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Systems: Infection AB > Pyrexia of Unknown Origin > Flashcards

Pyrexia of Unknown Origin Flashcards

1
Q

What is a normal temperature?

A

37C

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2
Q

Fever

A

Elevation of body temperature above normal 37C

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3
Q

What response is fever part of?

A

The systemic inflammatory response (SIRS)

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4
Q

How does temperature vary throughout the day?

A

Variation of up to 0.8C daily (circadian rhythm)

  • Low in the early morning
  • High in the early evening
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5
Q

Pyogenes

A

Substances which cause fever

  • Endogenous e.g. cytokine
  • Exogenous e.g. endotoxins from gram negative bacteria
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6
Q

How do pygogenes cause fever?

A

They act at the hypothalamic thermoregulatory centre to cause reduced heat loss and hence fever

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7
Q

How is pyrexia of unknown origin defined?

A

Fever with no diagnosis after:

  • 3 outpatient visits or
  • 3 days in hospital or
  • 1 week of outpatient investigation
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8
Q

Nosocomial PUO

A

Pyrexia which develops in hospital and is undiagnosed after 3 days

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9
Q

Neutropenic PUO

A

Undiagnosed fever in a patient with neutrophils <500mm^3

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10
Q

HIV associated PUO

A

Fever in a patient with HIV infection which is present and undiagnosed for more than 3 days in an inpatient stay or 4 weeks as an outpatient

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11
Q

Causes of classical PUO

A
  • Infection
  • Malignancy
  • Inflammatory
  • No diagnosis
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12
Q

What bacteria are commonly involved in HIV related PUO?

A
  • Mycobacterium tuberculosis
  • Mycobacterium ovium
  • Unknown
  • More than 1 causative agent
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13
Q

What history should be taken in PUO?

A
  • Travel
  • Occupation
  • Hobbies
  • Family history
  • Past medical and surgical history
  • Drug history
  • Pattern of fever
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14
Q

What examination should be carried out when assessing PUO?

A

Repeated examination is often worthwhile

  • Skin
  • Eyes
  • Oral cavity
  • Lymph nodes
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15
Q

What initial investigations should be carried out for PUO?

A
  • Chest X-Ray
  • Urinalysis and urine microscopy
  • Full blood count and differential white cell count
  • C-Reactive Protein and Erythrocyte Sedimentation Rate
  • Blood cultures taken at times of fevers
  • Urea, creatinine, electrolytes, liver function tests
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16
Q

What investigations should be carried out if there is tropical travel in the history?

A

-Blood for malarial parasites, Dengue and HIV
-Bone marrow for leishmaniasis
(It is likely if >21 days since return)

17
Q

What investigations should be carried out if there is a new heart murmur?

A

-Echocardiography (TOE may be required)

18
Q

What investigations should be carried out if there is a history of headaches?

A

Temporal artery biopsy

19
Q

What investigations should be carried out if there is micro haematuria?

A
  • Auto-antibodies +/- renal biopsy (polyarteritis)

- Ultrasound (renal cancer)

20
Q

What investigations should be carried out if there is a history of TB contact?

A
  • Sputum smear
  • Bone marrow
  • Mantoux
21
Q

What investigations should be carried out if there is a history of drug misuse?

A

Screen for blood-borne viruses

22
Q

What are the limitations of imaging in PUO?

A
  • Only valuable if directed
  • Cannot always differentiate between infection and inflammation
  • Anatomical changes may not develop in immunocompromised hosts (e.g. neutropenic patients and abscess)
23
Q

What invasive investigations may be carried out for PUO?

A
  • Obtaining tissue for culture and histology
  • Bone marrow and liver are often examined as part of blind investigation (malignancy, TB, lymphoma)
  • Diagnostic laparotomy (rarely necessary)
24
Q

How is PUO treated?

A

Therapeutic trial

  • Rare
  • Can be used for suspected mycobacterial infection (unlikely if no response within 2 weeks)
  • Can be used for suspected vasculitis or connective tissue disorder (steroids)
  • Response of temporal arteritis to steroids is usually within 48 hours
25
Q

What is a fabricated fever?

A

Self-induced fever

26
Q

How should fabricated fever be treated?

A

Psychiatric expertise is best

27
Q

What are the possible outcomes of PUO?

A
  • Spontaneous resolution of PUO commoner in young compared with old patient
  • Some patients with no diagnosis respond to NSAIDs or steroids (steroid responsive PUO)
  • Regular re-appraisal required (The answer may not become apparent for many months)

Systems: Infection AB (12 decks)

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