Fever febrile illness-Table 1 Flashcards
1
Q
What is tick bite prophylaxis in adults? Who is eligible for this tx?
A
doxycycline 200 mg po x1
Eligibility criteria :
•the attached tick can be reliably identified as an Ixodes tick that is estimated to have been attached for 36hours or longer
•preventive treatment can be started within 72 hours of the time the tick was removed
•ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi bacteria is 20% or greater
2
Q
How is the erythema migrans rash tx?
A
- Doxycycline 100 mg po bid x 14 days
- Amoxicillin 500 mg po tid x 14 days
- Cefuroxime 500 mg po bid x 14 days
3
Q
What is the difference in tx for pts with 2-3rd stage involvement of the face and or arthritis?
A
Same drug just tx 14-28 days
4
Q
How does tx change if carditis or NS dz accompanies the rash?
A
Add oral or IV abx for 14 days
5
Q
How can lyme dz be prevented?
A
- Wear light-colored clothes - easier to spot tick
- Wear long pants, long sleeves
- Use tick repellent, such as permethrin, on clothes
- Use DEET on skin
- Check for ticks after being outside
- Remove ticks immediately by head
6
Q
What is PTLDS?
A
Post-Treatment Lyme Disease Syndrome
Pts diagnosed later in the dz that have persistent fatigue, muscle aches, and reduced concentration
7
Q
What are potential causes of fever with regional lymphadenopathy?
A
- Pyrogenic Infections: S. aureas and group A strept
- TB
- Cat-Scratch Fever
- Tularemia (ulceroglandular fever)
- Bubonic plague
8
Q
What is the definition of fever of unknown origin?
A
> 38.3, 101
3 weeks long
remain undiagnosed after 3 days in hospital or 2 outpt visits
9
Q
What are the categories of FUO?
A
Classic, nosocomial, immune-deficient(neutropenic), HIV related
10
Q
What constitutes a classic FUO?
A
- Fever > 38.3°C (101°)on multiple occasions
- Duration > 3 weeks
- Uncertain diagnosis after evaluation of at least 3 outpatient visits or 3 days in-hospital
11
Q
What are common etiologies for classic FUO?
A
•Infection 1/3 = intraabdominal or pelvic abscesses Mycobacterial (TB) CMV Complicated infections of urinary tract Osteomyelitis Sinusitis Bacterial endocarditis •Connective Tissue Diseases Adult Still’s disease Giant Cell arteritis •Malignancies Lymphoma, especially non-Hodgkin’s Leukemia Renal cell carcinoma Hepatocellular carcinoma •Drugs Antibiotics, NSAIDS, antiepilectic drugs, antihypertensive drugs, antiarrhythmic drugs
12
Q
What constitutes a nosocomial FUO?
A
Hospitalization of at least 24 hrs with no fever on admission, evaluation of at least 3 days
13
Q
What are common etiologies of nosocomial FUO?
A
C.Difficile, drugs, PE, septic thrombophlebitis, sinusitis (intubated patients)
14
Q
What constitutes an immune def FUO?
A
Neutrophil count
15
Q
What are the common etiologies of immune def FUO?
A
Opportunistic bacterial infections, aspergillosis, candidiasis, herpes virus
16
Q
Why is it important to obtain a hx of sweating with fever?
A
Can change your ddx
Fever+ sweating+ heat intolerance may indicate hyperthyroidism
Fever+heat intolerance +no sweat may indicate ectodermal dysplasia
17
Q
What conditions might you have an intermittent high spike in fever with rapid defervescence?
A
- Pyogenic infection
* Can also occur in tuberculosis, lymphoma and juvenile rheumatoid arthritis
18
Q
What conditions might you have remittent fluctuating peaks and baseline that does not return to normal?
A
- Viral infections
* Can occur with bacterial infections, especially endocarditis, sarcoid, lymphoma and atrial myxoma
19
Q
What conditions might you suspect is the pt has a sustained persistent fever with little or no fluctuation?
A
Typhoid fever, typhus and brucellosis
20
Q
What might you consider if your pt has a relapsing fever? meaning they are afebrile for one or more days in between febrile episodes?
A
Malaria, rat bite fever, Borrelia infection and lymphoma
21
Q
If your pt has recurrent fever, characterized by episodes of fever of more than 6 mo duration, what should you consider?
A
- Metabolic defects
- CNS dysregulation of temperature control
- Periodic disorders such as cyclic neutropenia, hyperimmunoglobulin D syndrome and deficiencies of selected interleukin receptor sites
22
Q
What initial labs should you order when working up a FUO?
A
CBC and peripheral smear, ESR, CRP, Aerobic blood cultures, UA, urine culture, CXR, tuberculin skin test, electrolytes, BUN, creatinine, hepatic enzymes, HIV serology
23
Q
If the cbc comes back and your pt has anemia, what should you consider?
A
malaria, infective endocarditis, IBD, SLE or tuberculosis
24
Q
If the cbc comes back and your pt has thrombocytosis, what should you consider?
A
Kawaskai disease
25
If the cbc comes back and your pt has changes in the WBC, what should you consider?
atypical lymphocytes may suggest a viral infection, immature forms may suggest leukemia and eosinophilia is suggestive of parasitic, fungal, neoplastic, allergic or immunodeficiency disorders
26
Why should you avoid empiric tx in pts with FUO?
There is a chance you will mask or delay the diagnosis with use of abx or anti-inflammatory meds
27
When should you ignore the above statement and tx empirically?
* Nonsteroidal agents in children with presumed JIA
* Antituberculosis drugs in critically ill children with possible disseminated TB
* Patients who are clinically deteriorating and in whom bacteremia or sepsis is strongly suspected
* Patients who are immunocompromised
28
What are characteristics of brucellosis?
Indolent infection with persistent fever and lethargy, osteoarticular complaints, hepatosplenomegaly and mild LFT elevation
29
When might you consider brucellosis?
in patients exposed to animals or animal products, especially unpasteurized cheese
30
What is the clinical presentation of leptospirosis? What puts pts at risk for this dz?
* fever, rigors, myalgias, headache, cough and GI complaints
* Occurs after exposure to animal urine, contaminated soil or water (swimming) or infected animal tissue
31
What are s/s of malaria? When should you consider this?
* Splenomegaly typically accompanies fever
| * patients with history of travel to endemic areas, can present months after travel
32
What often accompanies fever in toxoplasmosis?
by cervical or supraclavicular lymphadenopathy
33
What dz should you consider in a child with FUO and contact with aninals/dead carcasses/ingestion of rabbit or squirrel meat?
Tularemia
34
What is one of the most common causes of FUO?
UTI
35
What is the second most common category of FUO in children?
Connective tissue dz
36
What should you consider if your pt is a child and presents with high, spiking fevers, lymphadenopathy, and an evanescent rash which may be present only when the patient is febrile and a positive ANA?
•Juvenile rheumatoid arthritis (juvenile idiopathic arthritis)
also look into polyarteritis nodosa and SLE
37
What are the most common malignancies that cause FUO in children?
Leukemia and lymphoma
38
You have a pt presenting with fever and you have ruled out almost all possible causes. What is something you should consider and how should you test for this?
Factitious fever- psych condition
| Get a UA and check the temp- this is the closest to core temp
39
What is familial dysautonomia?
Autosomal recessive disorder: autonomic and peripheral sensory nerve dysfunction results in defective temperature regulation
40
What are s.s of familiar dysautonomia?
* Poor swallowing coordination, excessive salivation, diminished tearing, excessive or diminished sweating, labile blood pressure, erythema or blanching of the skin
* Impairment of deep tendon and corneal reflexes
41
What are the 2 most common heritable periodic fever disorders in children?
familial Mediterranean fever and hyperimmunoglobulin D syndrome
42
What is familial Mediterranean fever?
autosomal recessive disorder in individuals of Mediterranean descent with episodic fever and serosal inflammation
43
What is Hyperimmunoglobulin D syndrome?
autosomal recessive disease with episodes of fever, skin eruptions, abdominal complaints and joint involvement and elevated serum IgD
44
What is cyclic neutropenia?
patients are prone to fever during periods of severe neutropenia, which occur at regular intervals of 15 to 35 days
45
What is tick bite prophylaxis in adults? Who is eligible for this tx?
doxycycline 200 mg po x1
Eligibility criteria :
•the attached tick can be reliably identified as an Ixodes tick that is estimated to have been attached for 36hours or longer
•preventive treatment can be started within 72 hours of the time the tick was removed
•ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi bacteria is 20% or greater
46
How is the erythema migrans rash tx?
* Doxycycline 100 mg po bid x 14 days
* Amoxicillin 500 mg po tid x 14 days
* Cefuroxime 500 mg po bid x 14 days
47
What is the difference in tx for pts with 2-3rd stage involvement of the face and or arthritis?
Same drug just tx 14-28 days
48
How does tx change if carditis or NS dz accompanies the rash?
Add oral or IV abx for 14 days
49
How can lyme dz be prevented?
* Wear light-colored clothes - easier to spot tick
* Wear long pants, long sleeves
* Use tick repellent, such as permethrin, on clothes
* Use DEET on skin
* Check for ticks after being outside
* Remove ticks immediately by head
50
What is PTLDS?
Post-Treatment Lyme Disease Syndrome
| Pts diagnosed later in the dz that have persistent fatigue, muscle aches, and reduced concentration
51
What are potential causes of fever with regional lymphadenopathy?
* Pyrogenic Infections: S. aureas and group A strept
* TB
* Cat-Scratch Fever
* Tularemia (ulceroglandular fever)
* Bubonic plague
52
What is the definition of fever of unknown origin?
>38.3, 101
>3 weeks long
remain undiagnosed after 3 days in hospital or 2 outpt visits
53
What are the categories of FUO?
Classic, nosocomial, immune-deficient(neutropenic), HIV related
54
What constitutes a classic FUO?
* Fever > 38.3°C (101°)on multiple occasions
* Duration > 3 weeks
* Uncertain diagnosis after evaluation of at least 3 outpatient visits or 3 days in-hospital
55
What are common etiologies for classic FUO?
```
•Infection
1/3 = intraabdominal or pelvic abscesses
Mycobacterial (TB)
CMV
Complicated infections of urinary tract
Osteomyelitis
Sinusitis
Bacterial endocarditis
•Connective Tissue Diseases
Adult Still’s disease
Giant Cell arteritis
•Malignancies
Lymphoma, especially non-Hodgkin’s
Leukemia
Renal cell carcinoma
Hepatocellular carcinoma
•Drugs
Antibiotics, NSAIDS, antiepilectic drugs, antihypertensive drugs, antiarrhythmic drugs
```
56
What constitutes a nosocomial FUO?
Hospitalization of at least 24 hrs with no fever on admission, evaluation of at least 3 days
57
What are common etiologies of nosocomial FUO?
C.Difficile, drugs, PE, septic thrombophlebitis, sinusitis (intubated patients)
58
What constitutes an immune def FUO?
Neutrophil count
59
What are the common etiologies of immune def FUO?
Opportunistic bacterial infections, aspergillosis, candidiasis, herpes virus
60
Why is it important to obtain a hx of sweating with fever?
Can change your ddx
Fever+ sweating+ heat intolerance may indicate hyperthyroidism
Fever+heat intolerance +no sweat may indicate ectodermal dysplasia
61
What conditions might you have an intermittent high spike in fever with rapid defervescence?
* Pyogenic infection
| * Can also occur in tuberculosis, lymphoma and juvenile rheumatoid arthritis
62
What conditions might you have remittent fluctuating peaks and baseline that does not return to normal?
* Viral infections
| * Can occur with bacterial infections, especially endocarditis, sarcoid, lymphoma and atrial myxoma
63
What conditions might you suspect is the pt has a sustained persistent fever with little or no fluctuation?
Typhoid fever, typhus and brucellosis
64
What might you consider if your pt has a relapsing fever? meaning they are afebrile for one or more days in between febrile episodes?
Malaria, rat bite fever, Borrelia infection and lymphoma
65
If your pt has recurrent fever, characterized by episodes of fever of more than 6 mo duration, what should you consider?
* Metabolic defects
* CNS dysregulation of temperature control
* Periodic disorders such as cyclic neutropenia, hyperimmunoglobulin D syndrome and deficiencies of selected interleukin receptor sites
66
What initial labs should you order when working up a FUO?
CBC and peripheral smear, ESR, CRP, Aerobic blood cultures, UA, urine culture, CXR, tuberculin skin test, electrolytes, BUN, creatinine, hepatic enzymes, HIV serology
67
If the cbc comes back and your pt has anemia, what should you consider?
malaria, infective endocarditis, IBD, SLE or tuberculosis
68
If the cbc comes back and your pt has thrombocytosis, what should you consider?
Kawaskai disease
69
If the cbc comes back and your pt has changes in the WBC, what should you consider?
atypical lymphocytes may suggest a viral infection, immature forms may suggest leukemia and eosinophilia is suggestive of parasitic, fungal, neoplastic, allergic or immunodeficiency disorders
70
Why should you avoid empiric tx in pts with FUO?
There is a chance you will mask or delay the diagnosis with use of abx or anti-inflammatory meds
71
When should you ignore the above statement and tx empirically?
* Nonsteroidal agents in children with presumed JIA
* Antituberculosis drugs in critically ill children with possible disseminated TB
* Patients who are clinically deteriorating and in whom bacteremia or sepsis is strongly suspected
* Patients who are immunocompromised
72
What are characteristics of brucellosis?
Indolent infection with persistent fever and lethargy, osteoarticular complaints, hepatosplenomegaly and mild LFT elevation
73
When might you consider brucellosis?
in patients exposed to animals or animal products, especially unpasteurized cheese
74
What is the clinical presentation of leptospirosis? What puts pts at risk for this dz?
* fever, rigors, myalgias, headache, cough and GI complaints
* Occurs after exposure to animal urine, contaminated soil or water (swimming) or infected animal tissue
75
What are s/s of malaria? When should you consider this?
* Splenomegaly typically accompanies fever
| * patients with history of travel to endemic areas, can present months after travel
76
What often accompanies fever in toxoplasmosis?
by cervical or supraclavicular lymphadenopathy
77
What dz should you consider in a child with FUO and contact with aninals/dead carcasses/ingestion of rabbit or squirrel meat?
Tularemia
78
What is one of the most common causes of FUO?
UTI
79
What is the second most common category of FUO in children?
Connective tissue dz
80
What should you consider if your pt is a child and presents with high, spiking fevers, lymphadenopathy, and an evanescent rash which may be present only when the patient is febrile and a positive ANA?
•Juvenile rheumatoid arthritis (juvenile idiopathic arthritis)
also look into polyarteritis nodosa and SLE
81
What are the most common malignancies that cause FUO in children?
Leukemia and lymphoma
82
You have a pt presenting with fever and you have ruled out almost all possible causes. What is something you should consider and how should you test for this?
Factitious fever- psych condition
| Get a UA and check the temp- this is the closest to core temp
83
What is familial dysautonomia?
Autosomal recessive disorder: autonomic and peripheral sensory nerve dysfunction results in defective temperature regulation
84
What are s.s of familiar dysautonomia?
* Poor swallowing coordination, excessive salivation, diminished tearing, excessive or diminished sweating, labile blood pressure, erythema or blanching of the skin
* Impairment of deep tendon and corneal reflexes
85
What are the 2 most common heritable periodic fever disorders in children?
familial Mediterranean fever and hyperimmunoglobulin D syndrome
86
What is familial Mediterranean fever?
autosomal recessive disorder in individuals of Mediterranean descent with episodic fever and serosal inflammation
87
What is Hyperimmunoglobulin D syndrome?
autosomal recessive disease with episodes of fever, skin eruptions, abdominal complaints and joint involvement and elevated serum IgD
88
What is cyclic neutropenia?
patients are prone to fever during periods of severe neutropenia, which occur at regular intervals of 15 to 35 days
