ChemPath: PUO Flashcards
Defined criteria commonly accepted definition of PUO
(Pyrexia of known definition
Durack and Street criteria
Temperature >38.3, Duration >3weeks, Evaluation in at least 3 outpatient visits / 3 days hospital
Other Categories of PUO in Durack criteria
Nosocominal
Patient hospitalised >24 hrs but no fever on admission
Immune deficient
Neutrophil count <500 per mm^3
HIV associated
Common Nosocomial causes of PUO
C.Diff
Drug induced
Pulmonary embolus
Septic thromboplebitis
Sinusitis
HIV related causes of PUO
CMV
Mycobacterium avium-intracellulare complex
Pneumocystis carinii pneumonia
Kaposi sarcoma
History points for PUO
- B Symptoms - FLAWS
- Medications Doses & initiation date
- Contact history - pets / animals
- Drug use
- Sexual history
- Foreign Travel
Points to ask on Hx of Foreign Travel
- Specific Village/ City?
- What they did there
- Where they stayed
- Others infected
- Walking barefoot?
- Mosquito Nets
Test to consider in all PUO
HIV
(consent needed)
Exclude malaria in patient with tropical travel in last 2 years
Is an Interferon Gamma release assay (IGRA) useful in diagnosing TB
No
Doesnt tell you much for active TB
Routine Investigations for PUO
A&E
FBC
U&E
LFT
CRP
CXR
Blood Cultures
Urine Dip
Medic
2x Blood Cultures
Urine Culture
Stool Culture + OCP (Ova, cysts paracites)
CMV/EBV serology
HIV / HBV / HCV
CK
Ferritin
LDH
ANCA
ANA
RhF
TFT
Any others - speak to consultant (money)
Best scan for Cancer?
FDG-PET
(Fluorescently lablled Glucose - uptake and localisation of tumour)
When to order Echocardiogram in PUO
?Infective Endocarditis =
When the patient meets the Duke Criteria
2 major or [1 Major + 3 minor]
Major criteria of Duke Criteria
Persistent bacteraemia (>2 BC positive)
Echocardiogram: Vegetation
Positive Serology for bartonella, Coxiella or Brucella
Minor Criteria for Duke Criteria
Predisposition (murmur, IVDU)
Inflammatory Markers (Fever, CRP high)
Immune complexes (splinters / RBC in urine)
Embolic Phenomena (Janeway lesions, Olsers)
1 positive BC
Where is Schistosomiasis commonly found
Africa - along the Nile Delta
Infective Causes of PUO
Viral
CMV, EBV
HIV
Hepatitis ABCDE
Fungal
Cryptococcosis
Histoplasmosis
Paracites
Malaria
Amoebic LIver abcess
Schistosomiasis
Toxoplasmosis
Bacterial
Q Fever, Bartonella, Brucella
Mycobacteria - TB / NTM
Eneteric Fevers
Zoonoses
How to order tests for infective PUO
REFER TO RIPL
Rare and imported pathogens laboratory
Include discriminating characteristics - eg. INdian man, swiming in freshwater…
Criteria for Adult onset stills disease
Major
Temp >39 for >1wk
Leukocytosis >10,000 /mm3
Typical Rash
Arthralgias >2weeks
Minor
Sore throat
Lymphadenopathy
Splenomeglay / Hepatomegaly
Abnormal LFTs (esp. AST, ALT, LDH ^^)
Neg ANA / Rf
Typical Adult onset stills rash
Salmon Pink rash
(Can be mistaken for drug eruption / rash)
Ferritin oftern very high in Adult onset stills
(macrophage activation syndrome)
Does Giant cell arteritis occur in Younger or older populaiton
Older
(almost never young ie. 20s 30s)
Inflammatory causes of PUO
Vasculitis
CTD
GCA
(involve Rheumatologist early)
Malignant causes of PUO
- Lymphoma (esp. non hodgkins)
Raised LDH, Weight Loss, Lymph nodes - Leukamia
Bone marrow biopsy - Renal Cell Carinoma
20% with Fever, (haematuria can occur) - Hepatocellular carcinoma or other tumor mets to liver
Overall general subheadings for causes of PUO
- Infective
- Inflammatory
- Malignant
Indications for URGENT (preconfirmation) treatment
- Infective endocarditis
- Disseminated TB (FLAWS)
- CNS TB (Headache / Reduced GCS)
- GCA
- SEPSIS
Define Sepsis
Disordered Host repsonse to infection
Define Septic Shock
End organ dysfunction / damage
due to sepsis
