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  1. 1. PUO By Dr Osman Sadig Bukhari
  2. 2. <ul><li>General consideration - average normal oral body temp taken in </li></ul><ul><li>mid morning is 26.7 C (36-37.4) </li></ul><ul><li>- rectal temp 0.5 C higher than oral and </li></ul><ul><li>axillary is 0.5 C lower </li></ul><ul><li>- there is diurnal variation of 0.5-1.0 C in </li></ul><ul><li>normal body temp, lowest in the early morning & highest in the evening </li></ul><ul><li>- slight rise following ovulation & during </li></ul><ul><li>menstruation </li></ul>
  3. 3. <ul><li>- body temp is regulated hypothalamic regulatory centres - Fever is the rise of body temp </li></ul><ul><li>- monocyte- macrophages when stimulated </li></ul><ul><li>release pyrogenic cytokines ( IL1 & 6, </li></ul><ul><li>TNF, interferon gamma) </li></ul><ul><li>- elevation of body temp results from either </li></ul><ul><li>increased heat production (e.g shivering) </li></ul><ul><li>or decreased heat loss (vasoconstriction ) </li></ul><ul><li>- fever may be constant, remittent, intermittent </li></ul><ul><li>- specific patterns of fever occur in malaria, </li></ul><ul><li>relapsing fever, brucellosis & Hodgkin’s </li></ul>
  4. 4. <ul><li>- fever is an important symptom of disease sp infections </li></ul><ul><li>- degree of temp elevation does not necessarily corresponds to the severity of the illness - hyperthermia is not mediated by cytokines and occurs when metabolic body heat production or enviromental heat load exceed normal heat loss capacity or when there is impaired heat loss. It causes irreversible protein denaturati and results in brain damage </li></ul><ul><li>- heat stroke, neuroleptic malig syndrome and </li></ul><ul><li>malig hyperthermia of anaethesia. </li></ul>
  5. 5. <ul><li>Prolonged fever ( FUO or PUO) </li></ul><ul><li>- most febrile illnesses are due to infections, short lived & relatively easy to diagnose, BUT </li></ul><ul><li>the origin of fever may remain obscure despite </li></ul><ul><li>protracted diagnostic examinations i.e. PUO </li></ul><ul><li>- PUO is defined as fever exceeding 38.3 C on several occasions persisting for >2 weeks with no clear diagnosis after a week of hospital investigations; patients with HIV or other immunosuppressing conditions are usually excluded from this definition </li></ul>
  6. 6. <ul><li>Causes of PUO include: </li></ul><ul><li>Depend on geographic locality </li></ul><ul><li>- infections: pyogenic abscess, Tuberculosis, brucellosis, endocarditis, viral infections. </li></ul><ul><li>Infections with neutropenia include typhoid, </li></ul><ul><li>brucellosis & visceral leishmaniasis. </li></ul><ul><li>- autoimmune diseases (collagen) </li></ul><ul><li>- malignancies (renal, hepatic, lymphomas, </li></ul><ul><li>leukaemias) - miscellaneous ( drugs, DVT and PE, thyrotoxicosis, factitious, IBS, liver granulomas, sarcoidosis, FMF - undiagnosed in 5-25% </li></ul>
  7. 7. <ul><li>Approach to the patient with PUO </li></ul><ul><li>- detailed history including travel history , occup, medications & recent surgery together with clinical examination is essential, taking into account possible causes , and examination should be repeated on regular basis looking for new signs. - Confirm objective evidence of raised temp. - Previous investigations are reviewed </li></ul><ul><li>- Routine lab tests and blood cultures provide important diagnostic clues that lead to a definite diagnosis in most cases. </li></ul><ul><li>- investigations are guided by the history and </li></ul><ul><li>abnormalities on examination. </li></ul>
  8. 8. <ul><li>- Some investigations should be repeated, sp </li></ul><ul><li>cultures </li></ul><ul><li>- CXR </li></ul><ul><li>- Imaging: US, Echo, CT, MRI & radionuclide scanning can all help in establishing a diagnosis </li></ul><ul><li>- Sputum & bronchoscopy for microbiological </li></ul><ul><li>and histological examination </li></ul><ul><li>- biopsies of the liver & bone marrow may be </li></ul><ul><li>useful </li></ul><ul><li>- serology </li></ul>
  9. 9. <ul><li>Treatment </li></ul><ul><li>- Only symptomatic should be given until </li></ul><ul><li>a diagnosis is made. </li></ul><ul><li>- Treatment of PUO is that of the underling cause. </li></ul><ul><li>- No place for blind antibiotic or empirical C/S therapy. </li></ul>