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A
MIK
SIE
JAS SUBJECT: Medicine 2 DATE: July 02, 2008
N
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
RAI
S
FAR TRANSGROUP:SMV
A
HU
JOS
DEFINITION
•
RCO
MA Classic definition by Petersdorf &Beeson, 1961
Y - An illness that is characterized by a
ISA temperature of 38.3°C or greater on
DY multiple occasions that lasts three weeks
CAN or longer, and that remains undiagnosed COMMON CAUSES OF CLASSIC FUO
NG after one week of in-hospital evaluation.
• Durack & Street, 1991
KRI
A Table 2. Causes of FUO in Adults
EIS - Proposed a new system of classification of Petersd
NE FUO orf Larson, Knockaert
Klejin
& Featherslone & Vanneste &
AN * (-) for any laboratory results Category Beeson Petersdorf Babbaers
(1997)
167
H (1961) (1982) (1992)
cases
KYT Table 1. Modifications of FUO definition by Durack & Street, 1991 100 105 cases 187 cases
ON IMMUNO- cases
HIV –
AAR DEFICIENT NOSOCOMIA Infections 36 31 23 26
CLASSIC ASSOCIAT
NEUTROPEN L
ED Malignancy 19 31 7 12.5
HE
ALP IC
Hospitalized Collagen-
Patients not 15 9 22 24
vascular disease
LA
, Acute
in other Confirmed
Has < 500 case, No
KAR
Patient categories HIV Others 23 7 23 8
neutrophils infection
G
type fever ≥ 3 positive Undiagnosed 7 12 25 30
PEN when
weeks
KC admitted *Naproxen – treatment for rheumatic fever
Duration of
ADI
illness
- test after 3 days = (-) fever → not infectious
AN 3 days or (+) fever → infectious
while 3 days or
MA 3 days 4 weeks 3 days
under 3 OPD visits
AM as OPD
investigati Table 3. Causes of FUO in Children
on
NA
Pizzo, et Mc
MO Septic Lohr &
Infections, Perianal al. Chung
F MAI, TB, thrombo- Hendley
malignanci infection, Category (1972) (1980)
non- phlebitis, (1974)
100 99
BUF
Example of es, aspergillosis 84 cases
Hodgkin’s sinusitis, C. cases cases
DIE etiology inflammato ,
lymphoma difficile
GOL ry disease candidemia Infections 82 33 29
A colitis
EZR Malignancy 20 18 11
Collagen-vascular
KIX
CATEGORIES disease
6 13 8
Diagnostic Categories of FUO
RIZ
NEY Miscellaneous 10 15 19
LAI • Infections – most common cause of
Undiagnosed 12 19 32
AN classical FUO
Systemic
XTI
CES Table 4. Local Experience (PGH, 1975-1990), unpublished
OPS Localized Number (%)
HO • Neoplasms Infections 34 (46.6)
• Collagen-vascular disease Malignancy 20 (27.4)
CE
VIN
Collagen-vascular (autoimmune) 10 (13.7)
E Inflammatory diseases
Hypersensitivity 2 (2.7)
CTD, autoimmune diseases
ESS
DEN Unknown 7 (9.6)
ILLE • Miscellaneous causes Total 73 (100)
CEC Drug fever Source: M.F. Mendoza MD, 29th PSMID Conv
Pulmonary embolism
JAM
KC Table 5. Diagnostic Categories of 72 Patients with FUO at the Santo
OY Factitious fever Tomas University Hospital
PIP • Undiagnosed Number (%)
Infections 44 (61)
CH
Neoplasms 9 (13)
NRI
HEI
T Connective tissue disease 4 (6)
BAR Miscellaneous 3 (4)
RYL Unknown 12 (17)
SHE
INFECTIONS
LH
1. TB
RAP
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A
TIN 2. Abdominal abscess
AIN 3. Cryptic abscess
ALL 4. Typhoid fever
TTE
YVE
RY
MA
SUBJECT: Medicine 2 DATE: July 02, 2008
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
TRANSGROUP:SMV
Drugs
• More in developed countries Immobilization
SUBJECT: Medicine 2 DATE: July 02, 2008
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
TRANSGROUP:SMV
hospitalization
NON SPECIFIC INFLAMMATORY MARKERS
1. Repeat tests done in OP setting
• Procalcitonin
SUBJECT: Medicine 2 DATE: July 02, 2008
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
TRANSGROUP:SMV
Table 7. The Value of Exploratory Laparotomy in FUO EVALUATION OF A PATIENT WITH FUO REQUIRES:
Operative findings in 70 FUO cases • Knowledge of those disorders that produce this
Number (%) syndrome (FUO)
Malignant 21 (30.0) • Recognition of the potential significance of
Specific infection 21 (21.4) subtle findings in the history and physical
Indeterminate disease 14 (20.0) examination
Miscellaneous 6 (8.6) • Awareness of the value in the clinical setting of
Nothing found 14 (20.0)
specific diagnostic procedures
Source: Mayo clinic
ESR
NOSOCOMIAL INFECTION
DEFINITION
• Sensitivity 53%
Nosocomial infection – are infectious which are the
• Specificity 33% result of treatment in a hospital or a healthcare service
• (-) PPV for bacteremia 94% unit.
• ↓ ESR (<20 mm/hr) helpful to r/o bacteremia - they appear as fever after 48 hours or more
after hospital admission or within 30 days after
DIAGNOSIS OF FEVER OF UNKNOWN ORIGIN discharge
* see last page - Other known as:
“Hospital-acquired infection”
EMPIRIC TREATMENT “Healthcare-associated infection”
TREATMENT AND MANAGEMENT
• Non-specific treatment is rarely curative and COMMON CAUSES
may delay diagnosis • Urinary tract infection
• NSAIDS – Ibuprofen, Indomethacin, Naproxen • Surgical sites
Response to ASA & NSAIDS – may mask • Pneumonias
fever of infection
TRANSMISSION
• Naproxen test
• Contact (direct or indirect) transmission
• Therapeutic trial
• Droplet transmission
THERAPEUTIC TRIAL • Airborne transmission
• Specific therapy – specific goal and hypothesis • Common vehicle-borne transmission
• Time limit • Vector-borne transmission
• Regular, reliable observation of vital signs and
clinical conditions PREDISPOSITION INFECTION
• Use drugs with limited spectrum • Host factors – poor state of health, advanced
age, prematurity, immunodeficiency
• May delay diagnosis
• Invasive devices – intubation tubes, catheters,
• Only for seriously ill patients – nosocomial FUO,
Page5
surgical drains
febrile neutropenia
• Host treatments – immunosuppressive,
• Some FUO may resolve spontaneously
antimicrobials or recurrent blood transfusion
SUBJECT: Medicine 2 DATE: July 02, 2008
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
TRANSGROUP:SMV
PREVENTION
• Isolation
• Handwashing and gloving
• Aprons
• Masks
Positive findings
No
Positive results
No
CT of abdomen/pelvic with
contrast
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SUBJECT: Medicine 2 DATE: July 02, 2008
TOPIC: Fever of Undetermined Origin
LECTURER: Mr. Alberto Gabriel
TRANSGROUP:SMV
Page5