PUO in a rural context Flashcards
Definition of PUO
Fever >38.3 on several occasions for more than 3 days (inpatient) or 3 clinic visits (outpatient), despite 3 weeks of study in hospital or despite 1 week of intelligent & intensive investigation
Types of PUO
- Infection: TB, infective endocarditis (subacute; strep viridans), intraabdominal abscess, HIV. think of RF e.g. dialysis, IVDU, pacing wires
- Inflammatory: vasculitis, SLE, granulamatous diseases (IBD, Sarcoidosis), Adult Still’s disease
- Malignancy: lymphoma, renal cell carcinoma, atrial myxoma
- Other: drug fever
Describe Q fever
- causative organism
- context
- Rx
Due to Coxiella burnetti
Farming context; cattle, sheep, goats, other domesticated animals etc
Treat with doxycycline
What do fever on alternate days indicate?
Established vivax malaria
What does relapsing fever indicate?
E.g. cyclic neutropaenia (21 days)
Pel-Epstein fever
Where does Staph tend to lodge?
Bones, joints, epidural abscess, heart valves
Days of antibiotics for:
- septic arthritis
- endocarditis
Septic arthritis: 2 weeks IV + 4 weeks oral (6 weeks total)
Endocarditis: 4 weeks IV (4 weeks total)
Is it uncommon to have a normal XR in septic arthritis or OM?
No. Commonly normal in EARLY days of OM/septic arthritis. Try MRI.
Osteopaenia as an early sign (due to non weight bearing from pain & cytokines)
What does low haptoglobin indicate?
Haemolysis
How would you Mx cholidocolithiasis with cholangitis?
ERCP, sphincterotomy (surgically drain it), ABx
A 18 yo male px with malaise, decreased physical endurance, pain in R hip, headache & fever while on holiday in Bega.
Febrile 40C, pain on weight bearing, no rash, no focal findings.
Hip XR is normal. ES 90, Gram positive cocci in blood cultures. The fever recurred at 6 hourly intervals in association with hip pain
Dx? What are the supportive Ix & Mx here?
Abscess in the hip
Subsequent Ix include: bone scan, hip aspirate, TTE & subsequent TOE.
Mx: repeated hip drainage, IV antibiotics.
A 53yo male px w/ malaise & fever for 3/52. No PMHx. Sx developed 3/12 following return from holiday in Cambodia.
Fever, rigors, hepatosplenomegaly, cervical lymph adenopathy, no rash.
Thick & thin blood smears normal, normal ICT rapid antigen test for P. falciparum, normal serology for Dengue fever.
CT shows some enlarged mediastinal lymph nodes. LN biopsy shows: loss of normal architecture, complete effacement by polymorphic cellular infiltrate, and areas of geographic necrosis.
High power shows Reed-Sternberg cell.
Dx?
Hodgkin’s lymphoma (anaplastic type)
A 21yo male previously well, px with febrile illness, fever, chills, severe shakes, headache, dry cough, dark brown urine in 1/12 on tour of camping safari near Alice Springs.
No rash, no eschar, no meningism, chest clear, no lymphadenopathy. abdomen SNT
Very high LDH, CK, creatinine. Blood film shows neutropaenia, macrocytes, no evidence of MAHA.
Dx?
Presumed Leptospirosis (but unlikely due to lack of animal exposure)
With further testing: CD16 negative on neutrophils. Dx: paroxysmal haemoglobinuria (PNH).
- Abnormal cells in urine are iron filled renal tubular cells
- Red cells (& other blood cells) lack a specific surface protein
- Now treatable with - Eculizumab (v v expensive)
Describe Leptospirosis
Etiology: L interrogans
Peak incidence: rainy season
Occupational & recreational exposures
Exposure: contact with animal urine (direct or indirect )
Portal of entry: abrasions or cuts on skin, conjunctiva
A 68 yo male px with malaise, fever, dark urine for 3/52. Australian born. Developed sx 3/12 following return from holiday in rural Phillipines.
O/E icteric, no rash.
MRCP shows a gall stone in the CBD.
Dx?
Choledocho-lithiasis with cholangititis
Expect the unexpected.
