Lecture 27: Systemic Syndromes/FUO Flashcards
What are the three major categories of diseases that cause FUO?
- Infection
- Malignancy
- Immune-mediated
Don’t forget drug reaction
Name 5 lab features of systemic inflammation!
- Leukocytosis with neutrophilia
- Thrombocytosis
- Anemia of inflammation (normochromic/normocytic)
- Raised CRP/ESR
- Evidence of liver dysfunction: increase in ALT/AST/PT or PTT or reduced albumin
How do you define FUO?
- Fever >101 F or 38.3 C on several occasions
- Duration of fever for at least three weeks
- Uncertain diagnosis after 1 week of study in hospital
What is the work-up for FUO?
- Good history and exam is vital. Need to repeat them as you do for tests
- Complete blood count, differential, platelet count
- Blood cultures
- Routine blood chemistry, liver enzyme, bilirubin; if abnormal, hepatitis serology
- Urinalysis, including microscopy and culture
- CXR
- S/S of any particular organ, further testing, imaging, or biopsy
If work-up is negative-FUO
What are the characteristics of anemia of inflammation?
Normocytic (normal MCV) and normochromic (normal MCH)
Low serum iron
Low total iron binding capacity
Percent saturation of transferrin and ferritin levels are normal (these would be low in iron deficiency)
How to diagnose polymyalgia rheumatic/giant cell arteritis?
- Middle aged; constitutional symptoms (fever weight loss), neck, scalp and upper back pain, can have low back pain extending to thighs are characteristic of polymyalgia rheumatic
- If eye symptoms are present, then giant cell arteritis.
Always look for elevated ESR, leukocytosis and temporal artery pain and tenderness
ACR GCA classification criteria
Look at slide 18
At least 3 criteria present
- Age of onset 50 or more
- New headache
- Temporal artery abnormality: Tenderness or decreased pulsation
- ESR 50 or more
- Abnormal temporal artery biopsy: Infiltration with mononuclear cells or multinucleated giant cells
Suspect diagnosis of GCA
Diagnosis: Suspect diagnosis of GCA:
patients aged >50 years presenting with
• Abrupt-onset headache (usually unilateral in the temporal
area and occasionally diffuse or bilateral).
• Scalp pain (diffuse or localized), difficulty in combing hair.
• Jaw and tongue claudication.
• Visual symptoms (amaurosis fugax, blurring and diplopia).
• Systemic symptoms of fever, weight loss, loss of appetite,
depression and tiredness.
• Polymyalgic symptoms.
• Limb claudication.
• Raised ESR, CRP, e.g. evidence of an acute-phase response
microcytic anemia should prompt the diagnosis of possible cancer and look for occult malignancy
Use FDG-PET/CT scan: Uptake in this test suggest large vessel vasculitis
What are the diagnostic criteria for Still’s disease?
See slide 40
Yamaguchi criteria (Need a total of 5 criteria, at least 2 major) Major (at least 2) 1. Fever of 39/102.2F for 1 wk 2. Arthralgia >2 wks 3. Skin rash (evanescent, salmon colored maculopapular) 4. Leukocytosis (>10,000) Minor 1. Sore throat 2. Lymphadenopathy 3. Hepatosplenomegaly 4. Abnormal LFT 5. Negative ANA and RF
Antisynthetase syndrome
Review slide 53
Presence of anti-synthetase antibodies in the setting of myositis and interstitial lung disease.
Negative ANA and positive anticytoplasmic suggest antisynthetase, most common autoantibody if Jo-1
Patients who are Jo-1 positive present with muscle or joint symptoms, whereas patients who are positive for a
non-Jo-1 antisynthetase present with pulmonary symptoms and Raynaud’s.
Antisynthetase syndrome
Anti-PL-12
Review slide 59
Gottron’s changes on knuckles, Raynaud’s, lung involvement and positive anti PL-12 antibodies
Study pictures of
- Raynaud’s scleroderma
- Gottron’s
- Mechanic’s hands
- Still’s rash
Sweet syndrome
Review slide 67
Characteristics . Koebner's phenomenon: Skin hypersensitivity to injury Rare skin condition • fever and leukocytosis • painful edematous and erythematous papules, plaques or nodules • Papillary dermal infiltrate of neutrophils • Seen with hematologic malignancies and systemic inflammatory conditions, RA, IBD, Behcet’s
