ChemPath: PUO

Question 1

Defined criteria commonly accepted definition of PUO

Answer 1

Durack and Street criteria

• Temperature >38.3
• Duration >3weeks
• Evaluation in at least 3 outpatient visits / 3 days hospital

Question 2

What are the categories of PUO under the Durack and Street criteria?

Answer 2

Question 3

What are the causes of classic PUO?

Answer 3

• Infection
• Malignancy
• Collagen vascular disease

Question 4

What are the causes of nosocomial PUO?

Answer 4

• C. difficile enterocolitis
• Drug-induced
• Pulmonary embolus
• Septic thromboplebitis
• Sinusitis

Question 5

What are some causes of immune deficient (neutropenic) PUO?

Answer 5

• Opportunistic bacterial infection
• Fungi - aspergillosis, candidiasis
• Herpes virus

Question 6

What are some causes of HIV-associated PUO?

Answer 6

• CMV
• Mycobacterium avium-intracellulare complex
• Pneumocystis carinii pneumonia
• Drug-induced
• Kaposi sarcoma

Question 7

History points for PUO

Answer 7

• B Symptoms (FLAWS), localising symptoms
• Medications - doses & initiation date
• Contact history - pets / animals
• Drug use
• Sexual history
• Foreign travel

Question 8

Points to ask on Hx of foreign travel

Answer 8

• Specific Village/ City?
• What they did there
• Where they stayed
• Others infected?
• Walking barefoot?
• Mosquito Nets

Question 9

Test to consider in all PUO

Answer 9

• HIV (consent needed)
• Exclude malaria in patient with tropical travel in last 2 years

Question 10

What investigations for PUO?

Answer 10

Any others - speak to consultant (money)

Question 11

What is the first line test in diagnosis of acute EBV infection?

Answer 11

Serum EBV IgM

Question 12

What imaging and tissue diagnositic techniques might you employ in PUO?

Answer 12

Imaging

• FDG-PET (?cancer)
• Echocardiogram

Tissue

• Biopsy
• LP
• Bone marrow aspiration

Question 13

When to order Echocardiogram in PUO?

Answer 13

?Infective Endocarditis - when the patient meets the Duke Criteria (2 major or 1 Major + 3 minor)

Question 14

Describe the Duke Criteria for infective endocarditis.
What is required for diagnosis?

Answer 14

Question 15

What are some infective causes of PUO?

Answer 15

Question 16

How to order tests for infective PUO

Answer 16

REFER TO RIPL (rare and imported pathogens laboratory) - include discriminating characteristics e.g. Indian man, swimming in freshwater…

Question 17

Describe the diagnostic criteria for Adult-onset Still’s disease

Answer 17

Question 18

List 2 clinical features of Adult-onset Still’s

Answer 18

• Salmon pink rash - can be mistaken for drug-induced rash
• Ferritin often very high in Adult-onset Still’s (macrophage activation syndrome)

Question 19

What are some clinical features of GCA?

Answer 19

• Age > 50
• Headache
• Jaw claudication
• 50% have vision changes
• High risk of blindness/stroke

Question 20

How is GCA diagnosed and managed?

Answer 20

Diagnosis

• Blood ESR > 45 (needs to be age adjusted)
• Temporal artery biopsy (gold standard)

Managment

• High-dose prednisolone immediately
• Refer to rheumatology and opthalmology

Question 21

Malignant causes of PUO

Answer 21

• Lymphoma (esp. non-Hodgkins) - raised LDH, weight loss, lymphadenopathy
• Leukamia - bone marrow biopsy
• Renal Cell Carcinoma - 20% present with fever, haematuria can occur
• Hepatocellular carcinoma or liver metastases

Question 22

What are is the most common miscellaneous cause of PUO?

Answer 22

Drug-induced

• 1/3 of hospitalised patients suffer form adverse drug reactions, including ‘drug fever’
• This can be an idiosyncratic reaction or because the drug affects thermoregulation
• Eosinophilia and rash accompany drug fever in 25%

Question 23

Conditions that require URGENT (preconfirmation) treatment

Answer 23

• Infective endocarditis
• Disseminated TB (FLAWS)
• CNS TB (headache / reduced GCS)
• GCA
• SEPSIS

Question 24

Which causes of PUO should you think of when ferritin is very high?

Answer 24

Adult-onset Still’s disease

Question 25

How would you diagnose active TB?

Answer 25

Sputum culture - gold standard but slow ## Footnote IGRA is not diagnostic of active TB