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D C Knockaert

Publications and source records attributed to D C Knockaert.

At least 19 recordsLinked to original sources
PubMed2003

Fever of unknown origin in adults: 40 years on.

A revision of the criteria of fever of unknown origin (FUO), established in 1961, is desirable because of important evolutions in medical practice and the emergence of new patient populations. The development of rapid laboratory tests and powerful diagnostic tools, such as ultrasonography, computed tomography and magnetic resonance imaging often makes hospitalization unnecessary and new categories of patients such as those with HIV infection, neutropenia, immunosuppression and nosocomial illness require an approach different from classical FUO. The more then 200 reported causes of FUO can be classified into four diagnostic categories; infections, tumours, noninfectious inflammatory diseases (NIID) and miscellaneous. A uniform classification system is highly wanted to allow comparison between different series. The reports of the 1990s show slight changes in the distribution of causes, namely less infections, less tumours, more NIID and more undiagnosed cases. A uniform diagnostic strategy cannot be determined. The initial investigation should be directed by potentially diagnostic clues revealed by extensive history, meticulous physical examination and a standard set of laboratory tests. 18Fluoro-deoxy-glucose-positron-emitted-tomography is a new valuable total body scintigraphy in the search for the site of origin of the fever. In view of the rather good long-term prognosis, a wait-and-see strategy may be more appropriate than a systematic staged approach. Elderly patients and patients with episodic fever represent two specific groups of classical FUO that require a distinct approach. HIV-associated, nosocomial and neutropenic FUO should be considered as separate clinical entities.

Algorithms↗
PubMed2002

Microscopic haematuria in giant cell arteritis.

Giant cell arteritis (GCA) is traditionally considered to spare the kidney, although an uncontrolled study reported microscopic haematuria in 10 out of 30 patients with GCA. To study the frequency and the characteristics of microscopic haematuria in GCA, we retrospectively studied 42 patients with biopsy-proven GCA, 39 patients with polymyalgia rheumatica (PMR) and 62 control patients >or=60 years of age, admitted to the general internal medicine unit. Patients with pyuria, significant bacteriuria or a known haematuric disorder were excluded. Microscopic haematuria was defined as the presence of >5 red blood cells (RBC) per high-power field (sediment counts) or of >8 RBC/microl (direct counting). Microscopic haematuria was present at presentation in 47.6% of the GCA patients, versus 17.9% of the PMR patients (P = 0.005) and 21.0% of the control patients (P = 0.008). Urinary RBC were predominantly dysmorphic in all GCA patients in whom RBC morphology was assessed (n = 7). Presenting symptoms, renal function, arterial blood pressure and degree of leukocyturia did not differ significantly between GCA patients with or without haematuria. After the initiation of corticosteroid therapy, microscopic haematuria was no longer detectable in 25 of 35 GCA patients (71.4%). Microscopic haematuria of renal origin is frequent but generally benign in patients with GCA. Its presence, if unassociated with blood pressure elevation or renal function deterioration, helps to rule in rather than to rule out the diagnosis of GCA. In the typical setting invasive urologic and nephrologic work-up may not be warranted.

Age Distribution↗
PubMed2002

Chest pain in the emergency department: the broad spectrum of causes.

We performed a prospective study to describe the broad spectrum of causes of chest pain in patients presenting to the emergency department and to compare the diagnoses in referred patients, self-referred patients and patients rushed in by ambulance. The final diagnosis in a consecutive case series of 578 chest pain patients was established after discharge from the hospital. The underlying disorders were grouped into cardiac, respiratory, gastro-oesophageal disorders, musculoskeletal pathology, somatization disorders, other diseases and unknown. For comparison of the frequencies of the disease categories the Chi-squared test was used. Out of 578 patients, 161 (27.9%) were self-referred, 369 (63.8%) were referred by the general practitioner and 48 (8.3%) were rushed in by ambulance. Cardiac diseases represented 51.7% of the cases, myocardial infarction and unstable angina 19% and 12.8% respectively Cardiac diseases were statistically significantly less common in self-referred patients (p<0.0005). Pulmonary diseases encompassed 14.2% of the population, followed by somatization disorders (9.2%), musculoskeletal pathology (7.1%) and other causes (4.3%). In 11.1% of the cases no definite final diagnosis could be established. Somatization disorders were significantly more frequent in self-referred and ambulance patients. Cardiac and pulmonary problems are the most frequent underlying disorders in acute chest pain patients in the emergency department. Somatization disorders and musculoskeletal pathology represented respectively 19.1% and 14.8% of the non-cardiac causes. The referral pattern influenced significantly the distribution of the disease categories with more cardiac and less psychiatric disorders in referred patients.

Adult↗
PubMed2002

Emphysematous pyelonephritis: no longer a surgical disease?

Emphysematous pyelonephritis is a rare, life-threatening infection of the kidney characterized by the presence of gas within the renal parenchyma, the renal collecting system and the perinephric tissue. It usually develops in diabetic patients and often presents abruptly with bacteraemia, septic shock and acute renal failure. Diagnosis can be delayed because the symptoms mimic a classical upper urinary tract infection. Aggressive management, including parenteral antibiotic therapy, treatment of septic shock and control of the glycaemia, is mandatory. Immediate nephrectomy has been considered to be essential to increase the chance of survival. Recently, percutaneous drainage has been reported as a kidney-saving and life-saving alternative to surgery. We present a case of severe emphysematous pyelonephritis in which there was full recovery after antibiotic treatment combined with temporary percutaneous drainage. The therapeutic options in this rare, life-threatening condition are discussed.

Adult↗
PubMed2001

Imported malaria in the 1990s: a review of 101 patients.

Imported malaria remains a difficult problem in nonendemic areas of the world. We describe the clinical presentation of 101 cases of malaria diagnosed at the Leuven University Hospital between 1 January 1990 and 31 December 1999. Ninety-three patients (92%) presented initially at the emergency department. Diagnosis was initially not suspected by the referring physician in 48 patients (47%). Plasmodium falciparum was the commonest species, accounting for 67% of the cases. All but three patients had fever as the presenting symptom, but only 10 had a typical tertian fever pattern. Haemolytic anaemia, thrombocytopenia and hyponatraemia represented a typical triad in 20% of the cases. Only 13% of the malaria patients had taken correct chemoprophylaxis according to WHO recommendations. Eighty-three per cent of the patients were admitted to the hospital with a median duration of hospitalization of 4 days. All complications occurred in cases with P. falciparum. All patients were cured.

Adolescent↗
PubMed2000

Comparison of premortem clinical diagnoses in critically iII patients and subsequent autopsy findings.

OBJECTIVE: To determine whether our practice of requesting an autopsy for patients who die in the medical intensive care unit (MICU) continues to be a valid approach to obtain clinically and educationally relevant findings. METHODS: In this retrospective study conducted in an adult MICU population of a university hospital, the clinical diagnoses and postmortem major diagnoses of 100 patients who died in 1996 (autopsy rate of 93%) were compared. RESULTS: Eighty-one percent of the clinical diagnoses were confirmed at autopsy. In 16%, autopsy findings revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival (class I missed major diagnoses). The most frequent class I missed major diagnoses were fungal infection, cardiac tamponade, abdominal hemorrhage, and myocardial infarction. Another 10% of autopsies revealed a diagnosis that, if known before death, would probably not have led to a change in therapy (class II error). CONCLUSIONS: Autopsy remains an important tool for education and quality control. In contrast with historical series of 1 to 2 decades ago, there is a clear shift in the type of class I missed major diagnoses toward opportunistic infections. Bedside-applicable techniques such as electrocardiography with supplemental posterior leads, echocardiography, and meticulous abdominal ultrasonography might improve the outcome in selected MICU patients.

Adolescent↗
PubMed1998

Fever of unknown origin due to inflammatory pseudotumour of lymph nodes.

The clinical features of inflammatory pseudotumour of lymph nodes, a distinct non-malignant histopathological entity firstly described in 1988, are summarized based upon a detailed analysis of 4 personal cases and 47 cases reported in the literature. The mean age of the patients is 38 years (range 8 to 82 years) and there is no gender predilection. One third present with asymptomatic lymphadenopathy and 47% present with fever, nearly all meeting the criteria of fever of unknown origin. Abdominal complaints are occasionally present. Intermittence of symptoms is common. Hepatosplenomegaly is unusual. All lymph node areas may be involved but abnormalities are mostly confined to one or two anatomic regions. No extranodal involvement has been reported although inflammatory pseudotumour may occur in several organs with similar morphological features and identical signs of inflammations. Routine blood tests are normal except for signs of inflammation. The lesions are Gallium-avid. Diagnosis is based upon typical histopathological features. The prognosis is favorable and surgical resection frequently leads to cure. Spontaneous resolution of symptoms has been reported and nonsteroidal anti-inflammatory drugs may suppress the clinical manifestations.

Adult↗
PubMed1996

Long-term follow-up of patients with undiagnosed fever of unknown origin.

BACKGROUND: A casual diagnosis cannot be established in 10% to 25% of the patients who are studied for fever of unknown origin (FUO). The long-term clinical outcome of these patients cannot be inferred from the literature. This study describes the results of a 5-year follow-up of 61 patients studied for FUO and discharged from the hospital with no causal diagnosis being established. METHODS: Patients meeting the classic criteria for FUO who were studied in the 1980s and discharged from the hospital without a casual diagnosis were followed up for at least 5 years or until death. Follow-up was performed by review of the patients' medical records or by consulting the treating physician and occasionally the patients themselves. The final diagnosis, clinical course (resolution of the fever and required treatments), and morality rate were studied. RESULTS: Of a cohort of 199 patients with FUO, 61 individuals (30%) were discharged from the hospital without a final diagnosis being established. A definite diagnosis could be established in 12 cases, mostly (eight of 12) within 2 months after discharge. Thirty-one individuals became symptom free during hospitalization or shortly following discharge. Eighteen patients had persisting or recurring fever for several months or even years after discharge, but 10 of them were considered to be finally cured. Four patients were treated with corticosteroids and six patients required intermittent therapy with nonsteroidal anti-inflammatory agents. Six patients died, but the cause of death was considered to be related to the disease that caused FUO in only two cases. CONCLUSION: No single disease, particularly not tuberculosis, was found to be a cause of undiagnosed FUO. Most cases resolved spontaneously, and corticosteroids were seldom required. Most symptomatic patients could be treated with nonsteroidal anti-inflammatory drugs. The mortality rate in patients with undiagnosed FUO who were followed up for 5 years or more was only 3.2%.

Diagnosis, Differential↗
PubMed1996

Electromyographic findings in ilioinguinal-iliohypogastric nerve entrapment syndrome.

The ilioinguinal-iliohypogastric nerve entrapment syndrome is a recognised cause of, usually chronic, lower abdominal pain. Diagnosis is based upon a typical clinical triad and relief of pain by injection of a local anaesthetic. In the present study we assessed the value of abdominal muscle electromyography in 41 patients with a clinical syndrome suggestive of ilioinguinal-iliohypogastric nerve entrapment. Electromyographic abnormalities were detected in 15 of 25 cases (60%) with definite diagnosis and in 6 of 16 (37%) of those with probable diagnosis of ilioinguinal-iliohypogastric nerve entrapment syndrome. The rather low sensitivity and the clinical value of this technique are discussed.

Abdominal Muscles↗
PubMed1995

Streptococcus pyogenes bacteremia: a retrospective study in a Belgian university hospital.

We retrospectively studied 29 cases of S.pyogenes bacteremia, treated from September 1985 through September 1993, in order to define the clinical pattern, predisposing factors and the outcome of S.pyogenes bacteremia in our region. The number of infections, the clinical picture and mortality rate of S.pyogenes bacteremia did not change during the study period and only 2 of 29 cases presented with a fulminant clinical course, meeting the criteria of streptococcal toxic shock syndrome. In many patients, predisposing factors such as skin abnormalities (n = 14) and airway diseases (n = 10) could be identified. Patients with underlying skin disease were mostly characterized by a clinically benign bacteremia with good prognosis. We suspect that the recently reported so-called rising incidence of severe S.pyogenes infections might be due to epidemiologic clustering and selection bias in certain regions.

Adolescent↗
PubMed1994

Clinical value of gallium-67 scintigraphy in evaluation of fever of unknown origin.

This report describes the diagnostic contribution of gallium-67 scintigraphy in 145 cases of fever of unknown origin (FUO) at University Hospital in Leuven, Belgium, in 1980-1989. A final diagnosis was established in 99 (68%) of the 145 cases. Sixty-three scans (43%) were normal, and 82 (57%) were abnormal; only 42 of the abnormal scans (29% of the total number of scans) were considered helpful in diagnosis. Thus 49% of the abnormal scans were considered noncontributory to the diagnosis. In the same population, 15 (6%) of 266 ultrasonograms and 32 (14%) of 233 computed tomograms were helpful in diagnosis. We conclude that gallium scintigraphy remains a valuable screening tool in the investigation of FUO: it yielded diagnostic information in 29% of cases in which the probability of a definitive diagnosis was only 68%. We suggest the use of gallium scintigraphy as a second-step (as opposed to a last-resort) procedure in the evaluation of FUO.

Adult↗
PubMed1994

Bacterial meningitis: diagnostic and therapeutic considerations.

In this review the epidemiology of bacterial meningitis and the new insights in the pathophysiology are thoroughly discussed. The different diagnostic steps are described and the present day antibiotic strategy and adjunctive inflammation-modulating therapy are delineated.

Adolescent↗
PubMed1993

Fever of unknown origin in elderly patients.

OBJECTIVE: To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients. DESIGN: Subgroup analysis of a prospectively collected case series followed more than 2 years. SETTING: General Internal Medicine Service based at University hospital, Leuven, Belgium. PATIENTS: Forty-seven consecutive patients, older than 65 years, meeting the classic criteria of fever of unknown origin. MEASUREMENTS: The final diagnosis established and the clinical value of diagnostic procedures. RESULTS: Infections, tumors and multisystem diseases (encompassing rheumatic diseases, connective tissue disorders, vasculitis including temporal arteritis, polymyalgia rheumatica, and sarcoidosis) were found in 12 (25%), six (12%) and 15 patients (31%), respectively. Drug-related fever was the cause in three patients (6%), miscellaneous conditions were found in five patients (10%), and six patients (12%) remained undiagnosed. Microbiologic investigations were diagnostic in eight cases (16%), serologic tests yielded one diagnosis, immunologic investigations had a diagnostic value in four cases, standard X-rays yielded a diagnostic contribution in 10 cases, ultrasonography and computed tomography were diagnostic in 11 cases, Gallium scintigraphy had a diagnostic contribution in 17 cases, and biopsies yielded the final diagnosis in 18 cases. CONCLUSIONS: Multisystem diseases emerged as the most frequent cause of fever of unknown origin in the elderly, and temporal arteritis was the most frequent specific diagnosis. Infections, particularly tuberculosis, remain an important group. The percentage of tumors was higher in our elderly patients than in the younger ones but still clearly lower than in other recent series of FUO in adults. The number of undiagnosed cases was significantly lower in elderly patients than in younger individuals (P < or = 0.01). The investigation of elderly patients with FUO should encompass routine temporal artery biopsy and extensive search for tuberculosis if the classic tests such as blood count, chemistry, urinalysis, cultures, chest X-rays, and abdominal ultrasonography do not yield any clue. Gallium scintigraphy should be considered as the next step and not as a last-resort procedure.

Age Factors↗