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Pyrexia of UnknownPyrexia of Unknown
OriginOrigin
Ahmed Alwassief, MDAhmed Alwassief, MD
Alazhar UniversityAlazhar University
PRE-TESTPRE-TEST
 The commonest cause of PUO is:The commonest cause of PUO is:
a)a) A common disease presenting in an atypical way.A common disease presenting in an atypical way.
b)b) A rare disease presenting in atypical way.A rare disease presenting in atypical way.
c)c) A common disease presenting typically.A common disease presenting typically.
d)d) A rare disease presenting typically.A rare disease presenting typically.
What is a PUO?What is a PUO?
1956 Age > 14
T > 37.4°C x3 or 38°C x1
Fever - predominant symptom
Insufficient symptoms / signs to localise
1961 Days > 21, T > 38.3°C
1/52 hospital investigation
1968 Days > 14
No clear diagnosis
Reid
Petersdorf
& Beeson
Dechovitz
& Moffet
What is a PUO now?What is a PUO now?
Now
+
2 hospital visits, or
Hospital investigations for 3 days
Neutropenic
PUO
Neutrophils < 1000
Diagnosis not clear at 3 days
Nosocomial
PUO
Admission infection screen negative
Diagnosis not clear at 3 days
HIV PUO HIV infected, fever for 4 weeks
Diagnosis not clear after 3 days
AetiologyAetiology
1.1. InfectionsInfections
2.2. MalignanciesMalignancies
3.3. Connective tissue disordersConnective tissue disorders
4.4. Endocrinal causesEndocrinal causes
MalignanciesMalignancies
 20 -25%% of all PUO Are much more common20 -25%% of all PUO Are much more common
in adultsin adults
 (40 vs. 10%).(40 vs. 10%).
 Either because of infection or cytokinesEither because of infection or cytokines
 Most commonly:Most commonly:
 LymphomaLymphoma
 LeukaemiaLeukaemia
 NeuroblastomaNeuroblastoma
 Sarcomas and HepatomasSarcomas and Hepatomas
} 80% of malignancies with PUO
Who should have a BMA?Who should have a BMA?
1.1. Patients with suggestive blood film / count orPatients with suggestive blood film / count or
other evidence pointing to Leukaemia /other evidence pointing to Leukaemia /
LymphomaLymphoma
2.2. Culture for TB, Salmonella, LeishmaniaCulture for TB, Salmonella, Leishmania
Infection frequenciesInfection frequencies
 Infectious mononucleosis (EBV or CMV)Infectious mononucleosis (EBV or CMV) (up to 20%)(up to 20%)
 Other viruses (NB. measles, hepatitis, HIVOther viruses (NB. measles, hepatitis, HIV (up to 15%)(up to 15%)
 UTIUTI (up to 15%)(up to 15%)
 PneumoniaPneumonia (up to 10%)(up to 10%)
 Various URTIsVarious URTIs (up to 10%)(up to 10%)
 Endocarditis (Staph. Strep. HACEK, Bruce, Cox, Rick)Endocarditis (Staph. Strep. HACEK, Bruce, Cox, Rick) (up to 5%)(up to 5%)
 TuberculosisTuberculosis (up to 5%)(up to 5%)
 StreptococcosisStreptococcosis (up to 5%)(up to 5%)
 Bartonella (cat scratch disease)Bartonella (cat scratch disease) (up to 5%)(up to 5%)
 Meningitis / para meningeal abscessMeningitis / para meningeal abscess (up to 5%)(up to 5%)
 Enteric infection (Salmonella, Yersinia)Enteric infection (Salmonella, Yersinia) (up to 5%)(up to 5%)
 MalariaMalaria (up to 1%)(up to 1%)
 BrucellaBrucella (up to 1%)(up to 1%)
 HSV (generalised but occult)HSV (generalised but occult) (up to 1%)(up to 1%)
Could it be TB?Could it be TB?
 YesYes
Infectious mononucleosisInfectious mononucleosis
 Diagnosis is made byDiagnosis is made by EBV PCR on blood (EDTA)EBV PCR on blood (EDTA)
 Support is offered bySupport is offered by
 Atypical lymphocytes (a late finding, in some)Atypical lymphocytes (a late finding, in some)
 Heterophile antibodies (IgM binding sRBCs)Heterophile antibodies (IgM binding sRBCs)
 IgM antibodies to EBVIgM antibodies to EBV
 Other causes includeOther causes include
 CMV, Toxoplasma, HIV, Rubella, Hep AB, HHV678CMV, Toxoplasma, HIV, Rubella, Hep AB, HHV678
Infective EndocarditisInfective Endocarditis
1.1. Is there a risk factor?Is there a risk factor?
2.2. Is there a new murmur?Is there a new murmur?
3.3. Is there a BC positive for Staph or viridansIs there a BC positive for Staph or viridans
Strep?Strep?
4.4. 5-10% of IE have negative BCs5-10% of IE have negative BCs
1.1. Because of antibiotics orBecause of antibiotics or
2.2. Fastidious organisms (HACEK) orFastidious organisms (HACEK) or
3.3. Aspergillus, Bart, Bruce, Cox, Rick, Mycobacteria,Aspergillus, Bart, Bruce, Cox, Rick, Mycobacteria,
Noca, Chlamydia, viruses…Noca, Chlamydia, viruses…
Rheumatology and PUORheumatology and PUO
 10-20% of cases in most series10-20% of cases in most series
 More recently, RA, SLE , vasculitis (PAN, Behcet, WG)More recently, RA, SLE , vasculitis (PAN, Behcet, WG)
& Sarcoidosis& Sarcoidosis
Endocrine causes for PUOEndocrine causes for PUO
 HyperthyroidismHyperthyroidism
 Occasionally cause PUO → most frequently diagnosedOccasionally cause PUO → most frequently diagnosed
clinically.clinically.
 Often accompanied by weight loss.Often accompanied by weight loss.
 No local neck pain and typically enlarged non-tender thyroid.No local neck pain and typically enlarged non-tender thyroid.
 AdrenalAdrenal
 Rare, potentially fatal, but eminently treatable cause of PUO.Rare, potentially fatal, but eminently treatable cause of PUO.
 primary adrenal insufficiency, secondary adrenal insufficiencyprimary adrenal insufficiency, secondary adrenal insufficiency
and pheochromocytomaand pheochromocytoma
 Consider if: nausea/vomit, ↓weight, ↓BP, ↓Na & ↑K.Consider if: nausea/vomit, ↓weight, ↓BP, ↓Na & ↑K.
How to solve the problemHow to solve the problem
 HistoryHistory
 Physical examinationPhysical examination
 Blood testsBlood tests
 ImagingImaging
 Endoscopy and tumour markersEndoscopy and tumour markers
HistoryHistory
 Fever: Pattern, periodicity, how was it measuredFever: Pattern, periodicity, how was it measured
 Associated symptoms such as sweating, vomiting,Associated symptoms such as sweating, vomiting,
headaches etc.headaches etc.
 Target specific organ systems if patient has problems inTarget specific organ systems if patient has problems in
that systemthat system
 Past med and surg hx.Past med and surg hx. NB prostheses in situNB prostheses in situ
 Medications/ vaccinesMedications/ vaccines
 Family hx of hereditary diseases, connective tissueFamily hx of hereditary diseases, connective tissue
disorders or recent illnesses (TB/ AIDS)disorders or recent illnesses (TB/ AIDS)
 Sexual historySexual history
 Occupation, pets, travelOccupation, pets, travel
ExaminationExamination
 Full physical examination is needed. Should be veryFull physical examination is needed. Should be very
detailed and review all systems.detailed and review all systems.
 For exams make sure to examine:For exams make sure to examine:
 Hands for stigmata of infective endocarditisHands for stigmata of infective endocarditis
 Retinal exam for candidiasis or toxoplasmosisRetinal exam for candidiasis or toxoplasmosis
 Teeth (infective endo or abscess)Teeth (infective endo or abscess)
 Lymphadenopathy (AIDS or chronic infections)Lymphadenopathy (AIDS or chronic infections)
 Hepatosplenomegaly (Lymphoma/leukaemia)Hepatosplenomegaly (Lymphoma/leukaemia)
 Breast/testicular examsBreast/testicular exams
 Any sore jointsAny sore joints
 Priority (arrival)Priority (arrival) Sutton's lawSutton's law:: “Look where the money is!”“Look where the money is!”
 Urinalysis and cultureUrinalysis and culture unless it is on the list,unless it is on the list,
 Blood cultureBlood culture it won’t get doneit won’t get done
 Throat swabThroat swab
 Catheter sample cultureCatheter sample culture
 FBC (and film)FBC (and film)
 CRP (and ESR)CRP (and ESR) (if the blood flows, take it)(if the blood flows, take it)
 PCR for virusesPCR for viruses Could it be ‘flu?Could it be ‘flu?
 Stool cultureStool culture Salmonella?Salmonella?
Investigations (step 1)Investigations (step 1)
 By days 5-7, if any focal signs or symptoms appeared, follow them.By days 5-7, if any focal signs or symptoms appeared, follow them.
 Carefully record antimicrobial prescriptionsCarefully record antimicrobial prescriptions
 Do anything missed from step 1 and organise:Do anything missed from step 1 and organise:
 CXRCXR occult pneumoniaoccult pneumonia
 LPLP occult meningitisoccult meningitis
 Repeat BCRepeat BC yield risesyield rises
 ASOTASOT Streptococcosis is commonStreptococcosis is common
 CoagulationCoagulation abnormalities will direct invabnormalities will direct inv
 FerritinFerritin massive elevation helpfulmassive elevation helpful
 Serum to be savedSerum to be saved acute serologyacute serology
 Request BMARequest BMA If haem abnormalIf haem abnormal
 US AbdomenUS Abdomen
Investigations (step 2)Investigations (step 2)
 By days 10-14, if no diagnosis is reached and not already done:By days 10-14, if no diagnosis is reached and not already done:
 ANA, dsDNA, C3, C4, ENA, Cardiolipin, RFANA, dsDNA, C3, C4, ENA, Cardiolipin, RF 20% risk20% risk
 Lupus anticoagulantLupus anticoagulant (if clotting abnormal)(if clotting abnormal)
 ECG, ECHO, converse with cardiologyECG, ECHO, converse with cardiology 1-5% risk1-5% risk
 Mantoux TBMantoux TB 1-5% risk1-5% risk
 CT of any suspect regionCT of any suspect region
 Brain, Chest, Abdo, ENTBrain, Chest, Abdo, ENT
 Bone scan for pelvic, skeletal osteomyelitisBone scan for pelvic, skeletal osteomyelitis 5% risk5% risk
 Serology for HIV, other microbes and save serumSerology for HIV, other microbes and save serum
Investigations (step 3)Investigations (step 3)
 By day 21,By day 21,
 Review everything again…Review everything again…
 TFTsTFTs
 CT abdomen (regardless of signs)CT abdomen (regardless of signs)
 Biopsy of abnormal tissue, inc:Biopsy of abnormal tissue, inc:
 LNsLNs
 GutGut
 SkinSkin
 (Liver)(Liver)
 Define immune status of child (call the immunologist)Define immune status of child (call the immunologist)
 Stop drugs, if startedStop drugs, if started
 Wait for clues.Wait for clues.
Investigations (step 4)Investigations (step 4)
HIV/ AIDSHIV/ AIDS
 No classical presentation. Can present withNo classical presentation. Can present with
fever, weight loss, sweats, lymphadenopathy orfever, weight loss, sweats, lymphadenopathy or
with opportunistic infectionwith opportunistic infection
 Hx: Sexual contacts, Birthplace, Maternal hx ifHx: Sexual contacts, Birthplace, Maternal hx if
child, Exposure events, occupationchild, Exposure events, occupation
 O/E Full exam. Lymph nodes and spleenO/E Full exam. Lymph nodes and spleen
 Ix: HIV antibody test and HIV viral load, CD4Ix: HIV antibody test and HIV viral load, CD4
countcount
 Mx: Refer to ID team. HAARTMx: Refer to ID team. HAART
ManagementManagement
 Determine if critically ill. If not can hold off onDetermine if critically ill. If not can hold off on
antibioticsantibiotics
 Don’t feel need to just treat a temperatureDon’t feel need to just treat a temperature
 Clue is in the history and the exam and thenClue is in the history and the exam and then
order relevant tests. Do not send randomorder relevant tests. Do not send random
serological tests off. Often these will cause moreserological tests off. Often these will cause more
trouble then you want!!!trouble then you want!!!
Returning TravellerReturning Traveller
 Very common problemVery common problem
 Geosentinel data reviewGeosentinel data review
 of 25,000 ill returning travellersof 25,000 ill returning travellers
 28% had fever and 26% of these needed admission28% had fever and 26% of these needed admission
 Malaria was the most common diagnosisMalaria was the most common diagnosis
 Considerable geographical variationConsiderable geographical variation
 17% had vaccine preventable diseases17% had vaccine preventable diseases
 Will discuss methods of diagnosing theWill discuss methods of diagnosing the
condition and not each disease in detailcondition and not each disease in detail
Treatment
Therapeutic trials in classic FUO
Therapeutic trails are seldom diagnostically rewarding and tend
to obscure rather than to illuminate.
Symptomatic:
-NSAID
Therapeutic trail to be considered in case of deterioration
* Antibiotics
Broad spectrum antibiotics: stop if no improvement after 3 days.
- Consider adding tetracyclines (or macrolides)
*Antituberculosis therapy:
strongly consider in case of clinical deterioration.
*Corticosteroids
• Do not start too early
• Consider adding antituberculosis therapy.
Pyrexia of unknown origin

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Pyrexia of unknown origin

  • 1. Pyrexia of UnknownPyrexia of Unknown OriginOrigin Ahmed Alwassief, MDAhmed Alwassief, MD Alazhar UniversityAlazhar University
  • 2. PRE-TESTPRE-TEST  The commonest cause of PUO is:The commonest cause of PUO is: a)a) A common disease presenting in an atypical way.A common disease presenting in an atypical way. b)b) A rare disease presenting in atypical way.A rare disease presenting in atypical way. c)c) A common disease presenting typically.A common disease presenting typically. d)d) A rare disease presenting typically.A rare disease presenting typically.
  • 3. What is a PUO?What is a PUO? 1956 Age > 14 T > 37.4°C x3 or 38°C x1 Fever - predominant symptom Insufficient symptoms / signs to localise 1961 Days > 21, T > 38.3°C 1/52 hospital investigation 1968 Days > 14 No clear diagnosis Reid Petersdorf & Beeson Dechovitz & Moffet
  • 4. What is a PUO now?What is a PUO now? Now + 2 hospital visits, or Hospital investigations for 3 days Neutropenic PUO Neutrophils < 1000 Diagnosis not clear at 3 days Nosocomial PUO Admission infection screen negative Diagnosis not clear at 3 days HIV PUO HIV infected, fever for 4 weeks Diagnosis not clear after 3 days
  • 5. AetiologyAetiology 1.1. InfectionsInfections 2.2. MalignanciesMalignancies 3.3. Connective tissue disordersConnective tissue disorders 4.4. Endocrinal causesEndocrinal causes
  • 6. MalignanciesMalignancies  20 -25%% of all PUO Are much more common20 -25%% of all PUO Are much more common in adultsin adults  (40 vs. 10%).(40 vs. 10%).  Either because of infection or cytokinesEither because of infection or cytokines  Most commonly:Most commonly:  LymphomaLymphoma  LeukaemiaLeukaemia  NeuroblastomaNeuroblastoma  Sarcomas and HepatomasSarcomas and Hepatomas } 80% of malignancies with PUO
  • 7. Who should have a BMA?Who should have a BMA? 1.1. Patients with suggestive blood film / count orPatients with suggestive blood film / count or other evidence pointing to Leukaemia /other evidence pointing to Leukaemia / LymphomaLymphoma 2.2. Culture for TB, Salmonella, LeishmaniaCulture for TB, Salmonella, Leishmania
  • 8. Infection frequenciesInfection frequencies  Infectious mononucleosis (EBV or CMV)Infectious mononucleosis (EBV or CMV) (up to 20%)(up to 20%)  Other viruses (NB. measles, hepatitis, HIVOther viruses (NB. measles, hepatitis, HIV (up to 15%)(up to 15%)  UTIUTI (up to 15%)(up to 15%)  PneumoniaPneumonia (up to 10%)(up to 10%)  Various URTIsVarious URTIs (up to 10%)(up to 10%)  Endocarditis (Staph. Strep. HACEK, Bruce, Cox, Rick)Endocarditis (Staph. Strep. HACEK, Bruce, Cox, Rick) (up to 5%)(up to 5%)  TuberculosisTuberculosis (up to 5%)(up to 5%)  StreptococcosisStreptococcosis (up to 5%)(up to 5%)  Bartonella (cat scratch disease)Bartonella (cat scratch disease) (up to 5%)(up to 5%)  Meningitis / para meningeal abscessMeningitis / para meningeal abscess (up to 5%)(up to 5%)  Enteric infection (Salmonella, Yersinia)Enteric infection (Salmonella, Yersinia) (up to 5%)(up to 5%)  MalariaMalaria (up to 1%)(up to 1%)  BrucellaBrucella (up to 1%)(up to 1%)  HSV (generalised but occult)HSV (generalised but occult) (up to 1%)(up to 1%)
  • 9. Could it be TB?Could it be TB?  YesYes
  • 10. Infectious mononucleosisInfectious mononucleosis  Diagnosis is made byDiagnosis is made by EBV PCR on blood (EDTA)EBV PCR on blood (EDTA)  Support is offered bySupport is offered by  Atypical lymphocytes (a late finding, in some)Atypical lymphocytes (a late finding, in some)  Heterophile antibodies (IgM binding sRBCs)Heterophile antibodies (IgM binding sRBCs)  IgM antibodies to EBVIgM antibodies to EBV  Other causes includeOther causes include  CMV, Toxoplasma, HIV, Rubella, Hep AB, HHV678CMV, Toxoplasma, HIV, Rubella, Hep AB, HHV678
  • 11. Infective EndocarditisInfective Endocarditis 1.1. Is there a risk factor?Is there a risk factor? 2.2. Is there a new murmur?Is there a new murmur? 3.3. Is there a BC positive for Staph or viridansIs there a BC positive for Staph or viridans Strep?Strep? 4.4. 5-10% of IE have negative BCs5-10% of IE have negative BCs 1.1. Because of antibiotics orBecause of antibiotics or 2.2. Fastidious organisms (HACEK) orFastidious organisms (HACEK) or 3.3. Aspergillus, Bart, Bruce, Cox, Rick, Mycobacteria,Aspergillus, Bart, Bruce, Cox, Rick, Mycobacteria, Noca, Chlamydia, viruses…Noca, Chlamydia, viruses…
  • 12. Rheumatology and PUORheumatology and PUO  10-20% of cases in most series10-20% of cases in most series  More recently, RA, SLE , vasculitis (PAN, Behcet, WG)More recently, RA, SLE , vasculitis (PAN, Behcet, WG) & Sarcoidosis& Sarcoidosis
  • 13. Endocrine causes for PUOEndocrine causes for PUO  HyperthyroidismHyperthyroidism  Occasionally cause PUO → most frequently diagnosedOccasionally cause PUO → most frequently diagnosed clinically.clinically.  Often accompanied by weight loss.Often accompanied by weight loss.  No local neck pain and typically enlarged non-tender thyroid.No local neck pain and typically enlarged non-tender thyroid.  AdrenalAdrenal  Rare, potentially fatal, but eminently treatable cause of PUO.Rare, potentially fatal, but eminently treatable cause of PUO.  primary adrenal insufficiency, secondary adrenal insufficiencyprimary adrenal insufficiency, secondary adrenal insufficiency and pheochromocytomaand pheochromocytoma  Consider if: nausea/vomit, ↓weight, ↓BP, ↓Na & ↑K.Consider if: nausea/vomit, ↓weight, ↓BP, ↓Na & ↑K.
  • 14.
  • 15. How to solve the problemHow to solve the problem  HistoryHistory  Physical examinationPhysical examination  Blood testsBlood tests  ImagingImaging  Endoscopy and tumour markersEndoscopy and tumour markers
  • 16. HistoryHistory  Fever: Pattern, periodicity, how was it measuredFever: Pattern, periodicity, how was it measured  Associated symptoms such as sweating, vomiting,Associated symptoms such as sweating, vomiting, headaches etc.headaches etc.  Target specific organ systems if patient has problems inTarget specific organ systems if patient has problems in that systemthat system  Past med and surg hx.Past med and surg hx. NB prostheses in situNB prostheses in situ  Medications/ vaccinesMedications/ vaccines  Family hx of hereditary diseases, connective tissueFamily hx of hereditary diseases, connective tissue disorders or recent illnesses (TB/ AIDS)disorders or recent illnesses (TB/ AIDS)  Sexual historySexual history  Occupation, pets, travelOccupation, pets, travel
  • 17. ExaminationExamination  Full physical examination is needed. Should be veryFull physical examination is needed. Should be very detailed and review all systems.detailed and review all systems.  For exams make sure to examine:For exams make sure to examine:  Hands for stigmata of infective endocarditisHands for stigmata of infective endocarditis  Retinal exam for candidiasis or toxoplasmosisRetinal exam for candidiasis or toxoplasmosis  Teeth (infective endo or abscess)Teeth (infective endo or abscess)  Lymphadenopathy (AIDS or chronic infections)Lymphadenopathy (AIDS or chronic infections)  Hepatosplenomegaly (Lymphoma/leukaemia)Hepatosplenomegaly (Lymphoma/leukaemia)  Breast/testicular examsBreast/testicular exams  Any sore jointsAny sore joints
  • 18.
  • 19.  Priority (arrival)Priority (arrival) Sutton's lawSutton's law:: “Look where the money is!”“Look where the money is!”  Urinalysis and cultureUrinalysis and culture unless it is on the list,unless it is on the list,  Blood cultureBlood culture it won’t get doneit won’t get done  Throat swabThroat swab  Catheter sample cultureCatheter sample culture  FBC (and film)FBC (and film)  CRP (and ESR)CRP (and ESR) (if the blood flows, take it)(if the blood flows, take it)  PCR for virusesPCR for viruses Could it be ‘flu?Could it be ‘flu?  Stool cultureStool culture Salmonella?Salmonella? Investigations (step 1)Investigations (step 1)
  • 20.  By days 5-7, if any focal signs or symptoms appeared, follow them.By days 5-7, if any focal signs or symptoms appeared, follow them.  Carefully record antimicrobial prescriptionsCarefully record antimicrobial prescriptions  Do anything missed from step 1 and organise:Do anything missed from step 1 and organise:  CXRCXR occult pneumoniaoccult pneumonia  LPLP occult meningitisoccult meningitis  Repeat BCRepeat BC yield risesyield rises  ASOTASOT Streptococcosis is commonStreptococcosis is common  CoagulationCoagulation abnormalities will direct invabnormalities will direct inv  FerritinFerritin massive elevation helpfulmassive elevation helpful  Serum to be savedSerum to be saved acute serologyacute serology  Request BMARequest BMA If haem abnormalIf haem abnormal  US AbdomenUS Abdomen Investigations (step 2)Investigations (step 2)
  • 21.  By days 10-14, if no diagnosis is reached and not already done:By days 10-14, if no diagnosis is reached and not already done:  ANA, dsDNA, C3, C4, ENA, Cardiolipin, RFANA, dsDNA, C3, C4, ENA, Cardiolipin, RF 20% risk20% risk  Lupus anticoagulantLupus anticoagulant (if clotting abnormal)(if clotting abnormal)  ECG, ECHO, converse with cardiologyECG, ECHO, converse with cardiology 1-5% risk1-5% risk  Mantoux TBMantoux TB 1-5% risk1-5% risk  CT of any suspect regionCT of any suspect region  Brain, Chest, Abdo, ENTBrain, Chest, Abdo, ENT  Bone scan for pelvic, skeletal osteomyelitisBone scan for pelvic, skeletal osteomyelitis 5% risk5% risk  Serology for HIV, other microbes and save serumSerology for HIV, other microbes and save serum Investigations (step 3)Investigations (step 3)
  • 22.  By day 21,By day 21,  Review everything again…Review everything again…  TFTsTFTs  CT abdomen (regardless of signs)CT abdomen (regardless of signs)  Biopsy of abnormal tissue, inc:Biopsy of abnormal tissue, inc:  LNsLNs  GutGut  SkinSkin  (Liver)(Liver)  Define immune status of child (call the immunologist)Define immune status of child (call the immunologist)  Stop drugs, if startedStop drugs, if started  Wait for clues.Wait for clues. Investigations (step 4)Investigations (step 4)
  • 23.
  • 24.
  • 25.
  • 26. HIV/ AIDSHIV/ AIDS  No classical presentation. Can present withNo classical presentation. Can present with fever, weight loss, sweats, lymphadenopathy orfever, weight loss, sweats, lymphadenopathy or with opportunistic infectionwith opportunistic infection  Hx: Sexual contacts, Birthplace, Maternal hx ifHx: Sexual contacts, Birthplace, Maternal hx if child, Exposure events, occupationchild, Exposure events, occupation  O/E Full exam. Lymph nodes and spleenO/E Full exam. Lymph nodes and spleen  Ix: HIV antibody test and HIV viral load, CD4Ix: HIV antibody test and HIV viral load, CD4 countcount  Mx: Refer to ID team. HAARTMx: Refer to ID team. HAART
  • 27.
  • 28.
  • 29. ManagementManagement  Determine if critically ill. If not can hold off onDetermine if critically ill. If not can hold off on antibioticsantibiotics  Don’t feel need to just treat a temperatureDon’t feel need to just treat a temperature  Clue is in the history and the exam and thenClue is in the history and the exam and then order relevant tests. Do not send randomorder relevant tests. Do not send random serological tests off. Often these will cause moreserological tests off. Often these will cause more trouble then you want!!!trouble then you want!!!
  • 30. Returning TravellerReturning Traveller  Very common problemVery common problem  Geosentinel data reviewGeosentinel data review  of 25,000 ill returning travellersof 25,000 ill returning travellers  28% had fever and 26% of these needed admission28% had fever and 26% of these needed admission  Malaria was the most common diagnosisMalaria was the most common diagnosis  Considerable geographical variationConsiderable geographical variation  17% had vaccine preventable diseases17% had vaccine preventable diseases  Will discuss methods of diagnosing theWill discuss methods of diagnosing the condition and not each disease in detailcondition and not each disease in detail
  • 31.
  • 33. Therapeutic trials in classic FUO Therapeutic trails are seldom diagnostically rewarding and tend to obscure rather than to illuminate. Symptomatic: -NSAID Therapeutic trail to be considered in case of deterioration * Antibiotics Broad spectrum antibiotics: stop if no improvement after 3 days. - Consider adding tetracyclines (or macrolides) *Antituberculosis therapy: strongly consider in case of clinical deterioration. *Corticosteroids • Do not start too early • Consider adding antituberculosis therapy.