4MB Clinical Problem-Solving

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4MB Clinical Problem-Solving

• Dr. Gerard Flaherty
• Dept. of Medicine

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42-yr-old ?Presenting Complaint Pyrexia of
Unknown Origin
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Definition

• Illness of more than three weeks duration,
  fever higher than 38.3C (101F) on several
  occasions, and diagnosis uncertain after one week
  of study in hospital. (Petersdorf and Beeson,
  1961)

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Definition

• Fever that does not resolve spontaneously in the
  period expected for self-limited infection and
  whose cause cannot be ascertained despite
  considerable diagnostic effort. (Arnow and
  Flaherty, 1997)

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History

• ?Night sweats
• ?Weight loss
• ?Pruritus
• Symptoms of underlying illness
• Previous illnesses
• Medications
• Occupational exposures
• Pets
• Foreign travel
• Family history

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Physical Examination

• Vital signs (?relative bradycardia)
• ?Jaundice
• Anaemia
• ?Hyperpigmentation
• Abdominal tenderness
• Hepatosplenomegaly
• Abdominal mass
• ENT examination
• Examine teeth
• ?Murmurs
• ?Wounds
• Auscultate chest

• Lymphadenopathy
• Clubbing
• Joint swelling
• Rash
• Thickened temporal artery
• Iritis
• Mouth ulcers
• Leg swelling (?DVT)
• Thyroid tenderness
• Signs of thyrotoxicosis
• Gouty tophi
• Tender prostate on PR exam
• Testicular tenderness

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76-yr-old ? with headache and scalp
tenderness.Give the diagnosis.
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Minimum diagnostic work-up to qualify as PUO

• Full history
• Repeated examination
• FBC
• SMAC, including LDH
• ESR
• Antinuclear antibodies
• Rheumatoid factor
• HIV serology
• MSU

• ACE
• Blood cultures 3
• CMV serology
• Monospot
• Mantoux test
• Chest radiograph
• Ultrasound Abdomen
• CT Abdomen

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Further Investigations

• Discontinue as many medications as possible
• Tumour markers
• Echocardiogram
• Gallium-67 or indium-111-labelled white cell scan
• Excision biopsy
• Laparotomy
• Temporal artery biopsy
• Sputum for acid-fast bacilli
• Bone marrow biopsy

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Infective endocarditis
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Differential Diagnosis

• Disease categories
• Infection
• Neoplasia
• Collagen vascular diseases

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• The causes of Pyrexia of Unknown Origin are
  usually familiar diseases with uncommon
  presentations rather than rare disorders.

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• Failure to utilise findings correctly, delay in
  requesting appropriate tests, and
  misinterpretation of results all contribute to
  missed diagnoses.

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Infection (a partial list!)

• Intraabdominal abscess Appendicitis
  Cholecystitis Cholangitis Mesenteric
  lymphadenitis Tubo-ovarian abscess Intracranial
  abscess Sinusitis Mastoiditis Otitis media
  Dental abscess Chronic pharyngitis
  Tracheobronchitis Lung abscess Septic jugular
  phlebitis Mycotic aneurysm Endocarditis IV
  catheter infection Vascular graft infection
  Wound infection Osteomyelitis Infected joint
  prosthesis Pyelonephritis Prostatitis TB Lyme
  disease Relapsing fever Syphilis Q fever
  Legionella Salmonella Listeria Campylobacter
  Brucellosis Psittacosis Chlamydia pneumoniae
  Gonorrhoea Meningococcaemia Actinomycosis
  Whipples disease Candidaemia Cryptococcus
  Histoplasma Coccidioidomycosis Blastomycosis
  Aspergillosis Pneumocystis carinii Visceral
  leishmaniasis Malaria Babesiosis
  Toxoplasmosis Schistosomiasis Toxocariasis
  Amoebiasis Hydatid cyst Trypanosomiasis CMV
  HIV, Herpes simplex Epstein-Barr virus.

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Hepatic abscess
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Neoplasia

• Pyrexia of unknown origin has been reported in
  association with 46 different malignancies.
• e.g. Lymphoma
• Renal-cell carcinoma

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Collagen vascular diseases

• Adult Stills disease SLE Cryoglobulinaemia
  Reiters syndrome Rheumatic fever Giant cell
  arteritis / Polymyalgia rheumatica Wegeners
  granulomatosis Ankylosing spondylitis Behçets
  disease Polyarteritis nodosa Sjögrens
  syndrome Polymyositis Rheumatoid arthritis
  Erythema multiforme Erythema nodosum Relapsing
  polychondritis Mixed connective-tissue disease
  Takayasus arteritis Feltys syndrome
  Eosinophilic fasciitis.

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Rheumatoid arthritis
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30-yr-old ? with arthralgia and pleuritic chest
pain.Give the diagnosis.
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Miscellaneous

• Haematoma Thrombosis Aortic dissection
  Femoral aneurysm Dresslers syndrome Atrial
  myxoma Drug fever Familial Mediterranean fever
  Familial Hibernian fever Inflammatory bowel
  disease Sarcoidosis Subacute thyroiditis
  Hyperthyroidism Addisons disease Hypothalamic
  hypopituitarism Gout Pseudogout Cirrhosis
  Chronic active hepatitis Alcoholic hepatitis
  Kawasakis disease Gauchers disease Fabrys
  disease Cholesterol emboli Sickle cell disease
  Cyclic neutropenia Hamman-Rich syndrome
  Hypersensitivity pneumonitis Extrinsic allergic
  alveolitis Stroke Brain tumour Encephalitis
  Psychogenic fever Factitious fever.

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24-yr-old ? with dyspnoea and a painful red
eye.Give the diagnosis.
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38-yr-old ? with bloody diarrhoea and
arthralgia.Give the diagnosis.
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Management of underlying conditions
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References

• Arnow PM, Flaherty JP (1997) Fever of unknown
  origin. Lancet 350 57-80.

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Next week.

• Headache