Pyrexia of unknown origin presentaion .pptx

https://ssd.dev.jvip.in/file/2022-hypertension-lecture-updated-guidelinespdf-253820678.pdf

1. PYREXIA OF UNKNOWN ORIGIN Dr ANAND TR

2. DEFINITION FEVER > 38 .3⁰C ON ATLEAST 2 OCCASIONS DURATION OF FEVER > 3 WEEKS NO KNOWN IMMUNOCOMPROMISED STATE DIAGNOSIS REMAIN UNCERTAIN EVEN AFTER HISTORY PHYSICAL EXAMINATION OBLIGATORY LAB INVESTIGATIONS

3. OBLIGATORY LAB INVESTIGATIONS CBC RFT/LFT/S.E CRP/ESR LDH FERRITIN ANA Rheumatoid Factor Urinalysis Blood culture Urine culture Chest Xray Abdominal USG Tuberculin Sensitivity Test

4. Causes of PUO A common disease presenting in an atypical way An uncommon disease presenting typically

5. DIFFERNTIAL DIAGNOSIS Infections (most) Malignancies Non inflammatory infectious disease Bacterial Viral Fungal Parasite Hematological Malignancies Solid tumors Benign tumors - Systemic rheumatic d/s (e.g. RA, AS) Vasculitis Granulomatous disease Miscellaneous

6. Miscellaneous Causes Drug induced fever Exercise induced hyperthermia Factitious fever - fever artificially induced by patients ( eg . IV injection of contaminated water) Fraudulent Fever ( Normothermic patient who manipulates the thermometer)

7. Diagnostic Approach

8. History Pattern and duration of fever Previous Medical history Family History Sexual history Country of origin Recent and Remote travel Animal Exposure

9. History of jaw claudication Giant cell Arteritis

10. Subtle change in behaviour /cognition Granulomatous Meningitis

11. Tooth sensitivity to cold/ gum tenderness Dental Abscess History of Nocturia Prostatitis

12. Physical Examination You should give special attention to: Eyes Lymph nodes Temperature Liver Spleen Site of previous Surgery Entire skin Surface Mucous Membrane

13. Before the Diagnostic test You should STOP any antibiotics and Steroids Reason : Blood cultures etc. are not reliable when samples are obtained during antibiotic treatment Size of the lymph node decreases with steroid treatment in any cause of lymphadenopathy

14. Structured Approach to PUO Fever >38.3⁰C lasting > 3 weeks & NO Known Immunocompromised state History & Physical Examination Stop antibiotic treatment and glucocorticoids

15. Obligatory Investigations Exclude manipulation with thermometer Stop or Replace the medications that are taken to exclude drug fever Look for Potential D iagnostic C lues(PDCs)

16. Potential Diagnostic clues Present Guided Diagnostic Tests Dx No Dx Potential Diagnostic clues Absent or misleading Cryoglobulin and fundoscopy FDG-PET/CT (or labelled leucocyte scintigraphy or gallium scan)

17. IF there is any abnormality If it is normal Confirm it by biopsy or culture FDG-PET/CT (or labelled leucocyte scintigraphy or gallium scan) Dx No Dx Repeat History & P/E Perform PDC driven invasive test Dx No Dx

18. No Dx Chest and Abdominal CT Temporal Artery Biopsy (Age>55) Dx No Dx Stable Condition: Follow up for new PDCs Consider NSAIDS Unstable Condition: Further Diagnostic Testing Consider Therapeutic trial

19. Therapeutic trials Empirical therapeutic trials with antibiotics, anti TB drugs and Steroids are indicated only when patient condition is unstable. NSAIDS, Glucocorticoids Anakinra (IL-1 Receptor antagonist) - less side effects than steroids

20. Fever higher than 38.3◦ C on atleast 2 occasions Duration of fever > 3 weeks No known immunocompromised state Uncertain diagnosis after one week of study in the hospital