Persistent Afternoon Fever: Chronic Symptoms and Causes

Fever every afternoon?

Hello doctor, I have been experiencing a fever for over a month now, with temperatures gradually rising in the afternoon, ranging from 37.5 to 38.5 degrees Celsius.
Two months ago, I had symptoms such as coughing and a runny nose, with occasional fevers around 37 to 38 degrees.
About a month ago, the coughing and runny nose subsided, but I developed pain on both sides of my trachea near the collarbone, along with a fever.
Swallowing saliva does not cause pain.
The next day, I noticed swelling and pain in the lymph nodes on the left side of my neck, which gradually extended from the area near the trachea to close to the upper neck near the ear.
After a week, the lymph nodes slowly decreased in size, but the pain in the area above the collarbone and on both sides of the trachea, approximately 1 to 2 centimeters in range, still persists.
I feel like there is something in the right side of my throat when swallowing, and I occasionally cough, which causes pain in the affected area.
I visited an otolaryngologist who performed an endoscopy on my trachea and vocal cords, finding no lesions or tumors, and no signs of inflammation.
Blood tests showed a CRP of 3.28, white blood cell count of 8460, lymphocyte percentage of 32, and liver enzymes GPT 85 and GOT 42.
I went to the emergency room for a cardiac ultrasound and abdominal ultrasound; the cardiac ultrasound showed no issues, while the liver showed severe fatty liver but no tumors or lesions.
Taking antipyretics (acetaminophen) sometimes does not help reduce the fever.
In addition to throat pain, I also feel fatigued, with pain in the back of my neck and occipital region.
A month ago, I took medication for mycoplasma for 6 days, followed by a 10-day course of antibiotics (amoxicillin and curam), and recently I have been on doxycycline for 4 days, but there has been no improvement.

Xiao Bai, 40~49 year old female. Ask Date: 2017/05/22

Dr. Liao Zhongxin reply Internal Medicine

Dear readers, regarding the above issue, here is my response.

Hello, doctor.
I have been experiencing a fever for over a month, with temperatures gradually rising in the afternoon, ranging between 37.5°C and 38.5°C.
Two months ago, I had symptoms of cough and runny nose, with occasional fevers around 37°C to 38°C.
About a month ago, the cough and runny nose symptoms improved, but I developed pain on both sides of my trachea near the collarbone, along with fever.
Swallowing saliva does not cause pain.
The next day, I noticed swelling and pain in the lymph nodes on the left side of my neck, which gradually extended from the area near the trachea to close to the upper neck near the ear.
After a week, the lymph nodes slowly decreased in size, but the pain around the collarbone and on both sides of the trachea, approximately 1 to 2 centimeters in area, still persists.
I feel like there is something in the right side of my throat when swallowing, and I occasionally cough, which aggravates the painful area.
I visited an ENT specialist who performed an endoscopy on my trachea and vocal cords, but found no lesions or tumors, nor any signs of inflammation.

It may be worthwhile to seek a second opinion from another ENT specialist before deciding on further tests.
My blood tests showed a CRP of 3.28, white blood cell count of 8460, lymphocyte percentage of 32%, and liver function indices with GPT at 85 and GOT at 42.
I also went to the emergency department for echocardiograms of the heart and abdomen; the cardiac ultrasound showed no issues, while the liver ultrasound indicated severe fatty liver without any tumor lesions.
During the fever, taking antipyretics (acetaminophen) sometimes does not help reduce the fever.
In addition to throat pain, I also feel fatigued, with pain in the back of my neck and occipital region.
A month ago, I took medication for mycoplasma for six days, followed by a ten-day course of antibiotics (AMOXICILLIN and CURAM), and recently I have been on DOXYCYCLINE for four days, but there has been no improvement.

Regarding the elevated CRP and WBC, as well as the increased liver function indices, further detailed examinations may be necessary, and I should ensure adequate hydration.
I should also consider whether I have taken too many medications recently, as this can lead to similar reports.
A small number of individuals may present with similar symptoms in the early stages of tuberculosis, so it may be advisable to consult a pulmonologist as well.
Thank you!

Reply Date: 2017/05/22

More Info

Persistent afternoon fever can be a perplexing and concerning symptom, especially when it lasts for an extended period, as you have described. Your symptoms, including the fluctuating fever, throat pain, swollen lymph nodes, and fatigue, suggest a complex underlying issue that may require a thorough investigation to determine the root cause.

Firstly, it’s important to understand that a fever is a natural response of the body to infection or inflammation. The fact that your fever occurs in the afternoon and ranges from 37.5 to 38.5 degrees Celsius indicates a low-grade fever, which can be associated with various conditions, including infections, autoimmune disorders, or malignancies. Given your history of respiratory symptoms (coughing and runny nose) two months ago, it is possible that you may have had a viral infection that has since evolved into a more chronic condition.

The pain you are experiencing around your throat and the swelling of the lymph nodes in your neck could suggest a lingering infection or inflammation. Even though you have undergone endoscopic examinations that did not reveal any tumors or significant inflammation, it is still possible that a chronic infection, such as a viral infection or even a bacterial one that may not have been fully resolved, could be contributing to your symptoms. Conditions like chronic pharyngitis or even post-viral syndrome can lead to prolonged symptoms after the initial infection has subsided.

Your blood tests indicate some abnormalities, particularly the elevated liver enzymes (GPT and GOT), which could suggest liver involvement, possibly due to fatty liver disease or another underlying condition. It is essential to follow up on these liver function tests, as they can sometimes be indicative of systemic issues that may also contribute to your overall symptoms.

The fact that you have been treated with antibiotics (Amoxicillin, Curam, and Doxycycline) without significant improvement raises the possibility of a non-bacterial cause of your symptoms. Antibiotics are ineffective against viral infections, and if your symptoms are indeed due to a viral etiology, this could explain the lack of response to the antibiotics.

Additionally, the persistent fatigue and pain in the neck and occipital region could suggest a more systemic issue, such as an autoimmune condition or even chronic fatigue syndrome. These conditions can present with vague symptoms, including fever, fatigue, and pain, and often require a multidisciplinary approach for diagnosis and management.

Given the complexity of your symptoms and the duration of your fever, it is crucial to continue working closely with your healthcare providers. You may benefit from further evaluations, including:
1. Imaging Studies: Consider a CT scan of the neck or chest to evaluate for any hidden infections or lymphadenopathy that may not be visible on ultrasound.

2. Autoimmune Panel: Testing for autoimmune markers could help rule out conditions like lupus or rheumatoid arthritis, which can present with systemic symptoms and fever.

3. Infectious Disease Consultation: A referral to an infectious disease specialist may provide additional insights, especially if there is a suspicion of a chronic infection that has not been adequately addressed.

4. Lifestyle and Supportive Care: Ensure you are maintaining a healthy diet, staying hydrated, and getting adequate rest. Sometimes, supportive care can significantly impact recovery.

In conclusion, while persistent afternoon fever can be alarming, it is essential to approach it systematically. Continued monitoring, thorough investigations, and possibly a referral to specialists will be key in uncovering the underlying cause of your symptoms and guiding appropriate treatment. Please ensure to keep your healthcare provider informed of any changes in your symptoms or new developments.

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