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Surprising Focus of Infection in Fever of Unknown Origin.

An 84-year-old male patient presented to the emergency department with an unexplained decrease in alertness (GCS 13). This was caused by infection accompanied by fever and elevated infection levels (CRP 194 mg/L, leukocytosis 14/nL). Findings at physical examination were unremarkable, with the exception of a large, painless inguinal hernia. Urine status revealed leukocyturia without nitrite detection. Chest X-ray was also normal, whereupon, given the patient‘s increasingly compromised condition and the lack of a clinical focus of infection, computed tomography of the chest and abdomen was performed for further diagnostic evaluation; this revealed a urinary bladder that had partly prolapsed into the scrotum and surrounding fat stranding (arrows). Ultrasound yielded no additional information. In light of the irreducible hernia and urinary tract infection, calculated intravenous antibiotic therapy with ceftriaxone was started and prompt inguinal hernia surgery according to the Lichtenstein technique with mesh implantation was carried out. Urine culture showed 10 CFU/mL; compliant with in-house guidelines, no further pathogen differentiation was performed. Material obtained intraoperatively for microbiological analysis remained sterile albeit with positive inhibition testing. The postoperative course was unremarkable and the patient was discharged symptom-free and with decreasing inflammatory parameters after 3 days with oral antibiotic therapy.