Pyrexia Of Unknown Origin (PUO)

1. Pyrexia of

Pyrexia of

Unknown

Unknown
OriginOrigin
PUOPUO
Prof. Nooruddin JafferProf. Nooruddin Jaffer
HCMD KarachiHCMD Karachi

2. PUO DefinitionPUO Definition
• Fever Persisting for more than 3 weeks.
• Documented Temp above 101 F Several Occasions.
• Uncertain diagnosis after extensive evaluation in hospital for
. 1 week.
• PUO of 2 weeks no diagnosis could be made.

5. Approach to Patient of PUOApproach to Patient of PUO
Painstaking History:Painstaking History:
A-Chronology of Symptoms.
B-Occupational History.
C-Travel History.
D-Drug History.
E-Geographical History.
F-Past History

7. Pyrexia of Unknown Origin
Causes:
D.Infections.
E.Neoplastic Diseases.
F.Auto Immune Disease.
G.Hentable Diseases.
H.Granulamatous Disease.
I.Drug Fever.
J.Miscellaneous Causes.

8. 1- Infections:1- Infections:
A.Viral Syndrome
1. Cytomegalovirus.
2. Epstein-Barr Virus (Mononucleosis)
3. HIV Infection.
B.Lyme Disease
C.Pyelonephritis or Urinary Tract Infection
D.Meningitis.
E.Pneumonia
F.Septicemia
G.Acute Sinusitis
H.Malaria
Causes

9. A.Osteomyelitis.
B.Typhoid Fever or Enteric Fever
C.Subacute Bacterial Endocarditis (SBE)
D.Tuberculosis.
E.Liver or Biliary infection.
F.Abdominal or Pelvic abscess
G.Dental Abscess
H.Psittacosis
I.Brucellosis

10. A.Tonsillitis or Peritonsillar Abscess
B.Herpes Simplex Virus
C.Streptococccosis
D.Gonococcal Arthritis
E.Prostatitis

11. 2- Neoplastic Disease:2- Neoplastic Disease:
A.Leukemia
B.Lymphoma
C.Sarcoma
D.Carcinomatosis
E.Renal cell carcinoma
F.Colon Cancer
G.Pancreatic
H.Hepatoma
I.Metastic cancer

12. 33- Autoimmune Disease:- Autoimmune Disease:
A.Juvenile Rheumatoid Arthritis (evanescent rash)
B.Henoch-Schonlein Purpura
C.Systemic Lupus Erythematosus
D.Rheumatic Fever (Migratory Polyarthritis)
E.Polymyalgia Rheumatica
F.Temporal Arteritis
G.Inflammatory Bowel Disease
H.Reiter’s Syndrome

13. 44- Heritable Disease Causes:- Heritable Disease Causes:
A.Fabry’s Disease
B.Familial Mediterranean fever
C.Lamellar Ichthyosis
D.Nephrogenic Diabetes Insipidus
E.Anhydrotic ectodermal dysplasia
F.Familial Dysautonomia

14. 5- Granulomatous Disease:5- Granulomatous Disease:
A.Sarcoidosis
B.Granulomatous Hepatitis
C.Inflammatory Bowel Disease
7- Miscellaneous:7- Miscellaneous:
A.Facticious Fever (Munchausen by proxy)
B.Thyroiditis
C.Neurogenic Fever
D.Milk Allergy
E.Behcet’s Syndrome
F.Anicteric Hepatitis
G.Pulmonary Embolism
H.Deep Vein Thrombosis

15. Drug-Induced FeverDrug-Induced Fever
1- Antibiotic Induced Fever:1- Antibiotic Induced Fever:
A.Erythromycin
B.Isoniazid
C.Penicillin
D.Nitrofurantoin
E.Procainamide
F.Quinidine

16. 2- Cardiovascular Medication Induced Fever:2- Cardiovascular Medication Induced Fever:
A.Atropine
B.Captopril
C.Clofibrate
D.Hydralazine
E.Hydrochlorothiazide
F.Methyldopa
G.Nifedipine

17. 33- Miscellaneous Medications Inducing Fever:- Miscellaneous Medications Inducing Fever:
A.Allopurinol
B.Antihistamines
C.Aspirin
D.Cimetidine
E.Heparin
F.Meperidine
G.Phenytoin

18. Physical Examination in PUOPhysical Examination in PUO
• Meticulous, repeated on regular basis.
• Temp Chart.
• Skin, Lymphnodes, Eyes, Nail Beds.
• CVS, Chest, Abd, Musculoskeletal Sys, CNS.
• Penis, Scrotum, Testes in males.
• Pelvic examination in female.

24. Thank You

26. Pyrexia of Unknown OriginPyrexia of Unknown Origin
1- Types:1- Types:
A. Pyrexia of Unknown Origin:A. Pyrexia of Unknown Origin:
1. Daily or Intermittent Fever >= 38.3 C (101F)
2. Duration for three consecutive weeks
3. No source by clinical evaluation
a. Hospital evaluation for 3 days
(previously 7) or
b. Intensive outpatient evaluation for 7
days or
c. Three outpatient visits

27. B. Nosocomial Fever or Unknown Origin:B. Nosocomial Fever or Unknown Origin:
1. Daily or Intermittent Fever >= 38.3 C (101F)
2. Hospitalized >1 day without fever on admission
3. Fever evaluation of 3 days of more
C. Immune-Deficient Pyrexia of UnknownC. Immune-Deficient Pyrexia of Unknown
Origin:Origin:
1. Daily or Intermittent Fever >=38.3 C (101F)
2. Neutrophil count < 500 per mm3
3. Fever evaluation of 3 days of more

28. D. HIV-Associated Fever of Unknown Origin:D. HIV-Associated Fever of Unknown Origin:
1. Daily or Intermittent Fever >= 38.3 C (101F)
2. Outpatient Fever >4 weeks or
3. Inpatient fever >3 days

29. Infection Microbiactoxins
Mediators of
inflammation Immune
Reaction
Monocytes / Macrophacites
Endothelial Cells
Pyogenic Cytokines I L-1,
I L-6, INF, IFN
Microbial Toxins
Hypothalamic Endotelium

30. PG E2
Cyclic AMP
Elevated
Thermoregulator Set
Point
Heat Conservation
Heat Production
Fever