PYREXIA OF UNKNOWN ORIGIN (PUO)

HPIM PG 236 C
NTOP PG 1767 C
 EXAM Q MEDICINE

LONG SHORT
• PYREXIA OF UNKNOWN ORIGIN
(PUO)
• Define
• Types
• Causes
• D/D
• Investigations
• Approach
 FEVER WITHOUT A FOCUS
NTOP PG 1767 C

• SOLE PRESENTING FEATURE

• Rectal temp ≥ 38℃ (100.4℉)

• SUBCATEGORIES
• Fever w/o Localizing Signs
• Fever of Unknown Origin (FUO)
 FEVER OF UNKNOWN ORIGIN (FUO)
HPIM PG 236 C

• PROLONGED FEBRILE ILLNESSES

• W/O Established Etiology
• Despite Intensive Evaluation & Diagnostic testing
• ORI DEF BY PETERSDORF & BEESON IN 1961
• Illness > 3 weeks’ duration
• Fever of ≥ 38.3℃ (101℉)
• On 2 Occasions
• Diagnosis Uncertain despite 1 week of Inpt evaluation
 DEF NOW
HPIM PG 236 C
• Fever > 38.3°C (101°F)
• On at least 2 occasions
• Illness duration of ≥ 3 weeks
• Diagnosis remains Uncertain after Thorough
• History-taking
• Physical examination
• Obligatory investigations
• Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)

• Hb
• TLC & DLC
• Platelet count

• Creatinine, Electrolytes

• Alanine aminotransferase, Aspartate aminotransferase

• Alkaline phosphatase, Lactate dehydrogenase

• Antinuclear Ab, Rheumatoid factor, Tuberculin skin test (TST)

• Blood cultures, Urine cultures
• Chest X-ray, Abdominal ultrasonography
• Creatine kinase, Ferritin, Protein electrophoresis, Urinalysis
• No known Immunocompromised state
ETIOLOGY W EPIDEMIOLOGY
HPIM PG 237 C
 ALAGAPPAN
• DURACK & STREET CLASSIFICATION
• CLASSICAL
• E.G. Abscess, Endocarditis, Lymphoma, TB, Viral inf
• HIV-RELATED
• E.G. CMV, Cryptococcus, NHL, Pneumocystis jiroveci, TB, Toxoplasma
• HOSPITAL-ACQUIRED/NOSOCOMIAL
• NO fever on admission
• Cathether inf, Drug fever, Thrombophlebitis, Transfusion reac
• IMMUNOCOMPROMISED/NEUTROPENIC
• Absolute neutrophil count < 500
• Fungal inf

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 ALAGAPPAN
• CAUSES : Infections Can Make Undergraduates Die
• Infection (20-40%)
• Tuberculosis
• Infective endocarditis
• Epstein-Barr virus (EBV)
• Cytomegalovirus (CMV)
• Connective tissue disorders (20%)
• Rheumatoid arthritis
• Systemic Lupus Erythematosus
• Adult-onset Still’s disease
• Malignancy (10-20%)
• Lymphoma
• Leukaemia
• Hepatocellular carcinoma
• Undiagnosed (20%)
• Drugs (e.g. Phenytoin) (Rare)
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 D/D
HPIM PG 237 C

• DICTUM
• FUO
• MORE OFTEN DUE TO ATYPICAL PRESENTATION OF COMMON DISEASE
• RATHER THAN BY VERY RARE DIEASE
 INVESTIGATIONS
ALAGAPPAN

IMPORTANT INVESTIGATIONS
ESR-PLATELET CORRELATION
ESR > 100 mm/hr + Thrombocytosis • TB
• Malignancy
ESR > 100 mm/hr - Thrombocytosis • Viralinf
↑ ALKALINE PHOSPHATASE (ALP)
BLOOD CULTURE
SEROLOGICAL TESTS • Brucellosis, Enteric fever, HIV
• Hepatitis, Q-fever, Syphilis

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 FEVER/PYREXIA OF UNKNOWN ORIGIN
IMPORTANT INVESTIGATIONS
IMAGING TECHNIQUES
PLAIN X-RAY CHEST • Miliary TB
• Mottling < 0.5 mm NOT detected
CONTRAST FILMS • Barium meal in IBD
ULTRASOUND • Excellent imaging in thin
• DETECTABLE SOL
• > 1 cm in Hepatobiliary tree
• > 2 mm Endocarditic vegetation
CT SCAN • Excellent imaging in obese also
• DETECTABLE SOL
• > 1 cm in Liver
• > 0.2 cm CNS lesions
MRI • BEST
BONE MARROW STUDY
CSF STUDY

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 APPROACH TO THE PT
HPIM PG 239 C

• FIRST-STAGE DIAGNOSTIC TESTS

• LATER-STAGE DIAGNOSTIC TESTS

• READ UP FROM HPIM IF GOT TIME

 TREATMENT
HPIM PG 242 C

• AVOID EMPIRICAL THERAPEUTIC TRIALS W

• Antibiotics
• Antituberculous agents
• Glucocorticoids

• EXCEPT WHEN
• Pts cond rapidly deteriorating
• Diagnostic tests failed to provide definite diagnosis

• ANTIBIOTICS & ANTITUBERCULOUS THERAPY

• COLCHICINE, NONSTEROIDAL ANTI-INFLAMMATORY DRUGS, GLUCOCORTICOIDS

• ANAKINRA
ANTIBIOTICS & ANTITUBERCULOUS THERAPY
COLCHICINE, NONSTEROIDAL ANTI-INFLAMMATORY DRUGS, GLUCOCORTICOIDS
ANAKINRA