L9: Pyrexia of Unknown Origin Flashcards
Def of PUO
New Def of PUO
Etiology & Epidemeology of PUO
PUOs that persist for more than 1 year are less likely to be caused by an infection or neoplasm and are much more likely to be the result of a …..
granulomatous disease (the most common cause in these cases).
Causes of Nosocomial PUO
Drugs Causing Nosocomial PUO
(antibiotics induced Clostridium difficile colitis, and drug fever)
Immobilization Issues Causing Nosocomial PUO
decubitus ulcers, deep-vein thrombophlebitis, and pulmonary embolism
Pyrexia in HIV Patient
PUO in Transplant Patient
According to time following transplantation (IN SOLID ORGAN RECIPIENTS)
According to time following transplantation (IN SOLID ORGAN RECIPIENTS)
- 0-1 Months
- bacterial or fungal infections related to underlying condition or surgical complications
According to time following transplantation (IN SOLID ORGAN RECIPIENTS)
- 1-6 Months
CMV ,opportunistic infections as PJP
According to time following transplantation (IN SOLID ORGAN RECIPIENTS)
- > 6 Months
bacterial pneumonia, community acquired infections, Post-transplant lymphoproliferative disorder(PTLD)
Def of Classic PUO
- Temperature >38.3 C (100.9 F)
- Duration of >3 weeks
- Evaluation of at least 3 outpatient visits or 3 days in
hospital
Etiology of Classic PUO
- Infection
- Malignancy
- Collagen vascular disease
Def of Nosocomial PUO
- Temperature >38.3 C
- Patient hospitalized ≥ 24 hours but drug-induced no fever or incubating on admission
- Evaluation of at least 3 days
Etiology of Nosocomial PUO
- Clostridium difficile enterocolitis
- Pulmonary embolism
- Septic thrombophlebitis
- Sinusitis
def of Immune deficient (neutropenic) PUO
- Temperature >38.3 C
- Neutrophil count ≤ 500 per mm3
- Evaluation of at least 3 days
Etiology of Immune deficient (neutropenic) PUO
 Opportunistic bacterial infections
 Aspergillosis
 Candidiasis,
 Herpes virus
Def of HIV associated PUO
- Temperature >38.3 C
- Duration of >4 weeks for outpatients, >3 days for inpatients
- HIV infection confirmed
Etiology of HIV associated PUO
- Cytomegalovirus,
- Mycobacterium avium- intracellulare complex,
- Pneumocystis carnii pneumonia,
- Drug-induced,
- Kaposi’s sarcoma, lymphoma
Etiologies of PUO
Same as first Page
Etiologies of PUO
- Infections
- Specifc Locations
- Soecific Organisms
- Specific Patient Groups
Etiologies of PUO
- Infections (Specifc Location)
Etiologies of PUO
- Infections (Specic Organsims)
 Tuberculosis (particularly extra pulmonary)
 Brucella
 Viral infections: CMV-EBV
 HIV-1 infection
 Fungal infections: Aspergillus spp, Candida spp.
Bacteria Causing PUO
Viruses Causing PUO
Fungi Causing PUO
- Candida albicans
- Cryptococcus neoformans
- Histoplasma capsulatum
- Aspergillus spp.
- Coccidioides immitis
- Pneumocystis jiroveci
Parasites Causing PUO
- Plasmodium–Malaria
- Leishmania
- Trypanosoma
- Toxoplasma
- Wuchereria bancrofti
- Babesia microti
Etiologies of PUO
- Specific Patients Groups
Etiologies of PUO
- Specific Patients Groups (imported Infections)
Malaria, dengue, rickettsia, brucella, amoebic liver
abscess, enteric fever, leishmaniasis
Etiologies of PUO
- Specific Patients Groups (HIV-Positive Patients)
disseminated Mycobacterium avium complex, Pneumocystis jiroveci (carnii) pneumonia, CMV and others
Etiologies of PUO
- Specific Patients Groups (Nosocomial Infections)
infections related to prosthetic materials and surgical procedures
Etiologies of PUO
- Malegnancies
Etiologies of PUO
- Malegnancies (Hematologic Malignancies)
 Lymphoma
 Leukemia
 Myeloma
Etiologies of PUO
- Malegnancies (Solid Tumors)
 Renal
 Liver
 Colon
 Stomach
 Pancreas
Etiologies of PUO
- Connective Tissue Disorders
Etiologies of PUO
- Connective Tissue Disorders (Older Adults)
 Giant cell arteritis
 Polymyalgia Rheumatica
Etiologies of PUO
- Connective Tissue Disorders (Younger Adults)
Miscellaneous Causes of PUO
- CVS
- RESP
- ENDO/META
- GIT
- HEMA
- INHERITED
- DRUGS
- FACTITIOUS
Miscellaneous Causes of PUO
- Xardiovascular
 Atrial myxoma
 Aortitis
 Aortic dissection
Miscellaneous Causes of PUO
- Respiratory
 Pulmonary embolism (PE)
 Sarcoidosis
 Extrinsic allergic alveolitis
Miscellaneous Causes of PUO
- GIT
 IBD
 Granulomatous hepatitis
 Alcoholic liver disease
 Pancreatitis
Miscellaneous Causes of PUO
- Endocrine/Metabolic
 Thyrotoxicosis
 Thyroiditis
 Pheochromocytoma
 Adrenal insufficiency
Miscellaneous Causes of PUO
- Hematological
 Hemolytic anemia
 PNH (Paroxysmal nocturnal hemoglobinuria)
 TTP (Thrombotic thrombocytopenic purpura)
 Myeloproliferative disorders
Miscellaneous Causes of PUO
- Inherited
 FMF (Familial Mediterranean Fever)
 Periodic fever syndromes
Miscellaneous Causes of PUO
- Drug reactions
 Antibiotic fever
 Drug hypersensitivity reactions
Characters of Factitious fever
Categories of Drug-Induced fever
- Antibiotic Induced fever
- Cardiovascular system drug induced fever
Examples of Antibiotic Induced fever
 Erythromycin
 Isoniazid
 Penicillin
 Nitrofurantoin
 Quinidine
Examples of Cardiovascular system drug induced fever
 Captopril
 Atropine
 Clofibrate
 Hydralazine
 Hydrochlorothiazide
 Alfa methyl dopa
 Nifedipine
approach to a patient with PUO
approach to a patient with PUO
- Stage I
 Careful history taking
 Physical examination
 Screening tests
approach to a patient with PUO
- Stage II
 Review the history
 Repeating physical examination
approach to a patient with PUO
- Stage III
 Specific diagnostic tests
 Noninvasive investigations
approach to a patient with PUO
- Stage IV
Invasive tests
What to ask during Hx Taking in a patient with PUO?
- Duration and characteristics of the fever
- Travel history or exposure to people who have traveled to regions endemic for particular diseases
- Exposure to unpasteurized dairy products
- Presence of rash, conjunctivitis. Mucous membrane changes, and arthritis
- Presence of associated cough, weight loss, or lymphadenopathy
What to ask during Hx Taking in a patient with PUO?
- Duration and characteristics of the fever
 Number of spikes per day
 Timing of the temperature elevation
 Whether the temperature returns to normal or below normal
What to ask during Hx Taking in a patient with PUO?
- Travel history or exposure to people who have traveled to regions endemic for particular diseases
 Cat-scratch disease
 Rat-bit fever
 Leptospirosis
What to ask during Hx Taking in a patient with PUO?
- Exposure to unpasteurized dairy products
Brucellosis
What to ask during Hx Taking in a patient with PUO?
- Presence of rash, conjunctivitis. Mucous membrane changes, and arthritis
 Juvenile arthritis
 SLE
 Kawasaki syndrome
What to ask during Hx Taking in a patient with PUO?
- Presence of associated cough, weight loss, or lymphadenopathy
 Lymphoma
 Leukemia
 Neuroblastoma
 TB
 HIV
Physical Examination in PUO
minimal diagnostic work up to qualify a case of PUO
Microbiological investigation of PUO
- Microscopy
- Culture
- Antigen detection
- Nucleic acid detection
- Immunological Tests
Microbiological investigation of PUO
- Microscopy
Microbiological investigation of PUO
- Microscopy (Blood Film)
 For direct identification of the organism as for malaria or trypanosomiasis
 Atypical lymphocytes ( EBV,CMV,HIV-1, hepatitis, Toxoplasma)
Microbiological investigation of PUO
- Microscopy (Sputum)
For mycobacteria and fungi
Microbiological investigation of PUO
- Microscopy (Stool)
for ova ,cysts and parasites
Microbiological investigation of PUO
- Microscopy (Urine)
for WBCs, RBCs, schistosoma ova, mycobacteria (early morning urine for three days)
Microbiological investigation of PUO
- Microscopy (LM)
L/M examination of biopsy for (bacteria, mycobacteria, fungi, leishmania and other parasites)
Microbiological investigation of PUO
- Microscopy (EM)
E/M for viruses, protozoa(e.g. microsporidia) and other fastidious organisms (e.g. T.whipplei)
Microbiological investigation of PUO
- Culture
Microbiological investigation of PUO
- Antigen Detection
Microbiological investigation of PUO
- Antigen Detection (Blood)
for HIV p24 antigen, Cryptococcal antigen, Histoplasma antigen, aspergillus ELISA.
Microbiological investigation of PUO
- Antigen Detection (BAL)
Aspergillus antigen
Microbiological investigation of PUO
- Antigen Detection (CSF)
Cryptococcal antigen
Microbiological investigation of PUO
- Antigen Detection (Nasopharyngeal-Throat Swap)
respiratory viruses
Microbiological investigation of PUO
- Antigen Detection (Urine)
For Legionella antigen
Microbiological investigation of PUO
- Nucleic acid detection
Microbiological investigation of PUO
- Nucleic acid detection (Blood)
Microbiological investigation of PUO
- Nucleic acid detection (CSF)
Microbiological investigation of PUO
- Nucleic acid detection (Nasopharyngeal aspirate or throat swab)
Microbiological investigation of PUO
- Nucleic acid detection (BAL)
Microbiological investigation of PUO
- Nucleic acid detection (Tissue Specimens)
Microbiological investigation of PUO
- Nucleic acid detection (urine)
Microbiological investigation of PUO
- Nucleic acid detection (Stool)
Microbiological investigation of PUO
- Immunological Tests
Microbiological investigation of PUO
- Other Tests
Endocarditis & PUO
Hepatobiliary infections & PUO
Osteomyelitis & PUO
Rickettsial & chlamydial infections & PUO
Systemic bacterial illnesses & PUO
Viruses & PUO
Fungal infections & PUO
Parasitic infections & PUO
Lymphomas & PUO
Leukemias & PUO
Solid tumors & PUO
Regional enteritis & PUO
Granulomatous hepatitis & PUO
Collagen-vascular and autoimmune diseases & PUO
PUO & Rash
Another Name of FMF
Def of FMF
Causes of FMF
Pathophysiology of FMF
CP of FMF
Complications of FMF
Dx of FMF
TTT of FMF
Managment of PUO
Managment of PUO
Managment of Nosocomial PUO
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