PUO Flashcards
define PUO
Durak definition
prescriptive set of mandatory ix
3 days of hospital Ix or 3 outpt apts
classic - most common
nosocomial - healthcare associated
causative agents different depending on whether got PUO from community or hospita;l
reasons for PUO
1/4-1/3 of PUI is infection
In most recent - the most common reason is no dx - because have more people with bad immune system so more cases of PUI with unknown origin
children more due to infection
causes of PUO in HIV pts
CD4 cell count dependent
high risk TB/NTM
PCP
cryptococcal meningitis
non-hodgekin’s lymphoma
causes of PUO in patients with neutropenia
underlying disease
fungal infection
hx for PUO
B-symptoms, localising symptoms
Medications - doses and initiation date
Contact history, pets / animal exposures
Injecting drug use, sexual history
Foreign travel - need to be specific
initial ix for PUO
stool OCP - ovum cysts and parasites
TFTs - thyroiditis can be a cause of PUO
Which would be the most useful test in confirming acute EBV infection
2 weeks after possible exposure in an immunocompetent patient
EBV IgM
Timeline for IgM going up or down - up by 2wks after infection, and stay up for 2more weeks and then come down
IgG - comes up by 2-3wks - sometimes takes 4 wks - then stays +ve for life.
what is a heterophile test
looks for something like EVB or CMV causing lymphocytes look weird
further ix for PUO if have good reason
- FDG-PET CT scan - radiolabelled glucose - show you anatomy and metabolism
- Echocardiogram - endocarditis, use Duke’s criteria - see who gets echo
- Biopsies
- Lumbar puncture
- Bone marrow aspirate
use of PET CT in PUO
-
Fluoro-D-Glucose accumulates in cells with an increased rate of glycolysis
– All activated leukocytes demonstrate increased FDG uptake - Allows metabolic correlation to anatomical scan
- Useful in endocarditis and vascular infections / inflammation
- Caution in those with poor glucose control
- Ensure patient fasted appropriately
use of echo for PUO
Duke’s criteria to see if need echo for IE:
* 2 major or 1 major + 3 minor criteria
* Major
* – Persistent bacteraemia (>2 BC pos)
* – Echocardiogram: vegetation
* – Positive serology for Bartonella, Coxiella or Brucella
- Minor
- – Predisposition (murmur, IVDU)
- – Inflammatory markers (fever , CRP high)
- – Immune complexes: splinters, RBCs in urine
- – Embolic phenomena: Janeway lesions, CVA
- – Atypical echo
- – 1 positive BC
which test is most useful for a patient from lebanon
brucella serology
what causes cryoglobinaemia
hep C
viral causes of PUO
– CMV / EBV
– HIV
– Hepatitis A,B,C,D,E
parastitic causes of PUO
– Malaria
– Amoebic liver abscess
– Schistosomiasis
– Toxoplasmosis
– Trypanosomiasis
inflammatory causes of PUO
autoimmune and primary inflammatory conditions have a high %
* Young patient = Adult onset Stills
* Older patient = GCA
* Involve rheumatologist
* Careful interpretation of results
what are the criteria for Adult onset Still’s
5 or more criteria including 2 or more major criteria
rash in adult onset stills
- Salmon Pink rash
- Can be mistaken for drug eruption / rash
- Ferritin often very high in Adult onset Stills → Macrophage activation
syndrome
miscellaneous causes of PUO
drugs
* 1/3 of patients suffer from adverse drug reactions - including drug fever
* idiosynchratic reaction or by affecting thermo reg
* eosinophiolia and rash accompany drug in only 25%
indications for urgent PUO rx before confirmation
