PUO Flashcards
What criteria define the classic PUO? Give 3 aetiologies
Temp >38.3
>3w
>,3 OP evaluations/ >,3d IP
Infection, Malignancy, Collagen vascular disease
What criteria define the nosocomial PUO? Give 3 aetiologies
Temp >38.3
Patient hospitalised >24h but no fever or incubating on admission
>,3d evaluation
C. diff enterocolitis, Drug induced, PE
What criteria define the immune deficient PUO? Give 4 aetiologies
Temp >,38.3
Neutrophils ,<500/mm3
>,3d evaluation
Opportunistic bacterial infections, Aspergillosis, Candidiasis, HSV
What criteria define the HIV-associated PUO? Give 3 aetiologies
Temp >38.3
>4w OP / >3d IP
HIV+
CMV, Mycobacterium avium complex, PCP
What is the trend in the number of patients with no identified diagnosis presenting with PUO? Why?
Increasing
Ageing populaiton
Development of immunosuppressive drugs
Increasingly survivable chronic conditions
How does PUO differ with geographic trends?
European: 11-26% due to infectious cause
India: 55% due to infectious cause
What broad causes predominate in children with PUO?
Infection 44%
No diagnosis 43%
Which 7 features should not be missed in taking a PUO history?
B-Sx
Localising Sx
DH: doses + initiation
Contact hx, Pets, Animal exposure
IVDU
Sexual hx
Travel, accommodation + activities abroad
Give 5 example risk activities that should be enquired about in PUO
White water rafting: water borne pathogens
Caving: bat poo
Safari: Tick bites
Prostitutes: STIs
Medical elective: sick contacts
Give 6 aspects of examination in PUO
Head to toe
Fundoscope: infective endocarditis
ENT: oral thrush- HIV seroconversion
Erythema migraines: Rickettsias
Thump Spine: many infections have predilection for vertebrae
Temporal artery palpation: Temporal arteritis
What 7 basic investigations may be taken in A+E for PUO?
FBC
U+Es
LFT
CRP
Urine dip
Blood cultures
CXR
What is the most useful test to confirm EBV infection 2 weeks after exposure in an immunocompetent patient?
EBV IgM
Rises in 1-2w, stays high for 2-4w, then decreases
What does and FDG-PET CT scan show?
Radiolabelled glucose accumulates in hyper metabolic cells (infection, inflammation, malignancy)
Identifies focus (doesn’t determine cause)
Which criteria is used in diagnosing infective endocarditis? Give the 3 major criteria
Duke’s criteria
Persistent bacteraemia >2 BC +ve
Echo: vegetation
+ve serology for Bartonella, Coxiella or Brucella
Give the 6 minor criteria in Duke’s criteria
Predisposition (murmur, IVDU)
Inflammatory markers (Fever, CRP high)
Immune complexes: splinters, RBCs in urine
Embolic phenomena: Janeway lesions, CVA
Atypical echo
1 +ve BC
When suspecting an infective cause of PUO, what blood tests do you request?
Rare + Imported Pathogens Laboratory bloods (RIPL)
What go to inflammatory cause of PUO should be considered in young patients and old patients?
Young: Adult-onset Stills
Old: GCA
What are 4 major criteria of adult-onset stills disease?
Temp >39 for >1w
Leukocytosis >10,000
Salmon pink rash
Arthralgias >2w
What measurement may be high and help diagnose adult onset Stills disease?
Serum ferritin
Due to macrophage activation syndrome
What is adult onset stills disease?
Rare inflammatory arthritis
Monophonic, Intermittent or Chronic
Give 5 minor criteria for adult onset stills disease
Sore throat
Lymphadenopathy
Splenomegaly/ hepatomegaly
Abnormal LFT
ANA + RF -ve
Give 3 investigations for GCA
High ESR + CRP
Duplex US
Temporal Artery Biopsy (GS)
How should suspected GCA be treated?
High dose glucocorticoids STAT e.g. Prednisolone
Involve rheumatology
Give 4 malignant causes of PUO
Lymphoma esp. non Hodgkins
Leukaemia: BM biopsy
Renal cell carcinoma +/- haematuria
Hepatocellular carcinoma/ liver mets
Why is PUO in lymphoma a difficult diagnosis?
Often advanced disease with aggressive subtype
Presentation overlaps with infectious causes e.g. TB
Raised LDH, weight loss, lymphadenopathy
Give a miscellaneous cause of PUO
Drug fever (ADR)
Idiosyncratic reaction / affect on thermoregulation
+/- Eosinophilia
+/- rash
Give 5 causes of PUO which warrant urgent treatment pre-confirmation
Infective endocarditis
Disseminated TB
CNS TB
GCA
Sepsis
Give 3 features raising suspicion of infective endocarditis and 3 investigations
New cardiac murmur
Splinter haemorrhages
Hx of valvular pathology /IVDU
BC
Echo
Serology for Brucella, Bartonella, Q fever
Give 4 features raising suspicion of disseminated TB and 4 investigations
Weight loss
Drenching night sweats
Cough
Travel/ time spent in endemic region
Mycobacteria BC
Sputum culture for acid-fast bacilli
HIV test
CXR
Give 3 features raising suspicion of CNS TB and 3 investigations
Headaches
Reduced level of consciousness
Travel/ time spent in endemic region
Cerebral MRI/ CT with contrast
LP
HIV test
Give 3 features raising suspicion of GCA
Unilateral headache
Jaw claudication
Scalp tenderness
Polymyalgia rheumatica
Visual loss
ESR
Temporal artery biopsy
Visual acuity assessment
Give 4 features raising suspicion of sepsis. What investigations/ management is necessary?
Resp rate >20
SBP <100
HR > 90
Altered mental status
Blood cultures
Urine output: measure- catheter
Fluids
Abx
Lactate
O2
