The Clinical Problem Solvers Episode 444: The Clinical Unknown Series – Sneaky fevers
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Feb 13, 2026 AMK (Anne‑Marie), a hospitalist at UNC who presented a clinical unknown, walks through a sneaky four‑week fever with liver injury. The conversation probes links between sinus symptoms, antibiotics, and hepatosplenomegaly. They weigh drug reactions, viral hepatitis, tickborne serologies, and testing strategies before confirming CMV hepatitis.
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Use IMAID For Fever Differential
- Fever differential should include infection, malignancy, autoimmune, drugs, and other causes using the IMAID framework.
- In subacute persistent fevers, prioritize complicated infection but keep broader causes in mind.
Stool Color Points To Biliary Obstruction
- Pale, greasy stools and epigastric pain strongly suggest extrahepatic biliary obstruction and possible cholangitis.
- Assess liver tests, abdominal exam, hemodynamics, and get imaging promptly to evaluate this pathway.
Hepatosplenomegaly Narrows Mechanisms
- Concurrent hepatosplenomegaly shifts the differential toward infiltrative, portal hypertension, or hematologic processes.
- Consider cardiac causes, portal hypertension mechanisms, and infiltrative disorders when both organs enlarge.
