Fever of unknown origin - Hidden in the head

The original algorithmic approach, as outlined by de Kleijn and colleagues and practiced commonly, envisages performing computed tomography (CT) of chest, abdomen, and pelvis in patients with classical fever of unknown origin (FUO), in whom no potentially diagnostic clue exists. It further envisages performing positron emission tomography (PET) scan, if CT scan is unrevealing. Imaging of head and neck especially magnetic resonance imaging (MRI) has not been included in this algorithm, that leaves these important regions unexplored in most settings where PET scan is unavailable. MRI is a safe modality for evaluating central nervous system lesions and its role in FUO has not been adequately evaluated. We present three patients of FUO in whom the diagnosis of tuberculoma of brain as a cause of prolonged pyrexia got delayed because the MRI of head was not done initially, to comply with the approach of minimum diagnostic evaluation.