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Block G -- Infection > Dr. Teltscher -- Fever of Unknown Origin > Flashcards

Dr. Teltscher -- Fever of Unknown Origin Flashcards

1
Q

6 sites to measure body temperature

A
  • Tympanic
  • Oral
  • Axillary
  • PA-catheter
  • Rectal
  • Vaginal/urethral
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2
Q

Gold standard site for body temp measurement

A

PA - catheter

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3
Q

2 cons of using PA-catheter to measure body temperature

A

Invasive

Limited availability

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4
Q

Best estimate of body temperature

A

Rectal

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5
Q

3 cons to using rectal temperature

A
  • Underestimate temp in shock
  • Small risk of cross contamination
  • Semi-invasive
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6
Q

Deviation from standard of oral temperature

A

-0.4 C

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7
Q

2 pros to using oral temperature

A
  • Accessible
  • Quickly change in response to change in core temp
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8
Q

Cons of using oral temperature

A

False readings from:

  • Ingestion
  • Mastication
  • Smoking
  • Mouth breathing (not tachypnea)
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9
Q

Deviation from standard of tympanic temperature

A

-0.8 C

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10
Q

Pros of TM

A

Rapid, very accesible

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11
Q

3 cons to using TM

A
  • Wide variability
  • User dependent concerns
  • Concerns about actual site (i.e. cerumen, canal)
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12
Q

Notoriously inaccurate and unreliable temperature

A

Axillary

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13
Q

3 fastest methods of body temperature measurement by adjustment period

A
  • TM (seconds)
  • Digital oral (seconds to minutes)
  • Rectal (1 - 5 min)
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14
Q

6 states that commonly cause variability in body temperature

A
  • Fertile women
    • Lower AM temp 2 wees prior to ovulation
    • Temp then rises by 0.6C until ovulation
  • Postprandial state
  • Pregnancy
  • Endocrinologic dysfunction
  • Age
    • Fixed variation in childhood
    • Inability to mount fever in even extreme infection in elderly
  • Nutritional status (i.e. catabolic, malnourished)
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15
Q

Define fever

A

Regulated rise in core temperature due to a corresponding rise in the thermoregulatory set point in response to a physiologic threat to the host

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16
Q

Define hyperthermia (3)

A
  • **Unregulated **increase in core temperature in which inflammatory cytokines play only a minor role
  • Sustained elevation of core temperature lacking diurnal fluctuations characteristic of both fever and normal body temp
  • Does not respond to antipyrtic drug therapy
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17
Q

Define hyperpyrexia

A

Fever >41.5 degrees C

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18
Q

2 conditions associated with hyperpyrexia

A
  • Severe infection
  • CNS hemorrhage
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19
Q

7 causes of hyperthermia

A
  • Heat stroke
  • Illicit drug induced
  • Neuroleptic Malignant Syndrome (NMS)
  • Toxidromes/ODs/Drug Fever
  • Malignant Hyperthermia
  • Andocrinopathies
  • CNS insults
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20
Q

6 illicit drugs that can cause hyperthermia

A
  • PCP
  • Ecstacy
  • LSD
  • Amphetamines
  • Cocaine
  • Lithium
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21
Q

2 causes of NMS

A
  • Antipsychotics
  • Withdrawal of dopaminergic agent
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22
Q

10 toxidromes or drugs that you can overdose on or which cause drug fever that can cause hyperthermia

A
  • SSRIs
  • MAOIs
  • TCAs
  • Anticholinergic
  • Salicylates
  • Antihistamines
  • Antiparkinsonian drugs
  • Diuretics
  • Cardiovascular meds
  • ABX
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23
Q

2 drugs that can cause malignant hyperthermia

A
  • Anesthetics
  • Succinylcholine
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24
Q

2 endocrinopathies that can cause hyperthermia

A
  • Thyrotoxicosis
  • Pheochromocytoma
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25
Q

3 CNS insults that can cause hyperthermia

A
  • Cerebral hemorrhage
  • Status epilepticus
  • Hypothalamic injury
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26
Q

4 increased endocrine components of febrile response

A
  • Glucocorticoid production
  • GH secretion
  • Aldosterone secretion
  • Acute-phase proteins
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27
Q

2 decreased endocrine components of febrile response

A
  • Vasopressin secretion
  • Levels of circulating divalent cations
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28
Q

3 autonomic components of febrile response

A
  • Shift of blood flow from cutaneous to deep circulatory beds
  • Increased HR and BP
  • Decreased sweating
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29
Q

5 neurobehavioral components of febrille response

A
  • Shivering
  • Search for warmth
  • Anorexia
  • Malaise
  • Somnolence
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30
Q

Describe the increase in heat production by the liver in response to fever

A
  • For each 1 degree C increase in body temperature, there is a 13% increase in O2 consumption without shivering
  • Shivering –> increased oxygen consumption to 100% - 200% above base-line
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31
Q

8 fever patterns

A
  • Circadian
  • Intermittent
  • Remittent
  • Continuous
  • Typhoid inversus
  • Temp-Pulse dissociation
  • Relapsing
  • Cyclic neutropenia
32
Q

Define circadian fever

A

Normal variation of increase in temperature as day progresses

33
Q

Define intermittent fever

A

Fever interrupted by at least a daily return to normal body temperature

34
Q

Define remittent fever

A

Fever may fluctuate but never returns to a normal body temperature

35
Q

Define continuous fever

A

Fever varies less than 1C over several days

36
Q

3 diseases that can cause intermittent fever

A
  • Abscess
  • Still’s disease
  • P. falciparum malaria
37
Q

3 diseases that can cause remittent fever

A
  • TB
  • Endocarditis
  • Typhoid
38
Q

4 diseases or conditions that can cause continuous fever

A
  • Encephalitis
  • Drug reactions
  • Salmonellosis
  • Factitious fever
39
Q

Defin typhoid inversus fever

A

Inversion of circadian pattern

40
Q

Define temp-pulse dissociation fever

A

Febrile episodes with relative bradycardia

41
Q

4 types of relapsing fever

A
  • Quartian
  • Tertian
  • Biphasic
  • Pel-Ebstein
42
Q

Define cyclic neutropenia fever

A

Fever occuring every 21 days accompanied by neutropenia

43
Q

Define relapsing fever

A

Febrile episodes separated by periods of normal body temp:

  • Quartian = every 3 days
  • Tertian = every 2 days
  • Biphasic = days of fever followed by afebrile period lasting days w/ subsequent days of fever recurring once
  • Pel-Ebstein = 3 - 10 days of fever –> 3 - 10 days afebrile
44
Q

Example of disease causing general relapsing fever

A

Brucellosis

45
Q

Example of disease causes Quartian fever

A

P. malariae

46
Q

Example of disease causing tertian fever

A

P. vivax

47
Q

3 examples of diseases causing biphasic fever

A
  • Borrelia
  • Rat bat fever
  • Dengue
48
Q

2 examples of diseases that cause Pel-Ebstein fever

A
  • Hodgkin’s disease
  • Lymphomas
49
Q

Classic definition of fever of unknown origin (FUO) (3)

A
  1. Temperature >38.3C on severl occasions
  2. Duration of fever >3 weeks
  3. Failure to diagnose despite 1 week of inpatient evaluation and investigation
50
Q

4 new paradigms of FUO

A
  • Classic FUO
  • Nosocomial FUO
  • Neutropenic FUO
  • FUO associated with HIV infection
51
Q

Define nosocomial FUO (4)

A
  • Hospitalized
  • Acute care
  • No diagnosis of infection when admitted
  • 3 days under investigation
52
Q

Define neutropenic FUO

A
  • ANC <500/ul or expected in 1 - 2 days
  • 3 days under investigation
53
Q

Treatment for neutropenic FUO

A

Empiric antibiotic coverage typically initiated early

54
Q

Define HIV-associated FUO

A
  • Confirmed HIV positive
  • 3 days under investigation
  • 4 weeks as outpatient
55
Q

Define classic FUO accordign to new paradigm

A
  • All other cases with fever of at least 3 weeks
  • 3 days or 3 outpatient visits or 1 week of intelligent and invasive ambulatory investigations
56
Q

2 requirements for all types of FUO according to new paradigm

A
  • Temperatures of at least 38.3 C on several occasions
  • 2 days of microbiology cultures
57
Q

8 infectious causes of FUO

A
  • Occult abscesses
  • Localized - prostatitis, sinusitis, dental abscesses, cholangitis
  • Infective endocarditis
  • TB: pulmonary and extrapulmonary (fever and night sweats)
  • Organisms difficult to culture
  • Prolonged viral syndromes
  • Fungal disease
  • Malaria, especially if cyclic or if returned traveler
58
Q

4 occult abscesses that can cause FUO

A
  • Intra-abdominal
  • Renal
  • Retroperitoneal
  • Paraspinal
59
Q

Pathogens responsible for FUO in IE

A

Culture negative – HACEK group

60
Q

6 difficult to culture organisms that can be the cause of FUO

A
  • Legionella
  • Brucella
  • Bartonella
  • Coxiella
  • Chlamydia
  • Francisella
61
Q

Describe fungal disease as a cause of FUO

A
  • Especially of RES – hepatosplenic, candidiasis, histoplasmosis
  • FUO + headache –> consider cryptococcus neoformans
62
Q

7 infectious causes of fever in returned traveler

A
  1. Malaria (P. falciparum)
  2. Malaria (P. falciparum)
  3. Malaria (P. falciparum)
  4. Enteric/typhoid fever (salmonellosis)
  5. RIckettsial diseases (i.e. African tick typhus, scrub typhus)
  6. Others (i.e. STDs, HAV, HBV, others based on geography)
  7. Standard diseases (i.e. pneumonia, URTI, UTI, etc)
63
Q

9 malignant diseases as possible causes of FUO

A
  • Colon
  • Gall bladder
  • Hepatoma
  • Hodgkin’s lympoma
  • Non-Hodgkin’s lymphoma
  • Leukemia
  • Pancreatic cancer
  • Renal cell carcinoma
  • Sarcoma
64
Q

3 non-malignant diseases that can be a cause of FUO

A
  • Atrial myxoma
  • Castleman’s disease
  • Renal angiomyolipoma
65
Q

9 infammatory causes of FUO (esp. non-infectious FUO)

A

Autoimmune, systemic rheumatologic, vasculitic disease, auto-inflammatory:

  • Temporal arteritis, Still’s disease
  • Polymyalgia rheumatica, SLE, RA
  • Wegener’s granulomatosis, polyarteritis nodosa
  • Granulomatous disease
66
Q

3 granulomatous diseases that may be the cause of inflammatory FUO

A
  • Sarcoidosis
  • Crohn’s disease
  • Granulomatous hepatitis
67
Q

8 types of causes for FUO

A
  • Infectious
  • Inflammatory
  • Malignant
  • Drug fever
  • Tissue sources
  • Central/peripheral thermoregulatory disorders
  • Familial disease
  • Other (i.e. habitual hyperthermia, factitious fever)
68
Q

4 types of drugs that can cause drug fever

A
  • Antimicrobial agents
  • Cardiovascular
  • Chemo treatment
  • CNS acting
69
Q

5 tissue sources of FUO

A
  • Gout
  • Recurrent/chronic PE
  • Hematoma
  • Infarction
  • Necrosis
70
Q

6 central/peripheral thermoregulatory disorders as potential causes of FUO

A
  • Brain tumors
  • CVA
  • Encephalitis
  • Hypothalamic dysfunction
  • Hyperthyroid
  • Pheochromocytoma
71
Q

2 familial diseases as potential causes of FUO

A
  • Familial mediterranean fever
  • Fabry’s disease
72
Q

4 considerations for causes of FUO in elderly

A
  • Most common = multisystem disease
    • Temporal arteritis
    • Giant cell arteritis/polymyalgia rheumatica
  • Infectious (mycobacterial leading)
  • Neoplastic (i.e. colon cancer)
  • Thrombosis
73
Q

7 investigative tests that have been proven to be useful in the work up of FUO

A
  1. CT scan
    • Esp. abdominal; high diagnostic yield, should be one of first)
  2. Nuclear medicine scans
    • Galium, PET, Technetium, Indium
  3. IE classification systems (Modified Duke’s Criteria and Echocardiogram)
  4. Liver biopsy
  5. Temporal artery biopsy
  6. Duplex doppler scans (for DVT)
  7. Bone marrow biopsy (for when other not yielding positive results)
74
Q

2 common causes of FUO that CT scan can identify

A
  • Occult intra-abdominal abscesses
  • Neoplasm
75
Q

3 complications of temporal artery biopsy

A
  • Damage of the facial nerve
  • Skin necrosis
  • Drooping of the eyebrow
76
Q

6 investigative tests for FUO that are often performed by have no evidence for their usefulness

A
  • Emperic antibiotic therapy (uncertain)
  • Exploratory laparotomy (uncertain)
  • ESR
  • CRP
  • D-Dimer
  • Bone scan

Block G -- Infection (23 decks)

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