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FEVER OF UNKNOWN ORIGIN

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FEVER OF UNKNOWN ORIGIN Dr. S. Aswini Kumar. MD. Professor of Medicine, Medical College Hospital, Thiruvananthapuram. HIV testing in FUO IV Generation Screening CD4 ... – PowerPoint PPT presentation

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Title: FEVER OF UNKNOWN ORIGIN


1
FEVER OF UNKNOWN ORIGIN
  • Dr. S. Aswini Kumar. MD.
  • Professor of Medicine,
  • Medical College Hospital,
  • Thiruvananthapuram.

2
Definition
Fever of unknown origin (FUO) was defined by
Petersdorf and Beeson in 1961 as temperatures
higher than 38.3C (101F) on several occasions,
a duration of fever of more than 3 weeks, and
failure to reach a diagnosis despite 1 week of
in-patient investigation.
3
New classification
  • Durack and Street have proposed a new system for
    classification of FUO
  • classic FUO,
  • nosocomial FUO,
  • neutropenic FUO, and
  • FUO associated with HIV infection

4
Classic PUO
This category corresponds closely to the earlier
definition of FUO , but the new definition is
broader, stipulating three outpatient visits or
3 days in the hospital without elucidation of a
cause or 1 week of "intelligent and invasive"
ambulatory investigation.
5
1. Diagnosis ?
  • A 50 year old man was admitted with fever of
    three weeks duration. On examination there was
    hepatosplenomegaly. Routine urine and blood
    examinations were normal. Widal test and Mantouex
    test were negative. Chest X-Ray and HIV were
    negative. Liver biopsy showed presence of
    granulomas

6
Granulomatous hepatitis
  • Systemic Sarcoidosis
  • Miliary tuberculosis
  • Lymphomas
  • Wegeners
  • Brucellosis
  • Histoplasmosis
  • Shistosomiasis

7
Liver Biopsy
  • To be cultured and retained
  • Mehngini/Vims/True cut needle

8
2. Diagnosis?
  • A 45 year old man was admitted to the CCU with
    acute MI, thrombolysed and reperfused, but then
    went into persistent hypotension following a
    cardiac arrest. He developed fever on Day5.
    Routine blood investigation showed a
    polymorpho-nuclear leucocytosis. Blood culture
    was diagnostic

9
Nosocomial FUO
In nosocomial FUO, a temperature of ³38.3C
(101F) develops on several occasions in a
hospitalized patient who is receiving acute care
and in whom infection was not manifest or
incubating on admission. Three days of
investigation, including at least 2 days'
incubation of cultures, is the minimum
requirement for this diagnosis
10
Nosocomial FUO
  • Post Myocardial infarction syndrome
  • Pulmonary thromboembolism
  • Occult Nosocomial infection
  • Transfusion related viral infections
  • Infected intra-vascular lines
  • Catheter related infections
  • Drug related fever

11
Blood Culture
  • Method
  • Rapid identification

12
3. Diagnosis?
  • A 30 year old farmer working in a diary farm in
    Tamilnadu was admitted to the ward with low grade
    fever and evening rise of temperature. On
    examination there was generalized lymphadenopathy
    and hepato-splenomegaly. Blood routine, Chest
    X-ray PA view Blood Widal test were negative

13
Systemic bacterial infections
  • Brucellosis
  • Typhoid fever
  • Leptospirosis
  • Campylobacter infection
  • Meningococcemia
  • Lymes disease
  • Legionaires disease

14
Serological Tests
  • Methadology
  • Widal Test

15
4. Diagnosis?
  • A 49 year old college Professor came with pain in
    the right loin and fever of one month duration.
    Loss of appetite and loss of weight were present.
    He was investigated for UTI. Repeated URE and
    urine cultures were negative. Renal angle was
    dull but non tender. CT scan of abdomen was
    diagnostic

16
Malignancies
  • Renal cell carcinoma
  • Pancreatic cancer
  • Cancer colon
  • Lymphoma
  • Leukemia
  • Hepatoma
  • Sarcoma

17
Ultra-sound scan in FUO
  • Look at
  • USS Abd in RCC

18
5. Diagnosis?
  • A 14 year old boy was admitted with high grade
    fever and pallor. On examination no
    hepatosplenomegaly, lymphadenopathy or bone
    tenderness were present. The blood counts were as
    follows Hb 8gm, TC 3800, P8 L86 E4 M2, ESR 20
    mm in 1st hr. Platelet count 2.5 lakhs, BT 130
    CT 330

19
Neutropenic FUO
Neutropenic FUO is defined as a temperature of
38.3C (101F) on several occasions in a patient
whose neutrophil count is lt500/L or is expected
to fall to that level in 12 days. The diagnosis
of neutropenic FUO is invoked if a specific cause
is not identified after 3 days of investigation,
including at least 2 days' incubation of cultures
20
Neutropenic FUO
  • Neutropenic patients are susceptible to focal or
    systemic infections
  • bacterial and fungal infections, bacteremic
    infections, infections involving catheters and to
    perianal infections.
  • infections due to HSV and CMV
  • consequences of untreated infections catastrophic

21
Bone Marrow studies
  • Yields
  • Bone marrow needle

22
6. Diagnosis?
  • A 55 year old woman presented with high grade
    remittent fever and severe pain in the right
    shoulder. No pallor/lymphadenopathy. Liver was
    palpable 8 cm below the costal margin. Soft and
    non tender. X ray chest and fluoroscopy showed
    elevated right hemi diaphragm with reduced
    movements

23
Pus somewhere
  • Pancreatic abscess
  • Pelvic inflammatory disease
  • Prostatic abscess
  • Tubo-ovarian abscess
  • Sub diaphragmatic abscess
  • Dental abscess
  • Liver abscess

24
CT Scan as a tool in FUO
25
7. Diagnosis?
  • A 19 year old girl was diagnosed to have
    infective endocarditis, because she had fever,
    pallor and systolic murmur. Repeated blood
    cultures were negative and she did not improve
    with antibiotics given for SBE. After 4 weeks she
    was skin and bones and still febrile. This time
    CXR was diagnostic

26
Bacterial Infections
  • Miliary tuberculosis
  • Pulmonary Tuberculosis
  • Tuberculous pleural effusion
  • Tuberculous pericarditis
  • Lung abscess
  • Bronchiectasis
  • Empyema

27
Chest X-Ray in FUO
  • Diagnosis from CXR
  • Encysted Empyema in CXR

28
8. Diagnosis?
  • A 25 year-old woman was admitted with a suspicion
    of rheumatic fever. A mid-diastolic murmur was
    audible to 4 out of 11 post graduate doctors in
    medicine who examined the case. ECG did not show
    RVH nor was there any straightening of the left
    border of heart in the chest X-ray PA view.

29
Cardiac Causes of FUO
  • Left atrial myxoma
  • Sub acute bacterial endocarditis
  • Prosthetic valve endocarditis
  • Aortic dissection
  • Tuberculous pericardial effusion
  • Chronic constrictive Pericarditis
  • Post myocardial infarction syndrome

30
ECHO in FUO
  • Diagnosis by ECHO
  • Vegetation in ECHO

31
9. Diagnosis?
  • A 45 year old man , who returned from Mumbai
    where he was working as a taxi driver for the
    past twelve years. He was admitted with low grade
    fever and cervical lymphadenopathy. He was
    undergoing treatment from various hospitals for
    irritable bowel syndrome since last six months

32
HIV associated FUO
HIV associated FUO is defined by a temperature
of 38.3C (101F) on several occasions over a
period of 4 weeks for outpatients or 3 days for
hospitalized patients with HIV infection. This
diagnosis is invoked if appropriate investigation
over 3 days, including 2 days incubation of
cultures, reveals no source.
33
Human Inmmuno Deficiency
  • HIV Infection as such
  • Pulmonary Tuberculosis
  • Pneumocystis Infection
  • Toxoplasmosis
  • Cytomegalovirus infection
  • M. Avium or M. Intracellulare
  • Non-Hodgkins Lymphoma

34
HIV testing in FUO
  • IV Generation Screening
  • CD4 counts and HIV RNA copies

35
10. Diagnosis?
  • A 15 year old boy was admitted with history of
    fever of seven days duration. Clinical
    examination showed a generalized maculopapular
    rash and generalized lymphadenopathy,
    hepatosplenomegaly. All the routine
    investigations for a underlying bacterial
    infection were found negative

36
Viral Infections
  • Infectious Mononucleosis
  • Hepatitis A B C D and E
  • Ebstein Barr virus infection
  • Cytomegalovirus infection
  • Parvovirus infection
  • Dengue hemorrhagic fever
  • Lymphocytic chorio-meningitis

37
Virology in FUO
  • Availability limitation
  • H1N1 Serology

38
11. Diagnosis?
  • A sixty year old man was admitted with history of
    fever, headache and vomiting. O/E neck stiffness
    was present. Initial CSF study showed 50cells P60
    L40. Repeat LP showed protein 45mg and sugar
    80mg. Patient did not improve much in spite of
    combined regimen with antibiotics and ATT

39
Fungal Infections
  • Cryptococcal meningitis
  • Aspergillosis
  • Blastomycosis
  • Candidiasis
  • Histoplasmosis
  • Mucormycosis
  • Sporotrichosis

40
CSF Study in FUO
  • Highly informative
  • Any time investigation

41
12. Diagnosis?
  • A 20 year-old college student ,while on an All
    India Tour on motor cycle , was involved in a
    road traffic accident and suffered from multiple
    fractures of the femur which necessitated
    multiple blood transfusions. He developed high
    grade fever with chills and rigor after one week

42
Parasitic Infections
  • Malaria
  • Amoebiasis
  • Leishmaniasis
  • P.carinii
  • Toxoplasmosis
  • Trichinosis
  • Strongiloidiasis

43
Peripheral Smear in FUO
  • Simple bed side test
  • Peripheral smear in Leukemia

44
13. Diagnosis?
  • A 14 year old girl was suffering from recurrent
    generalized seizures. She was put on
    Phenobarbitone and Dilantin sodium for the same.
    She had persistent low grade fever, but no lymph
    node enlargement or hepatosplenomegaly. Blood
    examination showed evidence of megaloblastic
    anemia

45
Drug fever
  • Gout
  • Hematoma
  • Haemolysis
  • Cirrhosis of liver
  • Pulmonary emboli
  • Subacute thyroiditis
  • Tissue infarction

46
Biochemical Tests in FUO
  • Function Tests
  • Blood Chemistry

47
14. Diagnosis?
  • A 30 year old police man came with recurrent
    episodes of abdominal pain and abdominal
    distension, loss of weight and loss of appetite.
    He had fistulectomy on 2 occasions. He was
    weighing only 32kg. Pallor . Abdomen was soft.
    No hepato-splenomegaly.Colonoscopy was diagnostic

48
Inflammatory Bowel Diseases
  • Crohns disease
  • Ulcerative colitis
  • Intestinal tuberculosis
  • Cholangitis
  • Cholecystitis
  • Mesenteric adenitis
  • Osteomyelitis

49
Tissue Biopsy in FUO
  • Biopsy specimens
  • Advaantages limitations

50
15. Diagnosis?
  • A 75 year-old man came with fever and headache of
    4 months duration. He had generalized body aches
    and pains.He was admitted to ophthalmic hospital
    one week before for complaints of sudden loss of
    vision in one eye. Routine investigations were
    negative except for a high ESR

51
Connective tissue disorders
  • Temporal arteritis
  • Adult Stills disease
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Poly-arteritis nodosa
  • Mixed connective tissue disease
  • Relapsing polychondritis

52
Collagen Work up in FUO
  • ANA Profile
  • Direct Immunoflourescence

53
16. Diagnosis?
  • A 45 year old lady came with generalized
    weakness, loss of weight and frequent loose
    stools. She always felt hot in her body and
    sweated excessively. Fine abnormal movements were
    present in the fingers. She had a fast heart rate
    which was out of proportion to her body
    temperature

54
Metabolic disorders
  • Hyperthyroidism
  • Central causes
  • Cerebrovascular accidents
  • Encephalitis
  • Brain tumor
  • Hypothalamic dysfunction
  • Pheochromocytoma

55
Endocrine Tests in FUO
  • Array of tests
  • Cover the system

56
17. Diagnosis?
  • A 19 year-old nursing student attending the OPD
    complained that she had high grade fever on
    several occasions in a a day for past four weeks.
    She was unable to attend the ward examinations
    during this period because of the persistent
    fever. In between the fevers she was apparently
    healthy

57
Factitious fever
  • Habitual hyperthermia
  • Maliganant Hyperthermia
  • Neuroleptic Malignant Syndrome
  • Afebrile FUO (lt38.3oC)
  • Exaggerated circadian rhythm
  • Hysterical Fever

58
Habitual hyperthermia
59
Conclusions
60
Thank You for the patient listening
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