pyrexia of unknown origin. By prof, Dr Abdul Baqi Durrani. HOD BMCH Quetta

1. Infections and Health in Pakistan

2. Preventable Cause
Estimated Deaths (% total deaths)
Infections(13%)
Tobacco (10%)
Poor diet and physical inactivity (10%)
Alcohol (3%)
Motor vehicle (2%)
Firearms (1%)
Illicit drug use (0.7%)

3. Preventive Service
Pure Water, Cleanliness, food quality, Air pollution,
living standereds
Blood pressure Recommended for all adults; interval
not stated Fair evidence for inclusion in routine care Joint
National Committee VII: Recommended for all adults at
each clinical encounter
Serum lipids Recommended for all middle-aged and
older adults and for young adults with multiple risk factors
Insufficient evidence for or against inclusion National
Cholesterol Education Panel Adult Treatment Panel III:
Recommended for all adults age 21 and older
Depression screening Recommended when support
systems in place (B recommendation) Recommended when
support systems in place

4. Counseling
Pure Water, Healthy diet and Cleanliness
Recommended for patients with increased risk; insufficient
evidence for or against in average-risk patients Fair evidence
for inclusion
Physical activity Recommended Fair evidence for
inclusion
Aspirin chemoprevention Recommended for adults at
increased risk for coronary heart disease (CHD) Insufficient
evidence for or against use American Heart Association:
Recommended for adults at increased risk for CHD
Influenza vaccination Recommended for all adults 65
and older and for selected high-risk groups Not addressed
Pneumococcal vaccination Recommended for
immunocompetent adults older than age 65 or for adults
younger than age 65 at increased risk Recommended for
healthy adults

5. PUO
 Illness of at least 3 weeks duration.
 Fever over 38.3 °C on several occasions.
 Diagnosis has not been made after three outpatient
visits or 3 days of hospitalization.
CAUSES OF PUO
Infections 45 % Malignancy 20 %
Connective Tissue
Diseases15 %
Other causes
20%

6. COMMON CAUSES
 Most cases represent unusual manifestations
of common diseases and not rare or exotic
diseases eg tuberculosis, endocarditis,
gallbladder disease and hepatitis are more
common causes of PUO or FUO than
Whipple disease or familial Mediterranean
fever

7. Infectious Causes of PUO
 Sepsis
 Abscess at any site: cholecytic/ cholangitis
 Urinary tract infection: prostatitis
 Dental and sinus infection
 Bone and Joint infection
 Malaria, dengue, brucellosis
 Enteric Fever, Infective endocarditis
 Tuberculosis (particularly extrapulmonary)
 Viral infections, Fungal infection

8. VIRAL CAUSES OF PUO
 CMV infection
 Infectious mononucleosis
 HIV infection
 Arbovirus infection
 Hepatitis A, B, C infection
 Erthrovirus infection

9. BACTERIAL
 Chlamydial infection
 Q Fever
 Brucellosis
 Mycoplasma infection
 Syphilis
 Rickttsial infection
 Melioidosis
 Leptospirosis
 Lyme disease
 Yersinia infection
 Relapsing fever
 Bartonoellosis

10. FUNGAL
 Crytococcosis
 Histoplasmosis
 Coccidioidomycosis

11. PROTOZOAL AND PARASITIC
 Toxoplasmosis
 Schistosomiasis
 Amoebiasis
 Leishmaniasis
 trypanosomiasis

12. MALIGNANCY
 Lymphoma
 Multiple myloma
 Leukaemia
 Solid tumours
- renal
- liver
- colon
- stomach
- pancreas

13. CONNECTIVE TISSUE
DISORDERS
 Vasculitic disorders ( including polyatertis nodosa and
rheumatiod diseases with vasculitis )
Temporal arteritis/ polymyalgia rheumatica
 Systemic lupus erthematosus (SLE)
 Still’s disease
 Polymyositis
 Rheumatic fever

14. MISCELLANEOUS
 Inflammatory bowel disease
 Liver disease: cirrhosis and garnulomatous Hepatitis
 Sarcoidosis
 Drug reaction
 Atrial myxoma
 Thyrotoxicosis
 Hypothalamic
 Familial Mediterranean fever

15.  NO DIAGNOSIS
OR RESOLVE SPONTANEOUSLY

16. EARLY TESTS IN THE
INVESTIGATION OF PUO
 Full blood count (FBC) and differential counts
 Erythrocyte sedimentation rate (ESR)and C-reactive
protein (CRP)
 Serum ferritin
 Urea, ceratinine and electrolytes
 Liver functions tests (LFTs)and r-glutmayl transferase
 Blood glucose
 Bone Biochemistry
 Creatine phosphokinase
 Malaria blood films

17. Other tests
 Urinalysis
 Midstream urine(MSU)for microscopy and culture
 Faeces culture
 Sputum for routine microscopy and culture, and
microscopy and culture for mycobacteria
 Blood culture x 3
 Chest X-Ray
 Ultrasound examination of abdomen
 Electrocardiogram (ECG)

18. Treatment
 In the seriously ill or rapidly deteriorating patient, empiric
therapy is often given. Once definitive culture results return,
streamlining therapy to the most narrow spectrum antimicrobial
should take place
 An empiric course of antimicrobials should also be considered if
a diagnosis is strongly suspected.
 However, if there is no clinical response in several weeks, it is
imperative to stop therapy and re-evaluate the
patient.Antituberculosis medications (particularly in the elderly)
and broad-spectrum antibiotics are reasonable in this setting.
 Empiric administration of corticosteroids should be discouraged;
they can suppress fever if given in high enough doses, but they
can also exacerbate many infections, and infection remains a
leading cause of FUO.