FUO


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Seyed Esmail    on Jan 27, 2012 Says :

thanks lot for your kind attention
anil    on Jan 23, 2012 Says :

NICE PRESENTATION ON PYREXIA OF UNKNOWN REGION
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1 : FUO Dr. S.Esmail Mogaddaspur IN THE NAME OF GOD
2 : Introduction Fever of Unknown Origin
3 : Terminology Old Definition Fever > 38.3oC (101 oF) on several occasions. Illness of more than 3 weeks’ duration. Uncertain diagnosis after 1 week of study in the hospital New Definition Classical FUO Nosocomial FUO Neutropenic FUO HIV-associated FUO
4 : Classical FUO 1. Fever = 38.3°C (>101°F) on several occasions 2. Duration = 2 to 3 weeks 3. Failure to reach a diagnosis despite 3 days appropriate in-hospital investigation or 3 outpatient visits
5 : Etiology Infection 30-50% Collagen vascular disease 10-20% Neoplasm 5-10% Miscellaneous 10-20% No diagnosis 10-25%
6 : USA India EUROPE Total
7 : Infections Bacterial Bacterial endocarditis Bartonella henselae Brucellosis Leptospirosis Liver abscess Mastoiditis (chronic) Osteomyelitis Pelvic abscess Perinephric abscess Pyelonephritis Salmonellosis Sinusitis Subdiaphragmatic abscess Tuberculosis Tularemia Intra-abdminal and Retroperitoneal Abscesses
8 : Infections Viral Cytomegalovirus Hepatitis viruses Epstein-Barr virus (infectious mononucleosis Fungal Blastomycosis (nonpulmonary) Histoplasmosis (disseminated Chlamydial Lymphogranuloma venereum Psittacosis Rickettsial Q fever Rocky Mountain spotted fever Parasitic Malaria Toxoplasmosis Visceral larva migrans
9 : Non Infectious Collagen vascular disease Juvenile rheumatoid arthritis Polyarteritis nodosa Systemic lupus erythematosus Malignancies Hodgkin disease Leukemia/lymphoma Neuroblastoma Unclassified Kawasaki disease Sarcoidosis FMF Miscellaneous Central diabetes insipidus Drug fever Ectodermal dysplasia Factitious fever Familial dysautonomia Granulomatous colitis Infantile cortical hyperostosis Nephrogenic diabetes Kidney Malacoplaquey Pancreatitis Periodic fever Serum sickness Thyrotoxicosis Ulcerative colitis
10 : The Most Common Causes Extra pulmonary TB Infectious Mono(EBV/CMV) HIV Abscess(Sp Intra abdominal & Retro peritoneal) Rheumatologic Disease Lupus Adult still`s Disease Granulomatous Disease Poly Myalgia Rheumatica Sarcoidosis Chron Granulomatous Hepatitis Temporal Arthritis Cancers (Lymphoma)
11 : In cases of over 6 month Usually Non Infectious causes Unknown 19% miscellaneous 13% Granulomatous Hepatitis 8% Neoplasm 7% still`s Disease 6% Infection 6%(Brucellosis, Coccidiomycosis, Malaria, TB) Collagen Vascular Diseases 4% FMF 3% No Real Fever after hospitalization 27% Common causes 9%
12 : Nosocomial FUO Hospitalized patient Fever = 38.3°C (>101°F) on several occasions Infection not present or incubating on admission(Usuly after 48 h of hospitalization) Diagnosis uncertain after 3 days despite appropriate investigations (including at least 48-h incubation of microbiological cultures)
13 : Causes of Nosocomial FUO Clostridium difficile ( Psudomembrane colitis) Drug induced(include blood Transfusion, withdrawals,..) Pulmonary embolism Septic thrombophlebitis (MAX) Sinusitis(ICU PATIONT) Infection in catheterization site Phlebitis UTI Prostatitis or Abscess formation , …. Surgical Site infection
14 : Allopurinol Captopril Cimetidine Clofibrate Erythromycin Heparin Hydralazine Hydrochlorothiazide Isoniazid Meperidine Methyldopa Nifedipine Nitrofurantoin Penicillin Phenytoin Procainamide Quinidine . Agents commonly associated with drug-induced fever
15 : Neutropenic FUO Less than 500 neutrophils mm3 or it will decrease to less than 500 in next 48 hours Fever = 38.3°C (>101°F) on several occasions Diagnosis uncertain after 3 days despite appropriate investigations (including at least 48-h incubation of microbiological cultures) Causes include Perianal infection, aspergillosis, candidemia ,Opportunistic bacterial infections ,Herpes Virus
16 : HIV-associated FUO Confirmed HIV infection Fever = 38.3°C (>101°F) on several occasions Duration of =4 weeks (outpatients) or =3 days in hospitalized patient Diagnosis uncertain after 3 days despite appropriate investigations (including at least 48-h incubation of microbiological cultures)
17 : CMV M. Avium / M. Intracellular TB PCP Drug induced Kaposi’s Sarcoma Lymphoma (non Hodgkin`s) CAUSES OF HIV FUO
18 : Clinical Evaluation of FUO Comprehensive history (Observation) Repeated physical examinations Investigations Diagnostic trial (Naproxen test)
19 : Observation Special attention to Identification(Age, Sex, Religion,..) Social history(habits, Economic condition, Job,…) Family History(Contact with infected or otherwise ill persons) Travel history (including place of residence), extending back to birth Site of travel Prophylactic medication & immunization. Measures taken to prevent exposure or contaminated food. Connect to pets,Domestics, Objects,… Past medical history(Surgery, hospitalization, drug history, underline diseases,…) Attention to fever pattern .
20 : Fever Patterns Intermittent (high spike & rapid defervescence )mostly in pyogenic infection but can see in tuberculosis, lymphoma, and juvenile rheumatoid arthritis) Remittent fluctuating peaks & baseline that does not return to normal .mostly in viral infection but can see (endocarditis, sarcoid, lymphoma and atrial myxoma) Sustained persist with little or no fluctuation (Typhoid fever, typhus, brucellosis)
21 : Fever Patterns Relapsing :afebrile for 1 or more days between febrile episode. (malaria, rat-bite fever, Borrelia infection, and lymphoma) Recurrent : recurrent episode of fever over a period of >6m. (cyclic neutropenia, hyperimmunoglobulin D syndrome, and deficiencies of selected interleukin receptor sites), and immunodeficiency states)
22 : Investigations CBC, Routine Blood Chemistry, LFT UA, U/C ESR, ANA, RF, CRP Blood culture Serologic testing for CMV, EBV, Bru,.. Stool examination, Stool C/S Anti HIV Tuberculin test, CMI PCR CXR, U/S, CT, Isotope Scan, MRI Echocardiogram GI Series or Endoscopic evaluations LP Lymph Nodes Bx Liver Bx BMA, Bone marrow Bx Less invasive More invasive Repeat Several times
23 : Physical Examination There is no difference in physical exam only : The Examination must be repeat, some times several times in one day Special attention to some sites include (skin, eyes, Nails, Lymph nodes, Abdomen, Heart,..) Some skin lesions appear later or remain only for shirt time like still dis. lesions Or Rose spots of typhoid fever Pay special attention to some parts of skin which are not in your visual site Pay attention to organomegaly & solid lesions Pay attention to color changes on skin & eyes
24 : DIAGNOSTIC IMAGING IN PATIENTS WITH FUO
25 : The Last steps Laparoscopy Laparotomy Autopsy
26 :
27 : Prognosis Determined by the cause of the fever and the nature of underlying disease or disease The time required to establish the diagnosis is less important Patients in whom FUO remains undiagnosed generally have a favorable outcome Most cases resolved spontaneously 5-year mortality rate for undiagnosed FUO was only 3.2%
28 : Empirical Therapy If There is no specific therapy Empirical Therapy recommended Empirical Therapy Can include NSAIDs Colchicin Steroids Broad Spectrum Antibiotics Anti TB
29 : Problems after Empirical Therapy Antiinflammatory medications or antibiotics generally should be avoided as diagnostic measures in children with FUO Antiinflammatory drugs do not help to distinguish fevers of infections from those of noninfectious causes. Empirical trials of broad-spectrum antibiotics can mask or delay the diagnosis of important infections such as meningitis, parameningeal infection, infectious endocarditis, or osteomyelitis.
30 : Erythma migrans uniform Malar erythmy in SLE
31 : Kawasaki conjunctivitis serum sickness
32 : CSD typical Papular lesion, systemic JRA rash
33 : Erythma migrans bulls eye tularemia Eschar
34 : Physical Examination Eye Palpebral conjunctivitis (viral infectious) Bulbar conjunctivitis (Kawasaki diseases) Ischemic retinopathy with hemorrhages and retinal detachment, ischemic optic neuropathy (PA ). Absence of the pupillary constrictor response Hypothalamic or autonomic dysfunction. Absent tears and corneal reflexes — Familial dysautonomia. (Riley-Day syndrome). Abnormal funduscopic examination.
35 : Physical Examination Sinuses : Chest ( pneumonia, infective endocarditis) Abdomen (Hepatic or splenic enlargement) Musculoskeletal Osteomyelitis Trichinellosis Dermatomyositis, or polyarteritis. Subdiaphragmatic abscess Hypo-hyperactive deep tendon reflexes
36 : Physical Examination Oropharynx  : Pharyngeal hyperemia without exudates (infectious mononucleosis). Dental abscess and other oral or facial infections Gingival hypertrophy or inflammation (lukemia) Genitourinary:
37 : Thanks

 

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