Download - Puo at aizawl hosp
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PYREXIA OF UNKNOWN ORIGIN
DR HONEY SAVLA
DNB MEDICINE STUDENT
(1ST YEAR)
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Pyrexia of Unknown Origin (PUO)
Definition:
by Petersdorf and Beeson in 1961
“Temperature higher than 38.3°C (101°F) on atleast two occasions ,
persisting without diagnosis for at least 3 weeks,
no known immunocompromised state,
Diagnosis that remains uncertain after a thorough history taking physical
examination and obligatory investigations.
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• Obligatory investigtions include• Esr,crp,platelet count,tlc,hb,electrolytes• Creatinine,total proteins,alkaline
phosphate,alt,ast,ldh,ck,ferritin,ANA,RF,• Protein electrophoresis• Urine analysis• Blood culture (3 times)urine culture,cxr• Usg,skin test.
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Approach to patient with PUO
• Stage 1: Careful history taking, physical examination and screening tests
• Stage 2: Review the history, repeating physical examination, specific diagnostic tests & non invasive investigations
• Stage 3: Invasive tests• Stage 4: Therapeutic trials
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Stage 1
History taking:
• Occupation
• Personal history
• Exposure to animals
• Travel history
• Past medical history
• Family history
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Fever patterns:
• Continuous
• Remittent
• Intermittent
• Tertian ( 48 hrs)
• Quotidian (24 hrs)
• Quartan (72 hrs)
• Saddle back
• Picket fence
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Body site Physical finding diagnosis
Head Sinus tenderness sinusitis
Temporal artery nodules & reduced pulsation
Temporal arteritis
oropharynx ulceration Disseminated Histoplasmosis
Tender tooth Periapical abscess
Fundi / conjunctiva Choroid tubercle Disseminated granulomatosis
Petechiae, Roth’s spots Infective endocarditis
Thyroid thyroid enlargement Thyroididtis
Physical examination:
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Heart murmur myxomas, endocarditis
Abdomen Enlarged lymph nodes , splenomegaly
lymphomas., disseminated granulomatosis
Rectum Perirectal tenderness Abcess
Prostatic tenderness Abcess
Lower limbs deep vein tenderness DVT & thrombophlebitis
Skin & nail Petechiae, splinter hemorrhages, subcutaneous nodules, clubbing
Vasculitis, endocarditis
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Laboratory investigations:
• Complete blood count
• Differential leukocyte count
• ESR/ CRP
• Electrolytes
• Microscopic urine analysis
• Cultures of blood & urine
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Stage 2• Review history & repeat physical examination
• Specific investigations
• Repeat sampling of blood & other body fluids.
• Skin tests
• Blood for antibodies – HIV antibodies, CMV
antibodies, EBV antibodies.
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• Serological tests for toxoplasmosis, psittacosis and
rickettsial infections, syphillis.
• Serology for rheumatologic disorders like antinuclear
and antineutrophilic cytoplasmic antibodies,
rheumatoid factor
• Quatiferon TB Gold in tube and T spot TB – detects
ϒ interferon release.
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Microscopy:
• Direct examination of blood smears: malaria,
trypanosomiasis ,babesia, leishmania, relapsing fever
rat bite fever, ehrlichiosis.
• Intra cellular organisms, bacteria, inclusion bodies,
protozoal amastigotes.
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Imaging studies:
• GI contrast study
• High resolution spiral CT
• Arteriography
• Echocardiography
• Duplex imaging
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Radionucleotide scanning:
• Flurodeoxy – PET scanning
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Stage 3
• Biopsy of liver and bone marrow
• Lymph node biopsy
• Blind biopsy of 1 or both temporal artery in
patient > 50 yrs
• Exploratory laparotomy
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MANAGEMENT
• Therapy withheld until cause is found
• Empirical corticosteroids or anti inflammatories in
temporal arteritis.
• Vital sign instability & neutropenia –
Fluoroquinolones + piperacillin,
vancomycin + ceftazidime/cefepime/
carbapenem with or without aminoglycoside,
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Management of Nosocomial PUO:
• Change of IV lines, catheters
• Empirical treatment:
Vancomycin for MRSA
Broad spectrum Gram negative coverage
Piperacillin + tazobactum
Ticarcillin + clavulinic acid
Meropenem
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Stage 4
Therapeutic trials:
• Empirical treatment with corticosteroids or NSAIDS
or antimicrobials
• Antimycobacterial agents in AIDS & neutropenic
• Blind therapy- delay in correct diagnosis
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PROGNOSIS
• Poorest prognosis - elderly & malignant
• Delay in diagnosis affects prognosis of
intraabdominal infections, miliary tuberculosis,
disseminated fungal infections & recurrent
pulmonary emboli
• Undiagnosed PUO for prolonged duration – good
prognosis.
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THANK YOU