Important questions in history of fever
Travel
Pets
Occupation
Immunosupression
Drugs - cocaine, antimicrobials, anticholinergic, amphetamine
Sexual history
Investigations to differentiate between infectious, malignant and autoimmune causes
Malignant - Weight loss, lymph involvement, CT
Autoimmune- ESR in giant cell, RF in rheumatoid, ANA in SLE, antibodies
LFT to differential Cirrhosis and Hepatitis,
D-dimer for DVT
ACE levels for Sarcoidosis
Name 10 infectious causes of fever
- UTI
- Pneumonia
- sinusitis
- Mengitis
- Bacteraemia
- Tuberculosis
- Abdominal abcess
- Endocarditis
- Osteomyelitis
- cytomegalovirus (CMV), Epstein-barr virus, influenza
Name three malignant cases of fever
Chronic leukaemia
Lymphoma
Metastatic cancer
Name four autoimmune causes of fever
Gaint cell arthritis
Inflammatory bowel disease - Chron’s, ulcerative colitis
Rheumatoid Arthriitis
Systemic lupus erythematosus
Lyssavirus
Symptoms, Examination, Diagnosis
Symptoms - Disoriented, insomnia, ataxia, rapidly deteriorating speech, hallucination, coma
Examination - Hydrophobia and intermittently febrile
Diagnosis - Serology – saliva test for rabies PCR
Brucellosis
Symptoms, Examination, Diagnosis
Symptoms- Remitting relapsing course of fever, Arthralgia, myalgia
Examination - none
Diagnosis - Serology = SAT (serum agglutination test), culture can be -ive due to biphasic nature, bone marrow = gold standard
Management -
- Doxycycline 100 mg 2 times daily for 6 wks +
- streptomycin 1 mg IM once daily for first 14 to 21 days +
- gentamicin 5mg/kg or streptomycin 5-14 days
Leptospirosis
Symptoms, Examination, Diagnosis
Symptoms - Biphasic illness with septicaemic and immune phase, High fever, headache, myalgia and arthralgia, rash, meningism and vomiting = common
Examination - Meningism, Jaundice
Diagnosis - Serology MAT (microagglutionation testing) or ELISA
Management - Antimicrobial therapy doxycycline or azithromycin
IV corticosteroids – vasculitis nature
Q fever
Symptoms, Examination, Diagnosis, Management
Symptoms - Similar to leptospirosis and brucellosis
Non-specific influenza like illness
Acute fever-myalgia, severe headache
Arthralgia, anorexia and acute weight loss
Examination none
Diagnosis - Serology – repeat 1-2 weeks later because negative at start of fever – PCR (NAAT)
Antibody – 4 fold rise
Echo - for management
Prevention - Vaccine in abattoirs
Management - spontaneously resolves
Acute - Doxycycline
- Transthoracic echo – valvular disease with a single agent
- Persistent endocarditis – hydrohloroquine + doxycycline for atleast 18 months
- Prosthetic valve endo – 24 months
Hydatid disease
Symptoms, Examination and Diagnosis
Symptoms - Right upper quadrant pain or epigastric pain, nausea vomiting
Examination - none
Diagnosis - Stool exam – eggs and proglottids in stool
Serum serology
FBC – moderate eosinophilia, megaloblastic perinicious anaemia
Management -
Definition of sepsis
Infection either suspected or confirmed with systemic features of fever, tachycardia, tachypnoea, or elevated white cell count
What is severe sepsis
sepsis complicated by acute organ dysfunction or hypoperfusion
What is septic shock
Sepsis complicated by hypotension that does not respond intravenous fluid administration
What situations warrent antimicrobial therapy in FUO
- Treatment must be started before the culture susceptibility results are available – TB
- Clinical situation is not serious enough to warrant taking culture
- Samples for culture can’t be obtained
Protocol to follow for sepsis
- Collect two sets of blood sample (4 bottles) and administer broad spectrum, antibiotics within one hour
- Being resuscitation with ABC – airway breathing and circulation
- Intubate and mechanical ventilation if necessary
- Assess for hypotension – Rx = IV bolus fluid
- For immunocompetent patient with community acquired sepsis or septic shock
- Gentamicin IV + Flucloxacillin IV
- For hypersensitive patient replace fluloxacillin with cephazolin or vancomycin
- Gentamicin IV + Flucloxacillin IV
Investigations for FUO
- FBC
- ESR or CRP - lymphoma
- Urinalysis or culture - UTI
- Lactate dehydrgenase - Elevated in megaloblastic anaemia, pernicious anaemia, Hodgkin’s disease, abdo and lung cancer, severe shock and hypoxia
- Tuberculin skin test
- 3 blood ulture, different sites
- Serology for EBV, CMV, HIV
- electrolytes for hydration
- ANA for SLE
- RF for Rheymatoid arhritis
- Liver function test - chirosis , hepatitis
- CT abdo - abcess or hematoma
