Pyrexia of Unknown Origin (PUO)
Pyrexia of unknown origin
Definition
· Illness of at least 3/52
· Fever of >38.3 deg c on several occasions
· No dx reached after 1/52 of intelligent and intensive ix
***Note: habitual hyperthermia = temps up to 38, normal in young, esp women***
Clinical features
Symptoms:
- Fever
- Other sx
- PMHx (immunosuppression)
- Drug hx
- SHx (sick contacts, occupation, travel, sports)
Signs:
- Skin (rashes, nodules, ulcers)
- Eyes (fundi)
- Temporal aa
- Teeth and gums
- Thyroid
- CVS (endocarditis, vasculitis)
- Lymph nodes
- Abdo/ pelvis/ rectum
- Genitalia
- CNS, neurocognitive
Investigations
- Septic screen (blood cultures >2 sets)
- ESR
- Thick/ thin film
- ANA, RF (lupus, RA)
- Bone marrow (TB - AFB, fungi, CMV, leishmaniasis)
- Serology (HIV, toxoplasmosis, hep, syphillis)
- Stool mcs, ocp
- Imaging
o USS abdo/ pelvis
o CT C/A/P (abscess, LN, malignancy, retroperitoneal masses)
o MRI
o Bone scan
o PET scan (malignancy, inflammation/ infection)
o TTE/ TOE (need TOE to exclude endocarditis)
- Tissue sample
o skin biopsy (if rash)
o LN
o BMAT
o Liver bx
o laparotomy/ laparoscopy
Differential diagnosis
Non-infective (most common)
- Malignancy
- Inflammatory (giant cell arteritis, PMR, SLE, vasculitides)
- Drugs
- VTE
- Endocrine (↑TR, addisons’s)
- chronic aortic dissection
- alcoholic hepatitis
System infections
- Bacterial
o S aureus
o TB
o Salmonella
o Q fever (Coxiella burnetii)
- Viral
o CMV, EBV, HIV
- Fungal
o histoplasmosis
- Protozoal
o malaria
o leishmania
o amoebiasis
Localised infections
- without abscess
o endocarditis
o osteomyelitis
o cholangitis
o pericarditis
- with abscess
o renal
o colon
o brain
o spine
Source
Dr Katie Flanagan 2015
Definition
· Illness of at least 3/52
· Fever of >38.3 deg c on several occasions
· No dx reached after 1/52 of intelligent and intensive ix
***Note: habitual hyperthermia = temps up to 38, normal in young, esp women***
Clinical features
Symptoms:
- Fever
- Other sx
- PMHx (immunosuppression)
- Drug hx
- SHx (sick contacts, occupation, travel, sports)
Signs:
- Skin (rashes, nodules, ulcers)
- Eyes (fundi)
- Temporal aa
- Teeth and gums
- Thyroid
- CVS (endocarditis, vasculitis)
- Lymph nodes
- Abdo/ pelvis/ rectum
- Genitalia
- CNS, neurocognitive
Investigations
- Septic screen (blood cultures >2 sets)
- ESR
- Thick/ thin film
- ANA, RF (lupus, RA)
- Bone marrow (TB - AFB, fungi, CMV, leishmaniasis)
- Serology (HIV, toxoplasmosis, hep, syphillis)
- Stool mcs, ocp
- Imaging
o USS abdo/ pelvis
o CT C/A/P (abscess, LN, malignancy, retroperitoneal masses)
o MRI
o Bone scan
o PET scan (malignancy, inflammation/ infection)
o TTE/ TOE (need TOE to exclude endocarditis)
- Tissue sample
o skin biopsy (if rash)
o LN
o BMAT
o Liver bx
o laparotomy/ laparoscopy
Differential diagnosis
Non-infective (most common)
- Malignancy
- Inflammatory (giant cell arteritis, PMR, SLE, vasculitides)
- Drugs
- VTE
- Endocrine (↑TR, addisons’s)
- chronic aortic dissection
- alcoholic hepatitis
System infections
- Bacterial
o S aureus
o TB
o Salmonella
o Q fever (Coxiella burnetii)
- Viral
o CMV, EBV, HIV
- Fungal
o histoplasmosis
- Protozoal
o malaria
o leishmania
o amoebiasis
Localised infections
- without abscess
o endocarditis
o osteomyelitis
o cholangitis
o pericarditis
- with abscess
o renal
o colon
o brain
o spine
Source
Dr Katie Flanagan 2015