fever of unknown origin
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on May 14, 2010 Says :
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Slide 1 :
Fever of Unknown Origin------------------------------------- Dr.Hanmantha Rao Mole PGY2
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FUO In 1961, Petersdorf and Beeson introduced the definition that subsequently became standard , illness of more than 3-week duration, fever higher than 38.3C on several occasions, diagnosis uncertain after 1 week of study in hospital
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FUO The revised criteria (Durack and Street) require an evaluation of at least 3 days in the hospital, three outpatient visits, or 1 week of logical and intensive outpatient testing without determining the fever’s cause
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FUO Infections (30-40%) neoplasms (20-30%) collagen vascular diseases (10-20%) miscellaneous diseases (15-20%) The literature also reveals that between 5 and 15% of FUO cases defy diagnosis, despite exhaustive studies.
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Bacterial- abscess Hx of surgery Hx of trauma Hx of endoscopy Hx gyneacological procedure Hx diverticulosis
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Bacterial- abscess common locations subphrenic space, liver, right lower quadrant, retroperitoneal space, female pelvis
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Bacterial-Tuberculosis TB of the kidney or mesenteric lymph nodes Disseminated visceral infections with atypical mycobacteria Chest radiography - may be normal. Results (PPD) tests may be negative, culture findings may not become positive for 4-6 weeks.
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Bacterial- Endocarditis This is now a rare cause of FUO Failure to diagnose endocarditis absence of a murmur or the failure of blood cultures to yield the organism Culture-negative endocarditis is reported in 5-10% of endocarditis cases. Prior antibiotic therapy is the most common reason for negative blood cultures.
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Bacterial - Rickettsia Chronic infections with Coxiella burnetii chronic Q fever, and Q fever endocarditis transmitted from cattle and sheep. Perform serologic tests in suspected cases
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Bacterial- Chlamydia Chlamydia psittaci infection, the cause of psittacosis Lymphogranuloma venereum history of contact with birds Diagnosis by serology
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Systemic bacterial illnesses Brucellosis fever contact with cattle, swine, goats, sheep hx of consume raw milk products. systemic infections with Salmonella Neisseria meningitidis Neisseria gonorrhoeae
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Bacterial -Hepatobiliary infections: Cholangitis Cholecystitis Gallbladder empyema
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Bacterial- Osteomyelitis This usually causes localized pain or discomfort The most common reason for misdiagnosis of osteomyelitis is the failure to consider the disease in a patient who is febrile with musculoskeletal symptoms. Radionucleotide studies , MRI are more sensitive than plain radiography
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Bacterial- Rickettsia chronic Q fever, and Q fever endocarditis have been identified in patients with FUO is transmitted from cattle and sheep hepatic involvement serologic tests are diagnostic
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Bacterial-Chlamydia Chlamydia psittaci infection causes psittacosis contact with birds Diagnosis by serology
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Bacterial-Spirochetal diseases relapsing fever.-Borrelia recurrentis transmitted my ticks. Rat-bite fever (Spirillum minor) Lyme disease (Borrelia burgdorferi) syphilis (Treponema pallidum)
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Collagen vascular and autoimmune diseases Collagen vascular and autoimmune diseases can manifest as FUO if the fever precedes other more specific manifestations (eg, arthritis, pneumonitis, renal involvement). Systemic-onset JRA is a cause of FUO High-spiking fevers, nonpruritic rashes, arthralgias and myalgias, pharyngitis, and lymphadenopathy , lab abnormalities-leukocytosis, an elevated (ESR), anemia, and abnormal liver function tests PAN, RA, and mixed connective-tissue diseases
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Granulomatous diseases Sarcoidosis: multiorgan involvement, ,rarely manifests as fever and malaise without evidence of lymph node and pulmonary involvement. Erythema nodosum is occasionally present, Crohn disease :Diarrhea and other abdominal symptoms are occasionally absent, particularly in young adults. Granulomatous hepatitis :fever, hepatomegaly, asthenia, and, sometimes, arthralgias and myalgias. An elevated alkaline phosphatase level is the most consistent laboratory abnormality.
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Drug fever beta-lactam antibiotics, procainamide, isoniazid, alpha-methyldopa, quinidine, and diphenylhydantoin. When suspecting drug fever, discontinue the implicated drug. Stopping the causative drug generally leads to defervescence within 2 days
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Inherited diseases In patients of Mediterranean descent with FUO, familial Mediterranean fever is most often the cause. Recurrent febrile episodes at varying intervals are associated with pleural, abdominal, or joint pain due to polyserositis. Diagnosis – Genetic testing
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Endocrine disorders Hyperthyroidism Subacute thyroiditis Adrenal insufficiency
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Neoplasms Lymphomas: Hodgkin and non-Hodgkin lymphomas frequently cause fever, night sweats, and weight loss. The correct diagnosis can be delayed -retroperitoneal lymph nodes Leukemias: Acute leukemias. Solid tumors: renal cell carcinoma is most commonly associated with FUO, with fever being the only presenting symptom in 10% of cases. Hematuria may be absent in approximately 40% of cases, whereas anemia and a highly elevated sedimentation rate are common. Malignant histiocytosis: This is a rare rapidly progressive malignant disease that manifests as high fevers, weight loss, enlarged lymph nodes, and hepatosplenomegaly.
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