Download fever of unknown origin

FEVER AND
FEVER OF UNKNOWN ORİGİN
Meral Sonmezoglu, MD.
Assoc Professor of Infectious Dıseases
2007
BODY TEMPERATURE
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BODY TEMPERATURE
 Heat is derived from biochemical reactions occuring in
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all living cells (glucose catabolism, ATP)
Shivering is primary means of by which heat is
enhanced
Heat is generated primarily in vital organs lying deep
within the body core
Distributed thoughout the body via the circulatory
system
Heat is lost from body surfaces to teh envirement
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BODY TEMPERATURE
 The mean oral temperature 36.8 ºC  0.4 ºC
 Low level at 6 AM and high level at 4 to 6 PM, with normal
daily variation is 0.5 ºC
 Rectal temperature 0.4 ºC higher than oral
 Unadjusted-mode TM temperature 0.8 ºC lower than rectal
 Lower esophageal temperature closely reflect core temperature
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NORMAL BODY TEMPERATURE
 Maximum normal oral temperature
At 6 AM : 37.2
At 4 PM : 37.7
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DISCOMFORT DUE TO FEVER
 For each 1 °C elevation of body temperature:
 Metabolic
rate increase 10-15%
 Insensible water loss increase
300-500ml/m2/day
 O2
consumption increase 13%
 Heart rate increase 10-15/min
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APPROACH TO THE PATIENT
HISTORY
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Combined symptoms
Fever pattern
Medication
Surgical or dental procedure
Any prosthetic materials or
implanted devices
 Occupation ( animal; fume;
infectious agent or infected
individuals )
 Travel history
 Unusual hobbies
 Dietary proclivities
 Household pets
 Sexual exposure
 IV drug abuse, alcoholism
 Trauma
 Animal or insect bite
 Blood transfusion
 immunization
 Family history
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APPROACH TO FEVER
 Underlying Diseases:
 Splenectomy
 Surgical Implantation of Prosthesis
 Immunodeficiency
 Chronic Diseases:
Cirrhosis
Chronic Heart Diseases
Chronic Lung Diseases
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APPROACH TO THE PATIENT
PHYSICAL EXAMINATION
 Head to toe
 Finger to hole
 Special attention to skin, lymph nodes, eyes, nail bed, CV
system, chest , abdomen, musculoskeletal system, and nerve
system.
 Rectal examination is imperative
 Penis, scrotum, testes , foreskin and pelvic examination in
women should be examined
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APPROACH TO FEVER
 Associated Symptoms:
 Shaking chills
 Ear pain,Ear drainage,Hearing loss
 Visual and Eye Symptoms
 Sore Throat
 Chest and Pulmonary Symptoms
 Abdominal Symptoms
 Back pain, Joint or Skeletal pain
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APPROACH TO THE PATIENT
LABORATORY TESTS
 Clinical Pathology
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CBC+DC+PLT, blood smear, UA, ESR, abnormal fluid accumulation
and CSF examination, bone mallow aspiration, stool routine
 Chemistry
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Electrolyte, BUN, creatinine, LFTs, amylase, CPK and serology…
 Microbiology
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Gram’s stain and culture
 Imaging
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Plain film, sonography, CT, MRI and Gallium scan
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 FEVER OF UNKNOWN ORIGIN
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FEVER OF UNKNOWN ORIGIN
DEFINITION
 Defined by Petersdorf and Beeson in 1961
Temperature > 38.3 ºC on several occasions
 A duration of fever of > 3 weeks
 Failure to reach a diagnosis despite 1 week of inpatient
investigation
Durack and Street proposed a new system in 1991
and suggested two changes to the earlier
definition.
Durrack and Street proposed four types of FUO
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Category of FUO
Feature
Nosocomial
Patient’s situation
Hospitalized, acute care, no Neutrophil count either
infection when admitted
<500 μL or expected to
reach that level in 1-2
days
b
3 days
3 daysb
Duration of illness
while under
investigation
Examples of cause
Neutropenic
HIV-Associated
Classic
Confirmed HIV-positive
All others with fever for
 3 weeks
3 daysb (or 4 weeks as out- 3 daysb or three outpatient
patient)
visits
Septic thrombophlebitis,
Perianal infection, aspergil- MAIc infection, tuberculosinusitis, Clostridium
losis, candidemia
sis, non-Hodgkin’s lymdifficile colitis, drug
phoma, drug fever
fever
a
All require temperatures for  38.3C on several occasions.
b
Includes at least 2 days’ incubation of microbiology cultures.
c
M. avium/M. intracellulare.
Infections, malignancy, inflammatory diseases, drug
fever
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Classic FUO
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Temperature > 38ºC (101ºF) recorded on
several occasions occurring for more than three
weeks
in spite of investigations on three OPD visits or
three days of stay in hospital or
one week of invasive ambulatory investigations
is called classic FUO
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Nosocomial FUO
• Temperature more than 38.3ºC (> 101°F) is
recorded on several occasions in a hospitalized
patient who is receiving acute care and in whom
infection was not manifest or incubating on
admission.
• Three days of investigations including at least two
days incubation of cultures, is the minimum
requirement for this diagnosis
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Neutropenic FUO
• Temperature of > 38.3ºC (101ºF) on several
ocasion is observed in a patient whose neutrophil
count is less than 500/microliter or is expected to
fall to that level in 1 or 2 days
• This diagnosis should be considered when
investigation including at least two days of
incubation of cultures.
• It is also called immunodeficient FUO
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HIV associated FUO
• Temperature of > 38.3ºC (>101ºF) on several
occasions is found over a period of more than 4
weeks for our patient or more than three days for
hospitalized patients with HIV infection
• This diagnosis is considered if appropriate
investigations over three days including two day
of incubation of cultures reveals no source
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FUO
CAUSE
 Big three
 Infection (25-30%)
 Malignancy (10-30%)
 Collagen vascular disorder (10-15%)
 Unknown (5-10%)
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FEVER OF UNKNOWN ORIGIN: REPORT
OF 27 CASES
2007
A clinical review of 449 cases with fever of unknown origin
 Out of the 449 FUO cases, definite diagnosis was
eventually achieved in 387 patients (86.9%).
 The most common causes of FUO were infectious
diseases (56.8%), with tuberculosis accounting for 43.6%
of cases of infection.
 76 patients were suffered from collagen vascular diseases
(CVD): with Still's disease, systemic lupus erythematosus
and vasculitis accounting for 34.2% (26/76), 18.4%
(14/76) and 13.2% (10/76) of the this category,
respectively.
 16.5% (64/449) of the FUO cases were diagnosed as
malignancy.
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Miscellaneous causes were found in 7.0% of the FUO cases. However, no definite diagnosis had
been made in the remaining 62 (13.8%) cases until they discharged from the hospital
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Fever of Unknown Origin
PK Agarwal*, A Gogia**
2007
Childhood
World J Pediatr 2011;7(1):5-10
2007
Infections in childhood
World J Pediatr 2011;7(1):5-10
2007
World J Pediatr 2011;
7(1):5-10
2007
FUO
MALIGNANCY ASSOCIATED
 Hodgkin’s lymphoma
 Non-Hodgkin lymphoma
 Leukemia
 Renal cell carcinoma
 Hematoma
 Colon carcinoma
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FUO
AUTOIMMUNE ASSOCIATED
 SLE
 RA
 Adult Still’s disease
 Temporal arteritis
 Mixed connective tissue disease
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FUO
INFECTION ASSOCIATED
 Intra-abdominal or pelvic abscess
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Abscess 1/3 infection origin of FUO, most intra-abdominal
or pelvic
Vague localized abdominal pain
Surgical complication or leakage of visceral contents
Liver abscess:
elevated ALK-p
K. pneumoniae bacteremia in DM, alcoholism, Liver cirrhosis
Liver echo may be negative, so abdominal CT is important for
diagnosis
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FUO
INFECTION ASSOCIATED
 Osteomyelitis and septic hip
 Tenderness over infected site, but some patients only with
fever
 Associated sign: L-spine OM with root compression sign,
vertebral OM with psoas muscle abscess or CV surgery
with sternal OM
 Septic hip: 16% of septic arthritis, most with OA or
destructive joint, so that with prolonged and insidious
onset
 Diagnostic tool: Bone scan or Gallium scan CT or MRI
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FUO
INFECTION ASSOCIATED
 Infectious endocarditis
 Clue of DX: continuous bacteremia, new murmurs,
vascular phenomenon, vegetation on cardiac echo, and
unexplained fever
 Culture negative endocarditis
Recently received antibiotics
HACEK group organisms. Haemophilus parainfluenaze/ aphrophilus,
Actinobacillus actinomycetemcomitans, Cardiobacterium hominis,
Eikenella corrodens, and Kingella kingae
Fungus, Rickettsia and Chlamydia
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TTE(60%) and TEE(95%)
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FUO
INFECTION ASSOCIATED
 Granulomatous infection
 TB( extrapulmonary TB or miliary TB) is the most common
cause in Taiwan
 TB may involve liver, spleen, bone, kidneys, pericardium or
meninges and in miliary TB of lung CXR may be negative
initial
 Bone marrow study may diagnose
 Nontuberculous mycobacterial infections and deep-seated
fungal infection
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FUO
INFECTION ASSOCIATED
 Dengue fever
 Infectious mononucleosis
 Scrub typhus
 Typhoid fever
 HIV
 Malaria
 Amebiasis
 NG related sinusitis
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2007
Thank You
2007