presentations in pediatrics. When routine investigations come back normal, clinicians often consider infectious, autoimmune, and malignant causes.
However, immune-mediated atopic cytokine fever is a lesser-known, benign but prolonged cause of recurrent fever—especially in children with underlying allergic sensitization.
This case highlights a 13-year-old male with FUO, normal routine labs, markedly elevated IgE, and a strongly positive Phadiatop inhalant allergen screen. The final diagnosis was atopic cytokine-mediated fever, an often overlooked but important differential diagnosis in persistent fever.
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👦 Case Summary
Patient Profile
Age: 13 years
Sex: Male
Location: Bihar, India
Duration of symptoms: >4 months
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Chief Complaint
Recurrent high-grade fever (101–103°F) for 4 months, with sudden defervescence without sweating, and no identifiable focus.
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🔍 Clinical History
Fever occurred every 5–10 days
Episodes lasted 1–2 days
Fever would drop abruptly
No cough, cold, rash, joint pain, abdominal pain
No weight loss or night sweats
No history of asthma, eczema, or allergic rhinitis
Child remained active between fever episodes
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🩺 Physical Examination
Afebrile during evaluation
Normal vitals
No lymphadenopathy
No organomegaly
Chest/abdomen/CNS exam normal
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🧪 Investigations
Complete Blood Count
TLC: 4,430 /cu.mm (Normal)
Neutrophils: 54.5%
Lymphocytes: 33.7%
Platelets: 3.19 lakh
No eosinophilia.
No inflammatory changes.
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Inflammatory Markers
ESR: Normal
CRP: Normal
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Immunology Profile
Total IgE
1399.5 IU/mL (Normal <150 IU/mL)
→ Indicates marked hyper-IgE and a strong atopic tendency.
Phadiatop Inhalant Allergen Screen
13.10 kUA/L (Normal <0.35 kUA/L)
→ Strongly positive for inhalant allergens.
These results confirm subclinical atopy even without visible allergic symptoms.
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🧠 Differential Diagnosis Considered
Ruled Out
Dengue, typhoid
TB
Autoimmune disorders
JIA
Malignancies (ALL/lymphoma)
Chronic bacterial foci
Parasitic infections
All ruled out due to normal systemic labs and clinical findings.
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🌈 Final Diagnosis
Atopic Cytokine-Mediated Fever
A fever pattern driven by:
Hyper-IgE state
Cytokine surges (IL-4, IL-5, IL-13)
Inflammatory response to allergens or minor viral triggers
Characteristic features:
Sudden high fever
Sudden cooling
No sweating
Normal blood counts
Positive allergen sensitization
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💊 Treatment Plan
1. Anti-Allergic Therapy
Montelukast 5 mg OD
Levocetirizine 5 mg HS
Duration: 6–12 weeks
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2. Immunomodulation
Vitamin D: Weekly high-dose × 6 weeks then daily maintenance
Omega-3 fatty acids: 250–500 mg/day
Probiotic (Lactobacillus GG): 1–2 weeks
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3. Environmental Allergen Control
Dust-free bedroom
Remove carpets & stuffed toys
Control dampness/mold
Improve ventilation
Keep pets out of child’s room
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4. Fever Management
Paracetamol for comfort
No antibiotics unless clear infection
Adequate oral hydration
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📈 Outcome & Follow-Up
At 4-week follow-up:
Fever episodes reduced significantly
No high-grade spikes
Improved appetite and sleep
Parents reassured
Consideration for allergen immunotherapy if symptoms recur
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🧠 Discussion
This case demonstrates that atopy may present as fever alone, especially in adolescents with hyper-reactive immune systems. Elevated IgE and a positive Phadiatop panel provide critical clues.
Clinicians should consider atopic cytokine fever when:
Routine labs are normal
Fever resolves suddenly
There are no signs of infection
IgE is significantly elevated
Recognizing this pattern prevents:
Unnecessary antibiotics
Unnecessary imaging
Invasive testing
Parental anxiety
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📚 Conclusion
This adolescent boy’s prolonged fever was ultimately traced to immune-mediated atopic cytokine response, not infection.
The case underscores the importance of including atopy in FUO differentials, especially when IgE levels are high and allergen sensitization is present.
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