Tropical Medicine

ME-TROP-324
Lecture No. 43 & 44
‫بسم هللا الرحمن‬
‫الرحيم‬

‫‪Dr. Haifa Yagoub Osman‬‬

 Definition

 Prevalence And Spectrum Of Disease

 CAUSES

 Evaluation Of Patient

 Laboratory Investigations

 MANAGEMENT

 PROGNOSIS

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Traditional definition

 In 1961 by Petersdorf and Beeson

1. A temperature greater than 38.3 C on several

occasions

2. of more than 3 weeks duration of illness and

3. without diagnosis despite 1 week of inpatient
investigation

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 In 1991, DT Durrack and AC Street3 suggested two
changes to the earlier definition. Durrack and
Street proposed four types of FUO
 1. Classic FUO
 2. Nosocomial FUO
 3. Neutropenic FUO
 4. HIV associated FUO

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 Represented by four general categories:
✓ infectious

✓ neoplastic

✓ non-infectious inflammatory diseases

✓ and miscellaneous.

✓ A fifth category is considered by some authors as

the idiopathic presentation of FUO,or true FUO

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 The most common infectious causes are tuberculosis
and intra-abdominal abscesses

 Most common malignancies are Hodgkin’s

disease and non-Hodgkin’s lymphoma

 Temporal arteritis accounts for 16-17% of all causes of

FUO in the elderly

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❖ Infections

 Abscess - sinus, dental osteomyelitis, hepatic,

subhepatic, gall bladder, etc

 Granulomatous - extra-pulmonary and miliary

tuberculosis, atypical mycobacteria infection,
fungal infection.

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 Intravascular - catheter-related endocarditis,
meningococcemia, gonococcemia, Listeria, Brucella,
rat bite fever, relapsing fever

 Viral, rickettsial and chlamydial – infectious

mononucleosis, cytomegalovirus, HIV, viral
hepatitis, Q fever, psittacosis

• Parasitic - extra-intestinal amoebiasis, malaria,

Kala azar, toxoplamosis
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❖Collagen vascular diseases

• Collagen vascular diseases - rheumatic fever,

systemic lupus erythematosus, rheumatoid arthritis
particularly Still’s disease, vasculitis (all types)

• Granulomtous - sarcoidosis, granulomatus hepatitis,

Crohn’s disease

• Tissue injury - pulmonary emboli, sickle cell

disease, hemolytic anemia. March 2020
❖Neoplasia

• Leukemias, Hodgkin’s and non-Hodgkin’s

lymphoma, acute leukemia, myelodysplasic
syndrome.

• Carcinoma - kidney, pancreas, liver, GI tract,

lung especially when metasatic

• Atrial myxomas

• Central nervous system tumors

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 Vascular - Haematoma, thrombosis, recurrent
pulmonary embolism, aortic dissection, femoral
aneurysm, postmyocardial infarction syndrome

 Drug fever

• Endocrinal - Subacute (de Quervain’s) thyroiditis,

hyperthyroidism, adrenal insufficiency, primary
hyperparathyroidism
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 Hepatic - Cirrhosis, chronic active hepatitis,
alcoholic hepatitis

 Allergic - Milk protein allergy, hypersensitivity

penumonitis, extrinsic allergic alveolitis, metal
fume fever, polymer fume fever, idiopathic
hypereosinophilic syndrome.

• Nervous system - Complex partial status

epilepticus, cerebrovascular accident, brain tumour,
encephalitis March 2020
Others - Anomalous thoracic duct,
psychogenic fever, habitual hyperthermia,
factitious illness , etc

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 In FUO, there is no diagnostic gold standard

✓ History

✓ repeated physical examination

✓ a host of laboratory investigations

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✓ Age

✓ Sex

autoimmune diseases are more common in female

✓ Residence present and past

some diseases are more prevalent in a particular area - Kalaazar .

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✓ Past infections are sometimes responsible for
reactivation or other effects.

✓ Immunization and medications.

✓Exposure to pets, other animals, contacts persons.

✓ Work environment/home environment.

✓ Drug, underlying disease, cardiac valve disorder,

previous surgeries including splenectomy.

✓ Family history of TB or rarely hereditary cause of

fever like familial Mediterranean fever .
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➢ Complete blood count and differential

➢ Erythrocyte sedimentation rate

➢ Blood film for malarial parasite and malarial serology.

➢ Routine blood chemistry (including lactate dehydrogenase,

bilirubin, and liver enzymes)

➢ Urinalysis and microscopy

➢ Blood (x3) and urine cultures and other ( joints pleura, CSF)
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➢ Chest radiography

➢ Abdominal ultrasonography

➢ Skin Testing-tuberculin skin test

➢ Serology HIV , PCR/NASBA for tuberculosis,

hepatitis, CMV.

➢ Collagen makers - antinuclear antibodies,

rheumatoid factors, ENA, pANCA, c ANCA,
complement levels.

➢ CT abdomen/chest
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➢ Echocardiography in case of cardiac murmur.

➢ Venous duplex scan of lower limbs.

➢ Invasive procedures-
▪ Bone marrow aspiration and Lymph node FNAC and
biopsy
▪ Liver biopsy/thoracoscopy (where indicated)
▪ Splenic aspirate (where indicated)
▪ CT guided FNAC of mass/lymph node
▪ Laparoscopy
▪ Bronchoscopy and transbronchial biopsy

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 Therapy should be delayed until the cause of fever has
been determined

 Non-specific treatment is rarely curative and has the

potential to delay diagnosis.

 At the same time diagnostic delay adversely affect the

prognosis in intra-abdominal infections, military TB,
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➢ like Antitubercular drugs may be accepted in
cases of prolonged low-grade fever , raised ESR, a
positive tuberculin Test with or without loss of
appetite and weight

➢ In temporal arteritis to prevent vascular

complications like blindness empirical
corticosteroids maybe given.

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 Overall, 12-35% of patients will die

 52% to 100% of patients with a final diagnosis of

malignancy will die within five years

 Mortality is much less if an infection is identified as

the cause of FUO (8%-22%).

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 Most of these patients have spontaneous recovery
(51%-100%) and only a small proportion have
persistent fever (0%-30%).

 The 5-year mortality rate of undiagnosed FUO was

only 3.2%.

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 ‫‪THANK‬‬

‫❑ نسأل هللا أن يعلمنا ما ينفعنا‪،‬‬

‫❑ وأن ينفعنا بما علمنا‪،‬‬

‫❑ وأن يزيدنا علما‬

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