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DR HONEY SAVLA
DNB MEDICINE STUDENT
(1ST YEAR)
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.
• 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.
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
Stage 1
History taking:
• Occupation
• Personal history
• Exposure to animals
• Travel history
• Past medical history
• Family history
Fever patterns:
• Continuous
• Remittent
• Intermittent
• Tertian ( 48 hrs)
• Quotidian (24 hrs)
• Quartan (72 hrs)
• Saddle back
• Picket fence
Puo at aizawl hosp
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:
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
Laboratory investigations:
• Complete blood count
• Differential leukocyte count
• ESR/ CRP
• Electrolytes
• Microscopic urine analysis
• Cultures of blood & urine
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.
• 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.
Microscopy:
• Direct examination of blood smears: malaria,
trypanosomiasis ,babesia, leishmania, relapsing fever
rat bite fever, ehrlichiosis.
• Intra cellular organisms, bacteria, inclusion bodies,
protozoal amastigotes.
Imaging studies:
• GI contrast study
• High resolution spiral CT
• Arteriography
• Echocardiography
• Duplex imaging
Radionucleotide scanning:
• Flurodeoxy – PET scanning
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
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,
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
Puo at aizawl hosp
Stage 4
Therapeutic trials:
• Empirical treatment with corticosteroids or NSAIDS
or antimicrobials
• Antimycobacterial agents in AIDS & neutropenic
• Blind therapy- delay in correct diagnosis
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.
Puo at aizawl hosp

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Puo at aizawl hosp

  • 1. DR HONEY SAVLA DNB MEDICINE STUDENT (1ST YEAR)
  • 2. 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.
  • 3. • 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.
  • 4. 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
  • 5. Stage 1 History taking: • Occupation • Personal history • Exposure to animals • Travel history • Past medical history • Family history
  • 6. Fever patterns: • Continuous • Remittent • Intermittent • Tertian ( 48 hrs) • Quotidian (24 hrs) • Quartan (72 hrs) • Saddle back • Picket fence
  • 8. 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:
  • 9. 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
  • 10. Laboratory investigations: • Complete blood count • Differential leukocyte count • ESR/ CRP • Electrolytes • Microscopic urine analysis • Cultures of blood & urine
  • 11. 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.
  • 12. • 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.
  • 13. Microscopy: • Direct examination of blood smears: malaria, trypanosomiasis ,babesia, leishmania, relapsing fever rat bite fever, ehrlichiosis. • Intra cellular organisms, bacteria, inclusion bodies, protozoal amastigotes.
  • 14. Imaging studies: • GI contrast study • High resolution spiral CT • Arteriography • Echocardiography • Duplex imaging
  • 16. 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
  • 17. 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,
  • 18. 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
  • 20. Stage 4 Therapeutic trials: • Empirical treatment with corticosteroids or NSAIDS or antimicrobials • Antimycobacterial agents in AIDS & neutropenic • Blind therapy- delay in correct diagnosis
  • 21. 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.