FEVER OF UNKNOWN ORIGIN (FUO)

KABERA René,MD
PGY III Resident
Family and Community Medicine
National University of Rwanda
PLAN
• Introduction
• Etiology
• Diagnosis
• Management
INTRODUCTION
 Definition
• Febrile illness 38.3o C on multiple occasions.
• Present for 3 weeks.
• Uncertain diagnosis after 1 week of investigations in the
hospital.
ETIOLOGY
• In adults, infections (25-40% of cases) and cancer (25-40% of
cases) account for the majority of FUOs.
• In children, infections are the most common cause of FUO (30-
50% of cases) and cancer a rare cause (5-10% of cases).
• Autoimmune disorders occur with equal frequency in adults and
children (10-20% of cases), but the diseases differ
ETIOLOGY
• Infection: abdominal abscesses ,Mycobacterial infection,
Cytomegalovirus. Endocarditis/pericarditis, sinusitis, HIV (late
stage), Renal, Osteomyelitis, Catheter infections, Amebic
hepatitis, Wound infections.
• Neoplasms :Lymphoma, Leukemia, Solid tumors
(hypernephroma) ,Hepatoma ,Atrial myxoma, Colon cancer.
ETIOLOGY
• Collagen vascular disease: Giant cell arteritis Polyarteritis nodosa
Rheumatic fever Systemic, lupus erythematosus, Rheumatoid
arthritis ,Polymyalgia rheumatica.
• Other causes :
 Granulomatous diseases, Pulmonary emboli/deep vein thrombosis.

 Drug fever, Thermoregulatory disorders, Endocrinologic diseases,

Occupational causes, Periodic fever, Factitious/fraudulent fever.
 Cerebrovascular accident ,Cirrhosis ,Alcoholic hepatitis.
SIGNS AND SYMPTOMS
• Fever does not present as the only manifestation of a disease.
• Constitutional symptoms that almost always accompany a fever.
 Night sweats, myalgia, weight loss wit an intact appetite
(infectious).
 Arthralgia, myalgia, fatigue(inflammatory).
 Fatigue, night sweats ,weight loss with loss of appetite
(neoplasms).
DIAGNOSIS
• LABORATORY:
• CBC - leukopenia, anemia, thrombocytopenia/thrombocytosis
• C-reactive protein
• Sedimentation rate - elevated
• Liver function tests (especially alkaline phosphatase) - evidence
of inflammation, obstruction or infiltrative disease
• Blood cultures (not to exceed 6)
• Urinalysis and urine culture
DIAGNOSIS
• SPECIAL TESTS:
• Tuberculin skin test - may not be helpful if anergic or acute
infection. If test negative, repeat in 2 weeks.
• Sputum and urine cultures for tuberculosis
• Gastric washing for tuberculosis.
DIAGNOSIS
• Serologic tests - Epstein-Barr, hepatitis, syphilis, Lyme disease,
Q fever, cytomegalovirus, amoebiasis/coccidioidomycosis
• HIV antibody test
• Serum protein electrophoresis - if immunologic etiology
suspected
• Thyroid function tests - if thyroiditis suspected.
• Rheumatoid factor and antinuclear antibody test - if collagen
vascular disease suspected
DIAGNOSIS
• Imaging
• chest x-ray
• · abdominal films
• · sinus x-rays - if clinically indicated
• · bone scan - if osteomyelitis or metastatic disease suspected
• · ct scan or mri of abdomen and pelvis
DIAGNOSIS
• DIAGNOSTIC PROCEDURES:
• · Bone marrow - if granulomatous disease, infection or
malignancy suspected
• · Liver biopsy - if granulomatous disease suspected
• · Temporal artery biopsy - if giant cell arteritis suspected
• Lymph node, muscle or skin biopsy - if clinically indicated
• · Spinal tap - if clinically indicated.
• · Exploratory laparotomy - if otherwise unsuccessful in
determining etiology
MANAGEMENT
MANAGEMENT
• GENERAL MEASURES:
• · Attempt to determine etiology before initiating therapy
• · Avoid therapeutic trials unless as a last resort and only if
therapy is reasonably specific
• "Shotgun" approaches are condemned since they do not solve
the problem, obscure the clinical picture and have effects
MANAGEMENT
• Drugs of choice
• Antipyretics such as acetaminophen or aspirin
• Non-steroidal anti-inflammatory drugs such as indomethacin or naproxen
• Steroid trial based on patient's history but Empirical administration of
corticosteroids should be discouraged
• Antibiotic trial based on patient's history
• Antituberculous therapy if at high risk for granulomatous disease pending
culture results
• Contraindications: Aspirin should be avoided in children because of the risk
of Reye syndrome
Thank you