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Infection > Pyrexia of unknown origin > Flashcards

Pyrexia of unknown origin Flashcards

1
Q

Define fever [3]

A
  • elevation of body temp above normal (37 degrees)

- variation of up to 0.8 degrees daily (circadian rhythm): low in morning high in evening

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2
Q

Pyrogens
2 types and give examples of each
Pathogenesis in 1 sentence

A

Substances causing fever

  • endogenous eg cytokines
  • exogenous eg endotoxins from Gram -ve bacteria
  • act at hypothalamic thermoregulatory centre to cause reduced heat loss and hence fever
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3
Q

Petersdorf and Beeson diagnosis of fever? (from 1961) [5]

A

-temp >38.3 degrees
-recorded on multiple occasions
-present for at least 3 outpatient visits
or
-3 days in hospital
or
- 1w outpatient investigation

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4
Q

What are the different variations of pyrexia of unknown origin (PUO)? [4]

A
  • Classical PUO
  • Nosocomial PUO (develops in hospital, undiagnosed after 3 days)
  • Neutropenic PUO (undiagnosed fever in patient with neutrophils <500/mm3)
  • HIV associated PUO (fever in patient with HIV - present and undiagnosed for >3d in inpatient or 4 wks in outpatient)
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5
Q

What are the most common causes of HIV associated PUO? [3]

A
  • Mycobacterium tuberculosis
  • Mycobacterium avium
  • unknown
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6
Q

Is it common for classical PUO to be undiagnosed? What percentage of cases goes undiagnosed?

A

yes - around 25%

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7
Q

Give some examples of infections causing PUO? [4]

A
  • TB
  • HIV
  • Endocarditis
  • Abdominal abscess
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8
Q

Give examples of malignancy causing PUO? [3]

A
  • lymphoma
  • metastatic disease
  • renal cancer
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9
Q

Give examples of inflammatory diseases causing PUO? [4]

A
  • GCA
  • IBD
  • SLE
  • Vasculitis
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10
Q

Other non-specific causes of PUO include…

[3]

A
  • Drug fevers
  • venous thrombosis
  • sarcoidosis
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11
Q

In a patient history what is important to cover? [5]

A
  • travel
  • occupation and hobbies (allergen exposure)
  • FH and age onset - familial fevers eg TNF receptor associated periodic syndrome - TRAPS
  • PMH and surgical history
  • DH
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12
Q

In examining patient what should you be sure to cover? [5]

NB Repeating exam often worthwhile

A

skin, eyes, oral cavity, nails and LN.

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13
Q

What are initial investigations of PUO? [6]

A
  • CXR
  • urinalysis and urine microscopy
  • FBC and differential WCC
  • CRP and ESR
  • Blood cultures
  • Urea, creatinine, electrolytes, LFTs
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14
Q

If the following indications are found:

  • tropical travel [3]
  • new murmur [1]
  • headaches [2]
  • micro haematuria [3]
  • TB contact [3]
  • drug misuse [1]

What further investigations should be made?

A

> Tropical: Blood for malarial parasites. Unlikely to be dengue if >21 days since return. Bone marrow biopsy for leishmaniasis
Murmur: Echocardiograph (trans-oesophageal)
Headaches: TA biopsy or CT PET
Micro-haematuria: auto-antib., renal biopsy (polyarteritis) USS (renal Ca)
TB: sputum smear, bone marrow, mantoux test
drug misuse: screen for blood borne viruses

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15
Q

name some imaging techniques involved in investigating PUO? [4]

A
  • CT
  • PET CT
  • ultrasound
  • isotope scanning
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16
Q

Discuss some invasive investigations used in diagnosing PUO [2]

A
  • tissue biopsy for culture and histology eg bone marrow, liver, TA biopsy
  • diagnostic laparotomy (rarely necessary)
17
Q

Discuss treatment which can be implemented in some PUO cases?
NB-unlikely to be correct diagnosis if there is a lack of response to treatment

A
  • Anti-TB treatment (if mycobacterial infection suspected)

- Steroids (vasculitis or conn. tissue disorder)

18
Q

Discuss features of fabricated fever

A
  • real fever but is self induced
  • self injection of feces common
  • patients often continues despite being sick
19
Q

2 modes of mx - fabricated fever

A
  • microbiology may be strongest clue (multiple different organisms on blood culture at different times)
  • psychiatric expertise needed
20
Q

Describe the patterns of intermittent fever and what they indicate [5]

A

 Daily spikes: abscess, TB, schistosomiasis
 Twice daily spikes: leishmaniosis
 Saddleback fever
 Longer periodicity: Pel-Ebstein (lymphoma)
 Remitting (diurnal variation; not dipping to normal):

21
Q

What is saddleback fever? [5]

What are causes of remitting fever? [6]

A

E.g. fever for 7d, normal for 3d
- Borrelia, Leptospirosis, Legionnaire’s, Dengue

Remitting fever:
- amoebiasis, malaria, salmonella, Kawasaki, CMV, TB

22
Q

Causes of generally intermittent fever [4]

A
  • malaria, filarial fever, brucellosis
  • sepsis, UTI, PID
  • infective endocarditis
  • amyloid

Infection (20 decks)

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