Pyrexia of Unknown Pyrexia of Unknown

OriginOrigin

PUOPUO

Prof. Nooruddin Prof. Nooruddin JafferJaffer

HCMD KarachiHCMD Karachi

PUO DefinitionPUO Definition

• Fever Persisting for more than 3 weeks.

• Documented Temp above 101 F Several Occasions.

• Uncertain diagnosis after extensive evaluation in hospital for . 1 week.

• PUO of 2 weeks no diagnosis could be made.

Approach to Patient of PUOApproach to Patient of PUO

Painstaking History:Painstaking History:

A- Chronology of Symptoms.

B- Occupational History.

C- Travel History.

D- Drug History.

E- Geographical History.

F- Past History

Pyrexia of Unknown Origin

Causes:

A. Infections.

B. Neoplastic Diseases.

C. Auto Immune Disease.

D. Hentable Diseases.

E. Granulamatous Disease.

F. Drug Fever.

G. Miscellaneous Causes.

1- Infections:1- Infections:A. Viral Syndrome

1. Cytomegalovirus.2. Epstein-Barr Virus (Mononucleosis)

3. HIV Infection.

B. Lyme Disease

C. Pyelonephritis or Urinary Tract Infection

D. Meningitis.

E. Pneumonia

F. Septicemia

G. Acute Sinusitis

H. Malaria

CausesCauses

I. Osteomyelitis.

J. Typhoid Fever or Enteric Fever

K. Subacute Bacterial Endocarditis (SBE)

L. Tuberculosis.

M. Liver or Biliary infection.

N. Abdominal or Pelvic abscess

O. Dental Abscess

P. Psittacosis

Q. Brucellosis

R. Tonsillitis or Peritonsillar Abscess

S. Herpes Simplex Virus

T. Streptococccosis

U. Gonococcal Arthritis

V. Prostatitis

2- Neoplastic Disease:2- Neoplastic Disease:

A. Leukemia

B. Lymphoma

C. Sarcoma

D. Carcinomatosis

E. Renal cell carcinoma

F. Colon Cancer

G. Pancreatic

H. Hepatoma

I. Metastic cancer

33- Autoimmune Disease:- Autoimmune Disease:

A. Juvenile Rheumatoid Arthritis (evanescent rash)

B. Henoch-Schonlein Purpura

C. Systemic Lupus Erythematosus

D. Rheumatic Fever (Migratory Polyarthritis)

E. Polymyalgia Rheumatica

F. Temporal Arteritis

G. Inflammatory Bowel Disease

H. Reiter’s Syndrome

44- Heritable Disease Causes:- Heritable Disease Causes:

A. Fabry’s Disease

B. Familial Mediterranean fever

C. Lamellar Ichthyosis

D. Nephrogenic Diabetes Insipidus

E. Anhydrotic ectodermal dysplasia

F. Familial Dysautonomia

5- Granulomatous Disease:5- Granulomatous Disease:

A. Sarcoidosis

B. Granulomatous Hepatitis

C. Inflammatory Bowel Disease 7- Miscellaneous:7- Miscellaneous:

A. Facticious Fever (Munchausen by proxy)

B. Thyroiditis

C. Neurogenic Fever

D. Milk Allergy

E. Behcet’s Syndrome

F. Anicteric Hepatitis

G. Pulmonary Embolism

H. Deep Vein Thrombosis

Drug-Induced FeverDrug-Induced Fever

1- Antibiotic Induced Fever:1- Antibiotic Induced Fever:

A. Erythromycin

B. Isoniazid

C. Penicillin

D. Nitrofurantoin

E. Procainamide

F. Quinidine

2- Cardiovascular Medication Induced Fever:2- Cardiovascular Medication Induced Fever:

A. Atropine

B. Captopril

C. Clofibrate

D. Hydralazine

E. Hydrochlorothiazide

F. Methyldopa

G. Nifedipine

33- Miscellaneous Medications Inducing Fever:- Miscellaneous Medications Inducing Fever:

A. Allopurinol

B. Antihistamines

C. Aspirin

D. Cimetidine

E. Heparin

F. Meperidine

G. Phenytoin

Physical Examination in PUOPhysical Examination in PUO

• Meticulous, repeated on regular basis.

• Temp Chart.

• Skin, Lymphnodes, Eyes, Nail Beds.

• CVS, Chest, Abd, Musculoskeletal Sys, CNS.

• Penis, Scrotum, Testes in males.

• Pelvic examination in female.

Thank You

Pyrexia of Unknown OriginPyrexia of Unknown Origin

1- Types:1- Types:

A. Pyrexia of Unknown Origin:A. Pyrexia of Unknown Origin:

1. Daily or Intermittent Fever >= 38.3 C (101F)

2. Duration for three consecutive weeks

3. No source by clinical evaluation a. Hospital evaluation for 3 days (previously 7) orb. Intensive outpatient evaluation for 7 days orc. Three outpatient visits

B. Nosocomial Fever or Unknown Origin:B. Nosocomial Fever or Unknown Origin:

1. Daily or Intermittent Fever >= 38.3 C (101F)

2. Hospitalized >1 day without fever on admission

3. Fever evaluation of 3 days of more

C. Immune-Deficient Pyrexia of UnknownC. Immune-Deficient Pyrexia of Unknown Origin:Origin:

1. Daily or Intermittent Fever >=38.3 C (101F)

2. Neutrophil count < 500 per mm3

3. Fever evaluation of 3 days of more

D. HIV-Associated Fever of Unknown Origin:D. HIV-Associated Fever of Unknown Origin:

1. Daily or Intermittent Fever >= 38.3 C (101F)

2. Outpatient Fever >4 weeks or

3. Inpatient fever >3 days

Infection Microbiactoxins Mediators of inflammation Immune Reaction

Monocytes / Macrophacites Endothelial Cells

Pyogenic Cytokines I L-1, I L-6, INF, IFN

Microbial Toxins

Hypothalamic Endotelium

PG E2

Cyclic AMP

Elevated Thermoregulator Set

Point

Heat Conservation Heat Production

Fever