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Internal Medicine > Chapter 17 - Fever of Unknown Origin > Flashcards

Chapter 17 - Fever of Unknown Origin Flashcards

1
Q

any febrile illness without an initially

obvious etiology

A

fever of unknown origin (FUO)

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2
Q

prolonged febrile illnesses without an established etiology

despite intensive evaluation and diagnostic testing

A

fever of unknown origin (FUO)

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3
Q

Definition of FUO

A
  1. Fever ≥38.3°C (≥101°F) on at least two occasions
  2. Illness duration of ≥3 weeks
  3. No known immunocompromised state
  4. Diagnosis that remains uncertain after a thorough history-taking,
    physical examination, and the following obligatory investigations:
    determination of erythrocyte sedimentation rate (ESR) and Creactive
    protein (CRP) level; platelet count; leukocyte count and
    differential; measurement of levels of hemoglobin, electrolytes, creatinine,
    total protein, alkaline phosphatase, alanine aminotransferase,
    aspartate aminotransferase, lactate dehydrogenase, creatine kinase,
    ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis;
    urinalysis; blood cultures (n = 3); urine culture; chest
    x-ray; abdominal ultrasonography; and tuberculin skin test (TST) or
    interferon γ release assay (IGRA).
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4
Q

accounts for about one-fifth of cases of FUO in Western countries

A

infection

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5
Q

common causes of FUO

A

infection

noninfectious inflammatory diseases (NIIDS)

neoplasms

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6
Q

diseases under NIIDS

A

collagen or rheumatic diseases, vasculitis

syndromes, granulomatous disorders, and autoinflammatory syndromes

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7
Q

50% of cases caused by infections in patients with FUO outside Western
nations are due what?

A

tuberculosis

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8
Q

repeated episodes
of fever interspersed with fever-free intervals of at least 2 weeks and
apparent remission of the underlying disease

A

recurrent fever

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9
Q

more common infectious

disease diagnoses that serves as differential diagnosis for FUO

A

Atypical
presentations of endocarditis, diverticulitis, vertebral osteomyelitis,
and extrapulmonary tuberculosis

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10
Q

quite rare but
should always be kept in mind as a cause of FUO since the presenting
symptoms can be nonspecific

A

Q fever and Whipple’s disease

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11
Q

results from exposure to animals or animal products, should be performed
when the patient lives in a rural area or has a history of heart
valve disease, an aortic aneurysm, or a vascular prosthesis.

A

Q fever

perform serologic testing

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12
Q

patients
with unexplained symptoms localized to the central nervous system,
gastrointestinal tract, or joints

A

Tropheryma whipplei (whipplei’s disease)

perform polymerase chain reaction test

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13
Q

diseases that could obtained when you travel to or (former) residence
in tropical countries or the American Southwest

A

infectious diseases such as malaria, leishmaniasis,

histoplasmosis, or coccidioidomycosis

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14
Q

disease that may be due to difficult-to-culture bacteria
such as nutritionally variant bacteria, HACEK organisms (including
Haemophilus parainfluenzae, H. paraphrophilus, Aggregatibacter actinomycetemcomitans,
A. aphrophilus, A. paraphrophilus, Cardiobacterium hominis,
C. valvarum, Eikenella corrodens, and Kingella kingae

A

Culture-negative endocarditis

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15
Q

sterile thrombotic disease that occurs as a paraneoplastic

phenomenon, especially with adenocarcinomas

A

Marantic endocarditis

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16
Q

seen in the context of systemic lupus erythematosus and antiphospholipid
syndrome

A

Sterile endocarditis

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17
Q

Of the NIIDs, these diseases are the common diagnoses in patients with FUO

A

large-vessel vasculitis, polymyalgia rheumatica, sarcoidosis,
familial Mediterranean fever, and adult-onset Still’s disease

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18
Q

of the NIIDs, this disease very is very rare and usually present in
young patients.

A

hereditary
autoinflammatory syndromes

HAS

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19
Q

can present at any age, is
uncommon but can often be diagnosed easily in a patient with FUO
who presents with urticaria, bone pain, and monoclonal gammopathy

A

Schnitzler syndrome

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20
Q

most common diagnosis of FUO among the neoplasms.

A

malignant lymphoma

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21
Q

miscellaneous causes of fever

A

drug-induced fever and exercise-induced hyperthermia

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22
Q

often accompanied by eosinophilia and also by lymphadenopathy,
which can be extensive

A

Drug-induced fever, including DRESS

(drug reaction with eosinophilia and systemic symptoms

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23
Q

More common causes of drug-induced fever

A

allopurinol, carbamazepine, lamotrigine, phenytoin, sulfasalazine,
furosemide, antimicrobial drugs (especially sulfonamides, minocycline,
vancomycin, β-lactam antibiotics, and isoniazid), some cardiovascular
drugs (e.g., quinidine), and some antiretroviral drugs (e.g., nevirapine)

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24
Q

characterized by an
elevated body temperature that is associated with moderate to strenuous
exercise lasting from half an hour up to several hours without an
increase in CRP level or ESR; typically these patients sweat during the
temperature elevation

A

Exercise-induced hyperthermia

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25
Q

fever artificially induced by the
patient—for example, by IV injection of contaminated water

more common among young women
in health care professions

A

Factitious fever

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26
Q

patient is normothermic
but manipulates the thermometer.

dissociation between
pulse rate and temperature.

A

fraudulent fever

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27
Q

FUO

in the elderly results from an atypical manifestation of a common disease, such as?

A

giant cell arteritis and polymyalgia rheumatica

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28
Q

most common infectious
disease associated with FUO in elderly patients, occurring much more
often than in younger patients.

A

Tuberculosis

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29
Q

most important step in the diagnostic workup in FUO

A

search for potentially diagnostic clues (PDCs)

through complete and
repeated history-taking and physical examination and the obligatory
investigations

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30
Q

blood and other cultures are not reliable

when samples are obtained during when

A

during antibiotic treatment

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31
Q

size

of enlarged lymph nodes usually decreases during when

A

glucocorticoid

treatment

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32
Q

low-cost
diagnostic tests remains obligatory in all patients with FUO in order
to separate cases that are caused by easily diagnosed diseases from
those that are not.

A

ultrasounds and chest xrays

33
Q

preferred to abdominal
CT as an obligatory test because of relatively low cost, lack of radiation
burden, and absence of side effects.

A

Abdominal ultrasound

34
Q

Given the absence of specific
symptoms in many patients and the relatively low cost of the test,
investigation of _________ appears to be a valuable screening
test in patients with FUO.

A

cryoglobulins

35
Q

Specialized media should

be used when the history suggests uncommon microorganisms, such as _________

A

Histoplasma or Legionella

36
Q

when is repeating blood or urine cultures useful?

A

previously cultured samples were collected during antibiotic treatment
or within 1 week after its discontinuation

37
Q

FUO with headache
should prompt microbiologic examination of cerebrospinal fluid
(CSF) for organisms including ____________

A

herpes simplex virus (especially

type 2), Cryptococcus neoformans, and Mycobacterium tuberculosis

38
Q

In

central nervous system tuberculosis, the CSF typically has _________

A 
-elevated
protein
-lowered glucose concentrations
-mononuclear
pleocytosis
39
Q

CSF protein level in CNS TB

A

100 to 500 mg/dL

40
Q

CSF glucose concentration level in CNS TB

A

<45 mg/dL in 80% of

cases

41
Q

usual CSF cell count

A

between 100 and 500 cells/μL.

42
Q

should not be included in the diagnostic

workup of patients without PDCs for specific infections

A

Microbiologic serology

43
Q

included in the obligatory investigations, but it may yield falsenegative
results in patients with miliary tuberculosis, malnutrition,
or immunosuppression.

A

TST

44
Q

diseases that could yield false-negative result

A

miliary tuberculosis, malnutrition,

or immunosuppression

45
Q

less influenced by
prior vaccination with bacille Calmette-Guérin or by infection with
nontuberculous mycobacteria, its sensitivity is similar to that of the
TST

A

IGRA

46
Q

Granulomatous disease in liver or bone marrow biopsy
samples, for example, should always lead to a (re)consideration of
this diagnosis.

A

Miliary tuberculosis

47
Q

diagnostics to be done to have highest diagnostic yield for miliary tuberculosis

A

liver biopsy for

acid-fast smear, culture, and polymerase chain

48
Q

One of the first steps in diagnosing FUO, particularly in patients without signs of inflammation in
laboratory tests.

A

rule out factitious or fraudulent

fever

49
Q

should be discontinued early in the

evaluation to exclude drug fever

A

medications, including nonprescription drugs

and nutritional supplements

50
Q

If fever persists beyond _____ after
discontinuation of the suspected drug, it is unlikely that this drug is
the cause

A

72 hr

51
Q

In patients without PDCs or with only misleading PDCs,
__________ may be useful in the early stage
of the diagnostic workup.

A

funduscopy

52
Q

When the first-stage diagnostic tests do
not lead to a diagnosis, ________ should be performed, especially
when the ESR or the CRP level is elevated.

A

scintigraphy

53
Q

In patients with recurrent fever lasting ______,

it is very unlikely that the fever is caused by infection or malignancy

A

> 2 years

54
Q

noninvasive method
allowing delineation of foci in all parts of the body on the basis
of functional changes in tissues.

A

Scintigraphic imaging

55
Q

Conventional scintigraphic methods used in clinical practice

A

67Ga-citrate scintigraphy and 111In- or 99mTc-labeled leukocyte scintigraphy.

56
Q

diagnostic test that routinely

provide information on only part of the body

A

CT and MRI

57
Q

diagnostic test that readily allows whole-body imaging

A

scintigraphy

58
Q

established imaging procedure in FUO

A

18F-Fluorodeoxyglucose
(FDG) positron emission tomography (PET) combined
with CT

59
Q

accumulates in tissues with a high rate of glycolysis, which
occurs not only in malignant cells but also in activated leukocytes
and thus permits the imaging of acute and chronic inflammatory
processes

A

FDG

60
Q

Normal uptake may obscure pathologic foci in the ________________

A

brain,

heart, bowel, kidneys, and bladder

61
Q

FDG uptake in the heart, which
obscures endocarditis, may be prevented by consumption of a
___________ before the PET investigation

A

low-carbohydrate diet

62
Q

offers the advantages of higher resolution,
greater sensitivity in chronic low-grade infections, and
a high degree of accuracy in the central skeleton.

A

FDG-PET/CT

63
Q

they often identify the anatomic location of a particular
ongoing metabolic process and, with the help of other techniques
such as biopsy and culture, facilitate timely diagnosis and treatment

A

scintigraphic techniques

64
Q

Abnormalities
found with scintigraphic techniques often need to be confirmed
by ____________

A

pathology and/or culture of biopsy specimens

65
Q

If no diagnosis is reached despite scintigraphic and PDC-driven
histologic investigations or culture, ____________________ should be considered

A

second-stage screening diagnostic

tests

66
Q

may be used as screening procedures at a later
stage of the diagnostic protocol because of their noninvasive nature
and high sensitivity.

A

chest

and abdominal CT

67
Q

Several studies
have shown a high prevalence of _________ among patients
with FUO, with rates up to 17% among elderly patients

A

giant cell arteritis

68
Q

recommended for patients ≥55 years of age in a later stage of the
diagnostic protocol

A

temporal artery biopsy

69
Q

will not be useful in vasculitis
limited to the temporal arteries because of the small diameter of
these vessels and the high levels of FDG uptake in the brain

A

FDG-PET/CT

70
Q

good indication

for empirical antibiotic therapy

A

hemodynamic instability or neutropenia

71
Q

when does trial of therapy for TB should be started?

A

TST or IGRA is positive

granulomatous disease is present with anergy and sarcoidosis
seems unlikely

72
Q

If the fever does not respond after ______ of
empirical antituberculous treatment, another diagnosis should be
considered.

A

6 weeks

73
Q

highly effective in preventing attacks of familial Mediterranean
fever but is not always effective once an attack is well
under way.

A

Colchicine

74
Q

If the fever persists and the source remains
elusive after completion of the later-stage investigations, supportive
treatment with _______ can
be helpful

A

NSAIDS

75
Q

their use should be avoided unless infectious diseases and malignant
lymphoma have been largely ruled out and inflammatory
disease is probable and is likely to be debilitating or threatening

A

NSAIDs and glucocorticoids

76
Q

a recombinant
form of the naturally occurring IL-1 receptor antagonist (IL-1Ra),
blocks the activity of both IL-1α and IL-1β

A

Anakinra

77
Q

extremely
effective in the treatment of many autoinflammatory syndromes,
such as familial Mediterranean fever, cryopyrin-associated periodic
syndrome, tumor necrosis factor receptor–associated periodic syndrome,
mevalonate kinase deficiency (hyper IgD syndrome), and
Schnitzler syndrome

A

Anakinra

78
Q

A therapeutic
trial with _____ can be considered in patients whose FUO has
not been diagnosed after later-stage diagnostic tests.

A

Anakinra

79
Q

can
provide improved control without the metabolic, immunologic, and
gastrointestinal side effects of glucocorticoid administration.

A

monotherapy with IL-1 blockade

Internal Medicine (3 decks)

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