puo2

Fever without a focus(Pediatric Mystery)

University Of Baghdad

College of Medicine
Dept. Of Pediatrics
5th Year
Infectious Diseases Module

LEARNING OBJECTIVES

1- Be able to understand the main clinical presentations of PUO
2- Be able to formulate a differential and provisional diagnoses.
3- Plan a panel of investigations according to the suspected diagnosis .
4- Decide the plan of treatment.

DEFINITION

FUO (Fever of unknown origin): Fever documented by a health care provider and for which the cause could not be identified after 3 wk of evaluation as an outpatient or after 1 wk of evaluation in the hospital.

between 5 and 15% of FUO cases defy diagnosis, despite exhaustive studies.

CAUSES
• 1- Infections:
• Bacterial
• Systemic: Brucellosis, Salmonella, Tuberculosis
• Localized infections: Osteomyelitis, Pneumonia and Sinusitis
• Viruses: CMV, Hepatitis viruses ,HIV, IM (Epstein-Barr virus)
• Parasitic Diseases: Malaria ,Toxoplasmosis
Fungal diseases

CAUSES

• 2- Rheumatologic diseases
• JRA, Rheumatic fever, SLE and drug fever.
• 3- Neoplasms
• Leukemia, Lymphoma, other malignancies.
• 4- Miscellaneous
• Familial Mediterranean fever, Kawasaki disease.
• 5- Undiagnosed


HISTORY
Fever specifications, sweating, antipyretics use and response, appearance, other complaints (CNS, urinary,,,,), pain (severity, site), rash and distribution, arthralgia / arthritis, travel, contact, animals, medications, hospitalization, immunizations, ethnicity, exposure to contaminated food or water.

CAREFUL PHYSICAL EXAMINATION

General appearance and vital signs (heart rate, pressure, respiratory, temperature), pallor, jaundice, clubbing, skin and scalp, eyes, sinuses, oropharynx, LN, abdomen, musculoskeletal, genitourinary.

INVESTIGATIONS

Level 1:

CBC differentials, ESR, CRP, metabolic panel (RFT, LFT, elects), GUE, stool, C/S, LP, CXR, US, TB, EBV, CMV, cultures.

INVESTIGATIONS

Level 2:

Echo, CT, Bone scan, Serology, Autoimmune, Bone marrow

INVESTIGATIONS

Level 3:
Tissue biopsy, Endoscopy

Treatment

• in general,
• NONE
• Until diagnosis

Infections

Oncology
Rheumatology

Hints

• As the duration of fever increases, infectious etiology decreases
• Malignancy and factitious fever should be considered with more prolonged fever
• The most critical features of the evaluation of a patient with FUO is to take a carefully history and to reassess the patient frequently.
• The Best Approach is “there is no substitute for observing the patient, talking to him and thinking about him”

Hints

• It is important to look for uncommon presentation of common disease and to perform a detailed physical examination
• Clinically challenging - get expert help! Clinical balance between trial antimicrobial (often anti tuberculosis regimen) or corticosteroid trial.
• avoid indiscriminately ordering a large battery of tests.

Approach

Complete history and physical examination
Positive findings: Order appropriate and specific diagnostic tests
Negative findings
CBC, ESR, LFT, GUE, Culture, Blood culture, Skin PPD, CXR, US, Muscle enzymes ,,,
Positive: Order appropriate and specific diagnostic tests and manage accordingly
Negative results
CT chest, abdomen and pelvis with contrast

Assign to most likely diagnosis

Infection
Autoimmune disease
Urine, sputum culture, AFB, HIV, CMV, EBV serology, LP, Echo
BMA, BMA, LN biopsy, Liver biopsy, colonoscopy
Malignancy
ASO, RF, ANA, muscle biopsy, skin biopsy


After full work up for PUO
Empirical therapy
Diagnosis
Anti Tb, Antimicrobial, NSAID
Watchful waiting
No diagnosis
Treatment

Task

• 1- Intra abdominal abscess
• History: Seven-year old male, PUO, Swinging in nature, with non specific localizing abdominal pain and a prior history of appendicitis.
• Physical examination: Febrile, Right iliac fossa mass
• Order relevant investigations and outline treatment accordingly.

Task

• 2- Pulmonary tuberculosis
• History: Eleven-year old male, PUO, cough, Weight loss, father have chronic undiagnosed cough.
• Physical examination: Febrile, cachectic, no LAP, bronchial breathing in the right upper zone.
• Order relevant investigations and outline treatment accordingly.

Task

• 3- Bacterial endocarditis
• History: Three-year old boy, PUO, known case of congenital heart disease (Ventricular septal defect),
• Physical examination: Febrile and heart murmur.
• Order relevant investigations and outline treatment accordingly.


Task
• 4- Urinary tract infection
• History: Seven-month old female, recurrent fever and diarrhea, failure to thrive, repeated episodes of vomiting
• Physical examination: Febrile, wasted,
• Order relevant investigations and outline treatment accordingly.

Task

• 5- Osteomyelitis
• History: Three-year old female, PUO, limping, tenderness in the right lower thigh.
• Physical examination: Febrile, toxic, swelling and tenderness in the lower right thigh.
• Order relevant investigations and outline treatment accordingly.

Task

• 6- Brucellosis
• History: Ten-year old girl, PUO, drenching sweating, history of ingestion of diary product, back pain
• Physical examination: Febrile, sweating
• Order relevant investigations and outline treatment accordingly.

Task

• 7- Kala-azar
• History: Three-year old female, from Diyala, PUO, abdominal distension, poor appetite.
• Physical examination: Febrile, organomegaly
• Order relevant investigations and outline treatment accordingly.


Task
• 8- Mononucleosis
• History: Nine-year old girl, PUO, bilateral cervical swelling, sore throat.
• Physical examination: Febrile, cervical LAP, exudative tonsillitis.
• Order relevant investigations and outline treatment accordingly.

Task

• 9- HIV
• History: Four-year old girl, recurrent fever, recurrent infections, skin rash (ecchymoses), mother is on regular blood transfusion
• Physical examination: Febrile, pneumonia, organomegaly, wasted
• Order relevant investigations and outline treatment accordingly.

Task

• 10- Leukemia
• History: Four-year old girl, PUO, abdominal distension, cervical swelling, skin rash (ecchymosis)
• Physical examination: Febrile, pallor, generalized LAP, petachial rash and ecchymoses, hepatosplenomegaly.
• Order relevant investigations and outline treatment accordingly.

Task

• 11- Lymphoma
• History: Four-year old girl, PUO, weight loss, sweating and abdominal distension
• Physical examination: Fever, pallor, abdominal mass
• Order relevant investigations and outline treatment accordingly.


Task
• 12- Juvenile Rheumatoid Arthritis
• History: Thirteen-year old girl, PUO, small joints swellings, skin rash.
• Physical examination: Febrile, joint swellings, maculopapular skin rash
• Order relevant investigations and outline treatment accordingly.

Task

• 13- Drug fever
• History: Four-year old girl, recurrent fever, case of undiagnosed fever on multiple drugs intake
• Physical examination: Febrile,
• Order relevant investigations and outline treatment accordingly.

Task

• 14- Factitious fever
• History: Five-year old girl, fever, non plausible manifestations, after a period of legitimate disorder, mother is a medical staff.
• Physical examination: Febrile.
• Order relevant investigations and outline treatment accordingly.

Task

• 15- Toxoplasmosis
• History: Seven-year old male, PUO, low grade with painless cervical swelling. History of raising pets at home.
• Physical examination: Febrile, unilateral cervical LAP.
• Order relevant investigations and outline treatment accordingly.


Thank you