Transcript Factitious fever

Pyrexia of unknown orgin (PUO)
Mosul Medical College
Presented by:
Dr. Salam Fareed
contents
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Objectives
Definition
Classification and causes
Approach to patient with PUO
Golden point
Case scenario
Objectives
• To be able to define PUO, and its tyups.
• To be able to have a plan to approach a patient with
Fever when the basic clinical and laboratory tests did
not reveal much as to the cause of fever
Fever of unknown origin (FUO) :is a sustained, unexplained fever despite a
comprehensive diagnostic evaluation. Patients with
undiagnosed FUO generally have a benign long-term
course, especially when the fever is not accompanied
by substantial weight loss or other signs of a serious
underlying disease.
Classification of PUO
Classic
Health care
associated
Neutropinc
HIV
associated
Classic
• Temperature >38.3 °C (100.9 °F)
• for at least 3 weeks
• with at least 1 week of in-hospital investigation
Causes
1- Infections (30%):•
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Abscess at any site; Cholecystitis/cholangitis
Urinary tract infection: prostatitis
Dental and sinus infections
Bone and joint infections
Imported infections, e.g. malaria, dengue, brucellosis
Enteric fevers
Infective endocarditis
Tuberculosis (particularly extra pulmonary)
Viral infections (cytomegalovirus-CMV, Epstein-Barr
virus-EBV, human immunodeficiency virus-HIV) and
toxoplasmosis
• 2-Malignancy (20%):• Lymphoma and myeloma
• Leukemia
• Solid tumors (renal, liver, colon, stomach,
pancreas)
3-connective tissue disorders(15%):• Vasculitic disorders (including polyarteritis
nodosa and rheumatoid disease with
vasculitis)
• Temporal arteritis/polymyalgia rheumatica
• Systemic lupus erythematosus (SLE)
• Still's disease
• Polymyositis
4-Miscellaneous (20%):-
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Inflammatory bowel disease
Liver disease: cirrhosis and granulomatous hepatitis
Sarcoidosis
Drug reactions
Atrial myxoma
Thyrotoxicosis
Hypothalamic lesions
Familial Mediterranean fever
5-Factitious
6-No diagnosis (15%)
Health care associated
Temperature >38.3 °C (100.9 °F) in patients
hospitalized ≥72 hours but no fever or
evidence of potential infection at the time of
admission, and negative evaluation of at least
3 days.
Causes
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Drug fever
thrombophlebitis
pulmonary embolism
sinusitis, postoperative complications
(occult abscesses)
• Clostridium difficile enterocolitis
• device- or procedure-related endocarditis
Neutropenic (immune deficient)
Temperature >38.3 °C (100.9 °F) and
neutrophil count <500/µL for >3 days and
negative evaluation after 48 hours.
Causes
• Occult bacterial and opportunistic fungal
infections (aspergillosis, candidiasis)
• drug fever
• pulmonary emboli
• underlying malignancy
• cause not documented in 40%-60% of cases
HIV associated
Temperature >38.3 °C (100.9 °F) for >3 weeks
(outpatients) or >3 days (inpatients) in
patients with confirmed HIV infection.
Approach to patient with PUO
History
Physical examination
Targeted investigations
History
• Inquire about symptoms involving all major organ
systems and get a detailed history of general
symptoms (eg, fever, weight loss, night sweats,
headaches, rashes).
• The history can provide important clues to FUO
due to surgery, zoonoses, malignancies, and
inflammatory/immune disorders.
• Record all symptoms, even those that
disappeared before the examination. Previous
illnesses (including psychiatric illnesses) and
surgeries are important.
Make a detailed evaluation that includes the following:
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Family history
Immunization status
Occupational history
Travel history
Nutrition (including consumption of dairy products)
Drug history (over-the-counter medications,
prescription medications, illicit substances)
• Sexual history
• Recreational habits
• Animal contacts (including possible exposure to ticks
and other vectors)
Physical Examination
• Definitive documentation of fever and exclusion
of factitious fever are essential early steps in the
physical examination.
• On physical examination, pay special attention to
the eyes, skin, lymph nodes, spleen, heart,
abdomen, and genitalia.
• Pulse-temperature relationships (ie, relative
bradycardia) are useful in evaluating for typhoid
fever, Q fever, psittacosis, lymphomas, and drug
fevers.
• Repeat a regular physical examination daily
while the patient is hospitalized. Pay special
attention to rashes, new or changing cardiac
murmurs, signs of arthritis, abdominal
tenderness or rigidity, lymph node
enlargement, funduscopic changes, and
neurologic deficits.
Investigations
PUO should be investigated in a stepwise
fashion in order of increasing complexity and
invasiveness, starting with blood tests and
moving to imaging techniques and, finally,
more invasive procedures such as 'blind'
biopsies
• FBC with differential , (ESR) and C-reactive
protein (CRP)
• Urea, creatinine and electrolytes
• Liver function tests (LFTs) and γ-glutamyl
transferase
• Blood glucose
• Urinalysis, Midstream urine (MSU) for
microscopy and culture
• Creatine phosphokinase
• Malaria blood films
• Faeces culture
• Sputum for routine microscopy and culture
and microscopy and culture for mycobacteria
• Blood cultures ×3
• Chest X-ray
• Ultrasound examination of abdomen
• Electrocardiogram (ECG)
• Echocardiogram
• Viral (CMV, Infectious mononucleosis, HIV,
Hepatitis A, B and C)
• Bacterial (chlamydial infection, Q fever,
brucellosis , mycoplasma infection, syphilis,
leptospirosis, Lyme disease, Yersinia infection,
streptococcal infection)
• Fungal(Cryptococcus antigen, histoplasmosis,
coccidioidomycosis)
• Protozoal and parasitic (toxoplasmosis,
amoebiasis, schistosomiasis, leishmaniasis,
trypanosomiasis)
• PCR e.g for tuberculosis, herpes simplex virus
(HSV), CMV, HIV, erythrovirus, dengue,
Toxoplasma, Whipple's disease
• Immunology like Autoantibody screen, including
anti-double-stranded DNA, anti-neutrophil
cytoplasmic antibody (ANCA), Immunoglobulins,
Complement (C3 and C4) levels &Cryoglobulins
• Imaging like CT/MRI chest and abdomen, skeletal
survey , isotope bone scan, labelled white cell
scan
• Biopsy: Bone marrow biopsy, Temporal artery
biopsy
Factitious fever
• It is most commonly encountered among young
adults with health care experience or knowledge.
• Evidence of psychiatric problems or a history of
multiple hospitalizations at different institutions
is common in patients with factitious fever.
• Rapid changes of body temperature without
associated shivering or sweating, large
differences between rectal and oral temperature,
and discrepancies between fever, pulse rate, or
general appearance are typically observed in
patients who manipulate or exchange their
thermometers.
Golden Point
1-The most probable cause of immune
deficient PUO is :Streptococcal pneumonia
Thrombophlebitis
Drug fever
Unknown
2-A 45 years old male known to have chronic renal
failure, admitted to the hospital to start hemodialysis
at that time he was afebrile, 3 days later he developed
fever of (39°C) persist for 3 days.
CBC showed Hb=9 g/dl, WBC=13*109 cells/l, platelets
count=170*109 this type of fever is most probably:• Immune deficient PUO
• Health care associated PUO
• Classic PUO
• None of above
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3) All the followings are criteria for immune
deficient (neutropenic) PUO except :• Temperature >38.3°C
• Duration > 3 weeks
• Neutrophile count 400
• No valuabie diagnosis despite initial 48 hours
of assessment
4-A patient can be considered to have classic PUO in
which of the followings scenario :• 69 years old female with fever ranging (38.4°C - 38.8°C)
for 40 days without finding a source of infection
despite 10 days of inpatient investigations.
• 33 years old diabetic female present with fever of
(39.5°C) for 3 days associated with rigor and loin pain.
• 18 years old female presented with fever ranging
(38.5°C -39.7°C) for 1 month duration, with previous
history of multiple hospital admissions and history of
psychiatric problem.
• 23 years old female presented with fever of (38.9°C)
and backache for 14 days duration, initial assessment
showed high titer of Brucella agglutination test.