Check PUO under clinical cases as well
Approach to the patient with fever
(Fever + inflammation) + /- infection
- Fever with infection
- Fever without infection
Does the patient have fever?
- Measured by an instrument
- Measured correctly
- Chart maintained
Approach to the patient with fever - history
- Type of fever
- Intermittent
- Remittent
- Continuous
- Duration
- Accompanying symptoms
- Respiratory
- Genitourinary
- Abdominal
- CNS
ØTravel
ØAnimal exposure (eg, pets, occupational, living on a farm)
ØImmunosuppression (with the degree noted)
ØDrug and toxin history, including exposure to agrochemicals
localising symptoms
●changes in behavior or cognition consistent with granulomatous meningitis
●jaw claudication consistent with giant cell arteritis;
●nocturia consistent with prostatitis
●Back ache consistent with UTI
Cough
Pain over thyroid => sub acute thyroiditis
Rash with fever => exanthems
Presence or absence of
- Respiratory tract
- GI Tract
- Urinary tract
- Biliary tract
Classification of fever
Intermittent – Intermittent fevers with a high spike and rapid defervescence to base line
Sustained – Sustained fevers persist with little or no fluctuation but can appear to be intermittent if antipyretic agents are administered
Remittent fevers are characterized by fluctuating peaks and a baseline that does not return to normal
Relapsing – Relapsing fevers with periods during which patients are afebrile for one or more days between febrile episodes
Investigations - to confirm clinical diagnosis
Investigations will be directed along localizing symptoms and signs
ØRespiratory tract – X-ray chest CT Chest, Bronchoscopy
ØUrinary tract : UFR, Urine culture. X ray KUB U/S abdomen
ØBiliary tract : U/S abdomen
....
- Fever with infection
- Fever without infection
can present with backpain at first and be treated with UTI and then later herpes zoster
Clamydia - lymphogranuloma venereum, psittacosis
Rikettsial infections - Q fever, Rocky Mountain spotted fever
Fungal - blastomycosis (nonpulmonary) , Histoplasmosis (disseminated)
Parasitis - malaria, toxoplasmosis, visceral larva migrans, leshmaniasis,
FEVER WITHOUT INFECTIONS
Malignancies
- Renal cell carcinoma
- Hodgkin's Lymphoma/ NHL /leukaemia
- Atrial myxoma
- Neuroblastoma
Connective tissue disorders (sero-positive)
- SLE
- Rheumatoid disease
- Systemic sclerosis
- Polymyositis Dermatomyositis
- MCTD
Seronegative arthropathies
- Ankylosing spondylitis
- Arthropathy associated with inflammatory bowel disease. ( UC and Chron’s disease)
- Reiter’s disease
- Psoriatic arthropathy
Vaculatidies
- Large vessel vasculitis( TA/ TA)
- Medium vessel vasculitis ( KA / PAN)
- Small vessel vasculitis ( GA / AGP/ MP )
Clots or thrombi at any source
Miscellaneous
- Drug fever /DRESS syndrome
- Factitious fever
- Familial dysautonomia
- Hemophagocytic lymphohistiocytosis
- Kikuchi-Fujimoto disease
- Periodic fever
- Serum sickness
- Thyrotoxicosis
DRESS syndrome
- Drug Rash/Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a distinct, severe, idiosyncratic reaction to a drug characterized by
- prolonged latency period ( 2-8 weeks after drug )
- Fever,
- rash,
- lymphadenopathy,
- eosinophilia, and a wide range of
- mild-to-severe systemic presentations is the major cause of morbidity and mortality in this syndrome. (hepatitis, pneumonitis, myocarditis, pericarditis, nephritis, and colitis)
Management : supportive with ? steroids
GO THROUGH VIRAL EXANTHEMS : https://www.slideshare.net/pedgishih/viral-exanthemsmodule
Management of fever
Management of a febrile child
ADD?
FUO/PUO - Pyrexia/fever of unknown origin
- Connective tissue diseases — 22 percent
- Infection — 16 percent
- Malignancy — 7 percent
- Miscellaneous — 4 percent
- No diagnosis — 51 percent
•Fever higher than 38.3ºC on several occasions
- Duration of fever for at least three week
- Uncertain diagnosis after one week of study in the
hospitals with (level 1 investigations )
another definition: Fever of unknown origin (FUO) is defined as fever at or above 101°F (38.3°C) for 3 weeks or more that remains undiagnosed after 3 days of in-hospital testing or during two or more outpatient visits
FUO- only if following fail to identify a cause for the fever ( Level 1 investigations )
- History
- Physical examination
- Complete blood count, including differential and platelet count
- Blood cultures (three sets drawn from different sites over a period of at least several hours without administering antibiotics)
- Routine blood chemistries, including liver enzymes and bilirubin
- Hepatitis serology (if liver tests abnormal)
- Urinalysis, including microscopic examination, and urine culture
- Chest radiograph
INVESTIGATIONS LEVEL 2
US scan
CT scan
Echo cardiography
Serology
Ø ANA
Ø ds DNA / rf
Ø HIV
Ø EB virus antibodies
Ø Brucellosis
Ø Melioidosis
Ø Hepatitis
Serum protein electrophoresis
Tuberculin test
INVESTIGATION LEVEL 3
CSF ANALYSIS
LYMPH NODE BIOPSY
BONE MARROW BIOPSY
LIVER BIOPSY
PLEURAL BIOPSY/ PERITONEAL BIOPSY
TEMPORAL ARTERY BIOPSY
Outcome
Rate of no diagnosis 9- 51%
In a study of 199 patients with FUO
61 were discharged without a diagnosis - 30%
Definite diagnosis became apparent in 12 ie - 5%
No diagnosis in the remaining 49 ( 25% )
Symptom free and recovered - 35
Continued to have fever - 8
Death 6
Management
- Empirical therapy with Broad spectrum antibiotics
- Therapy with anti TB medication
- If any CNS involvement anti viral therapy - aciclovior
- Steroid with of without antimicrobial therapy
Long case book
Casebook
CHECK PUO on theory lec (infectious diseases as well) .............................................
History
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Examination
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Investigations
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Management
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Discussion
Guide to Long Cases
Other casebook
