University Of Baghdad College of Medicine Dept. Of Pediatrics 5th Year Infectious Diseases Module

1. University Of Baghdad
College of Medicine
Dept. Of Pediatrics
5th Year
Infectious Diseases Module

2. LEARNING OBJECTIVES
1- Be able to understand the main clinical presentations of PUO
2- Be able to formulate a differential and provisional diagnoses.
3- Plan a panel of investigations according to the suspected
diagnosis .
4- Decide the plan of treatment.

3. DEFINITION
• FUO (Fever of unknown origin): Fever documented by a health care
provider and for which the cause could not be identified after 3 wk of
evaluation as an outpatient or after 1 wk of evaluation in the hospital.

4. between 5 and 15% of FUO cases defy diagnosis, despite exhaustive studies.

5. CAUSES
1- Infections:
Bacterial
Systemic: Brucellosis, Salmonella, Tuberculosis
Localized infections: Osteomyelitis, Pneumonia and Sinusitis
Viruses: CMV, Hepatitis viruses ,HIV, IM (Epstein-Barr virus)
Parasitic Diseases: Malaria ,Toxoplasmosis
Fungal diseases

6. CAUSES
2- Rheumatologic diseases
JRA, Rheumatic fever, SLE and drug fever.
3- Neoplasms
Leukemia, Lymphoma, other malignancies.
4- Miscellaneous
Familial Mediterranean fever, Kawasaki disease.
5- Undiagnosed

7. HISTORY
Fever specifications, sweating, antipyretics use and response, appearance,
other complaints (CNS, urinary,,,,), pain (severity, site), rash and
distribution, arthralgia / arthritis, travel, contact, animals, medications,
hospitalization, immunizations, ethnicity, exposure to contaminated food
or water.

8. CAREFUL PHYSICAL EXAMINATION
General appearance and vital signs (heart rate, pressure, respiratory,
temperature), pallor, jaundice, clubbing, skin and scalp, eyes, sinuses,
oropharynx, LN, abdomen, musculoskeletal, genitourinary.

9. INVESTIGATIONS
Level 1:
CBC differentials, ESR, CRP, metabolic panel
(RFT, LFT, elects), GUE, stool, C/S, LP, CXR,
US, TB, EBV, CMV, cultures.

10. INVESTIGATIONS
Level 2:
Echo, CT, Bone scan, Serology,
Autoimmune, Bone marrow

11. INVESTIGATIONS
Level 3:
Tissue biopsy, Endoscopy

12. Treatment
in general,
NONE
Until diagnosis

13. Infections
Oncology
Rheumatology

14. Hints
As the duration of fever increases, infectious etiology decreases
Malignancy and factitious fever should be considered with more prolonged
fever
The most critical features of the evaluation of a patient with FUO is to
take a carefully history and to reassess the patient frequently.
The Best Approach is “there is no substitute for observing the patient,
talking to him and thinking about him”

15. Hints
It is important to look for uncommon presentation of common disease and
to perform a detailed physical examination
Clinically challenging - get expert help! Clinical balance between trial
antimicrobial (often anti tuberculosis regimen) or corticosteroid trial.
avoid indiscriminately ordering a large battery of tests.

17. Approach

18. Complete history
and physical
examination
Positive findings: Order appropriate and specific
diagnostic tests
Negative findings
CBC, ESR, LFT,
GUE, Culture,
Blood culture,
Skin PPD, CXR,
US, Muscle
enzymes ,,,
Positive: Order
appropriate and
specific diagnostic
tests and manage
accordingly
Negative results
CT chest,
abdomen and
pelvis with
contrast

19. Assign to most
likely diagnosis
Infection
Autoimmune disease
Urine, sputum
culture, AFB, HIV,
CMV, EBV
serology, LP, Echo
BMA, BMA, LN
biopsy, Liver
biopsy,
colonoscopy
Malignancy
ASO, RF, ANA,
muscle biopsy, skin
biopsy

20. After full work up
for PUO
Empirical therapy
Diagnosis
Anti Tb,
Antimicrobial,
NSAID
Watchful waitingNo diagnosis
Treatment

21. Task
1- Intra abdominal abscess
History: Seven-year old male, PUO, Swinging in nature,
with non specific localizing abdominal pain and a prior
history of appendicitis.
Physical examination: Febrile, Right iliac fossa mass
Order relevant investigations and outline treatment
accordingly.

22. Task
2- Pulmonary tuberculosis
History: Eleven-year old male, PUO, cough, Weight loss,
father have chronic undiagnosed cough.
Physical examination: Febrile, cachectic, no LAP,
bronchial breathing in the right upper zone.
Order relevant investigations and outline treatment
accordingly.

23. Task
3- Bacterial endocarditis
History: Three-year old boy, PUO, known case of
congenital heart disease (Ventricular septal defect),
Physical examination: Febrile and heart murmur.
Order relevant investigations and outline treatment
accordingly.

24. Task
4- Urinary tract infection
History: Seven-month old female, recurrent fever and
diarrhea, failure to thrive, repeated episodes of vomiting
Physical examination: Febrile, wasted,
Order relevant investigations and outline treatment
accordingly.

25. Task
5- Osteomyelitis
History: Three-year old female, PUO, limping, tenderness
in the right lower thigh.
Physical examination: Febrile, toxic, swelling and
tenderness in the lower right thigh.
Order relevant investigations and outline treatment
accordingly.

26. Task
6- Brucellosis
History: Ten-year old girl, PUO, drenching sweating,
history of ingestion of diary product, back pain
Physical examination: Febrile, sweating
Order relevant investigations and outline treatment
accordingly.

27. Task
7- Kala-azar
History: Three-year old female, from Diyala, PUO,
abdominal distension, poor appetite.
Physical examination: Febrile, organomegaly
Order relevant investigations and outline treatment
accordingly.

28. Task
8- Mononucleosis
History: Nine-year old girl, PUO, bilateral cervical
swelling, sore throat.
Physical examination: Febrile, cervical LAP, exudative
tonsillitis.
Order relevant investigations and outline treatment
accordingly.

29. Task
9- HIV
History: Four-year old girl, recurrent fever, recurrent
infections, skin rash (ecchymoses), mother is on regular blood
transfusion
Physical examination: Febrile, pneumonia, organomegaly, wasted
Order relevant investigations and outline treatment
accordingly.

30. Task
10- Leukemia
History: Four-year old girl, PUO, abdominal distension,
cervical swelling, skin rash (ecchymosis)
Physical examination: Febrile, pallor, generalized LAP,
petachial rash and ecchymoses, hepatosplenomegaly.
Order relevant investigations and outline treatment
accordingly.

31. Task
11- Lymphoma
History: Four-year old girl, PUO, weight loss, sweating
and abdominal distension
Physical examination: Fever, pallor, abdominal mass
Order relevant investigations and outline treatment
accordingly.

32. Task
12- Juvenile Rheumatoid Arthritis
History: Thirteen-year old girl, PUO, small joints
swellings, skin rash.
Physical examination: Febrile, joint swellings,
maculopapular skin rash
Order relevant investigations and outline treatment
accordingly.

33. Task
13- Drug fever
History: Four-year old girl, recurrent fever, case of
undiagnosed fever on multiple drugs intake
Physical examination: Febrile,
Order relevant investigations and outline treatment
accordingly.

34. Task
14- Factitious fever
History: Five-year old girl, fever, non plausible
manifestations, after a period of legitimate disorder,
mother is a medical staff.
Physical examination: Febrile.
Order relevant investigations and outline treatment
accordingly.

35. Task
15- Toxoplasmosis
History: Seven-year old male, PUO, low grade with
painless cervical swelling. History of raising pets at home.
Physical examination: Febrile, unilateral cervical LAP.
Order relevant investigations and outline treatment
accordingly.

36. Thank you