Pyrexia of Unknown Origin

With a focus on large vessel

vasculitis
Mrs A

77y, F PC: PMHx: O/E:

Collapse due to OA, HTN, T2DM, RR 19; HR 96; 97%
general weakness, hypothyroidism, RA; BP 114/84; T
fever. No other glaucoma, 38.5˚C
symptoms. Recent cataracts, B12 def No cardiovascular,
booster. respiratory or
neurological signs
 Key results:
• Hb 101, WCC 10
• Na 125, K 4.1, Creat 73
• CRP 263
Mrs A • Urine dip: 2+ blood, nitrate neg, 2+ leuc
• ECG: sinus tachy, 1st degree heart block
• CXR NAD

IMP: ?Urinary source, ?Booster side effect

Differential Diagnosis
Infection Malignancy
• IE • NHL/HL
• • Leukemia
Osteomyelitis
• Solid tumors
• Abscess
• Sinusitis Autoimmune/Inflammatory
• Cholangitis • SLE
• • RA
UTI
• Polyarteritis nodosum
• Meningitis • Giant cell arteritis
• HIV • PMR/temporal arteritis
• EBV • Sarcoidosis
• Granulomatous disease
• CMV • IBD
• Hepatitis
• Enterovirus Other
• Fungal/protozoa/parasite • Drug fever
• Recurrent PE
Large Vessel Vasculitis

• A spectrum of primary vasculitis that causes chronic granulomatous

inflammation predominantly of the aorta and its major branches. (1)

• 2 main forms:
 Giant Cell Arteritis (GCA)
 Almost always >50y
 Takayasu Arteritis (TAK)
 Almost always <50y

• Pathophysiology
 Activation of adventitial dendritic cells, recruitment of CD4+ T-
lymphocytes and infiltration of macrophages, resulting in cytokine
driven neovascularisation and intimal hyperplasia. (2)
Giant Cell Arteritis

About
• Immune-mediated, ischaemic condition, caused by inflammation in the wall of
medium to large arteries
• 2-3:1 (F:M), Caucasians
• Risk of permanent vision loss, large vessel stenosis, aortic aneurysm

Presentation/Assessment
• Headache
• Systemic symptoms – fever, anorexia, fatigue
• 15% patients with PUO will have GCA
• Visual disturbances
• Raised CRP
Giant Cell Arteritis

Management
• Rheumatology review/advice
• Prednisone
• Consider temporal artery biopsy
• Histology: inflammation of inner media and intima;
granulomas
• Low dose aspirin
• PPI (omeprazole)
• Regular follow-up
References
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855435/
2. https://journals.sagepub.com/doi/10.1177/1358863X18802989
3. Health pathways