1. An Update on
‘Pyrexia of Unknown Origin’
Speaker
Dr. AL TARIQUE
Registrar- Medicine
Chairperson
Prof. Mufti Munsurar Rahman
Prof. & Head
Department of medicine
Enam Medical college
2. Pyrexia of Unknown Origin
• A temperature above 38°C on multiple occasions for more than 3
weeks, without diagnosis, despite initial investigation in hospital for 1
week.
• The definition has been relaxed to allow for investigation over 3 days
of inpatient care, three outpatient visits or 1 week of intensive
ambulatory investigation.
21. Fever > 38°C (100.4°F) and illness lasting > 3 weeks, without
diagnosis, despite initial investigation during 3 days of inpatient care
or after more than three outpatient visits.
History and physical examination
Stop antibiotic treatment and glucocorticoids
23. Exclude manipulation with thermometer
Stop or replace medication to exclude drug fever
PDCs present PDCs absent or misleading
24. PDCs present PDCs absent or misleading
Guided diagnostic tests Cryoglobulin & fundoscopy
NO DIAGNOSISDIAGNOSIS
FDG-PET/CT
(or labeled leukocyte scintigraphy or
gallium scan)
25. Scintigraphy abnormal Scintigraphy normal
Confirmation of abnormality
(e.g. biopsy, culture)
• Repeat history &
physical examination
• Perform PDC-driven
invasive testing
NO DIAGNOSISDIAGNOSIS
DIAGNOSIS NO DIAGNOSIS
26. Stable condition:
Follow-up for new PDCs
Consider NSAID
Deterioration :
Further diagnostic tests
Consider therapeutic trial
Chest and abdominal CT
Temporal artery biopsy (>55years)
NO DIAGNOSISDIAGNOSIS
27. Potentially diagnostic clues (PDCs)
• The most important step in the diagnostic workup is the
search for potentially diagnostic clues (PDCs) through
complete and repeated history taking and physical
examination and the obligatory investigations.
28. • PDCs are defined as all localizing signs, symptoms, and
abnormalities potentially pointing toward a diagnosis.
30. History taking
History of presenting complaint-
1. Onset :
Acute : Malaria, Pyogenic infection
Gradual : TB, Typhoid fever
2. Character
High grade fever : UTI, Malaria
Low grade fever : TB
31. 3.Pattern: Despite historical claims, pattern of fever are not
especially helpful in establishing a specific diagnosis.
• Continued fever: Fluctuation of fever not >1°C ,does not touch
baseline.
• Intermittent fever: Fever that persist for several hours ,always touches
baseline
• Remittent fever: Fever fluctuates > 2°C , does not touch the baseline.
32. 4.Associated symptoms
• Chills and rigors : acute pyelonephritis, acute cholangitis,
subphrenic abscess, pyogenic lung abscess, SBE, lobar
pneumonia
• Night sweats : TB, infective endocarditis
• Loss of weight : Malignancy, Vasculitis, TB, HIV, IBD,
thyrotoxicosis
34. 5. Antecedents -prior to onset of fever:
Dental extraction – infective endocarditis
Urinary catherization – UTI, bacteremia
35. History of past illness
• Past history of infection . e.g. malaria, kala-azar, tuberculosis.
• History of recent dental procedure.
• History of surgery and trauma.
• History of neoplasia, connective tissue disorders, prosthetic
valve, liver disorder.
36. Sexual history
• HIV 1 transmission
Family history
• TB, familial Mediterranean fever.
History of Intravenous drug injection or receipt of
blood products
• HIV -1, HBV and HCV
37. Travel history
• Amoebiasis, typhoid fever, malaria, schistosomiasis
Occupation
• E.g. anthrax in leather tannery workers
History of Animal exposures
• Brucellosis, Toxoplasmosis, Leptospirosis, Q fever,
Psittacosis
Diet history
• Consider undercooked meats , shellfish, unpasteurized
dairy products or well water
47. Prognosis
• The overall mortality is 30-40%, mainly attributable to
malignancy in older patients.
• If no cause is found, the long term mortality is low and fever
often settles spontaneously.
48. Home massage
• PUO is far more often caused by an atypical presentation of a
rather common disease than by a very rare disease.
• Because of unavailability of all diagnostic facilities and the
poverty of general population, PUO can not be evaluated in
every case
49. • The most likely cause of PUO, like all other countries of the
world, is infection in our country.
• Studies support that 50% of cases are caused by infections,
eg, tuberculosis in western nations.
50. • As the duration of fever increases, the likelihood of an
infectious cause decreases.
• Empirical therapeutic trials with antibiotics, glucocorticoids,
or antituberculous agents should be avoided in PUO except
when a patient’s condition is rapidly deteriorating.