pyria of unknown origin
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PUOPUO Illness of at least 3 weeks duration. Fever over 38.3 °C on several occasions. Diagnosis has not been made after three outpatient
visits or 3 days of hospitalization.
CAUSES OF PUO
Infections 45 % Malignancy 20 %Connective Tissue
Diseases15 %
Other causes
20%
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COMMON CAUSESCOMMON CAUSES
Most cases represent unusual manifestations of common diseases and not rare or exotic diseases eg tuberculosis, endocarditis, gallbladder disease and hepatitis are more common causes of PUO or FUO than Whipple disease or familial Mediterranean fever
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Infectious Causes of PUOInfectious Causes of PUOSepsisAbscess at any site: cholecytic/ cholangitisUrinary tract infection: prostatitis Dental and sinus infectionBone and Joint infection Malaria, dengue, brucellosisEnteric Fever, Infective endocarditisTuberculosis (particularly extrapulmonary) Viral infections, Fungal infection
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VIRAL CAUSES OF PUOVIRAL CAUSES OF PUO
CMV infection Infectious mononucleosisHIV infection Arbovirus infection Hepatitis A, B, C infection Erthrovirus infection
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BACTERIALBACTERIAL
Chlamydial infection Q Fever Brucellosis Mycoplasma infection Syphilis Rickttsial infection Melioidosis
Leptospirosis Lyme disease Yersinia infection Relapsing fever Bartonoellosis
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FUNGAL FUNGAL
Crytococcosis Histoplasmosis Coccidioidomycosis
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PROTOZOAL AND PARASITICPROTOZOAL AND PARASITIC
Toxoplasmosis Schistosomiasis Amoebiasis Leishmaniasis trypanosomiasis
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MALIGNANCYMALIGNANCY Lymphoma Multiple myloma Leukaemia Solid tumours
- renal
- liver
- colon
- stomach
- pancreas
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CONNECTIVE TISSUE CONNECTIVE TISSUE DISORDERSDISORDERS
Vasculitic disorders ( including polyatertis nodosa and rheumatiod diseases with vasculitis )
Temporal arteritis/ polymyalgia rheumatica
Systemic lupus erthematosus (SLE)
Still’s disease
Polymyositis
Rheumatic fever
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MISCELLANEOUS MISCELLANEOUS
Inflammatory bowel disease Liver disease: cirrhosis and garnulomatous Hepatitis Sarcoidosis Drug reaction Atrial myxoma Thyrotoxicosis Hypothalamic Familial Mediterranean fever
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NO DIAGNOSIS OR RESOLVE SPONTANEOUSLY
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EARLY TESTS IN THE INVESTIGATION EARLY TESTS IN THE INVESTIGATION OF PUOOF PUO
Full blood count (FBC) and differential counts Erythrocyte sedimentation rate (ESR)and C-reactive
protein (CRP) Serum ferritin Urea, ceratinine and electrolytes Liver functions tests (LFTs)and r-glutmayl transferase Blood glucose Bone Biochemistry Creatine phosphokinase Malaria blood films
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Other testsOther tests
Urinalysis Midstream urine(MSU)for microscopy and culture Faeces culture Sputum for routine microscopy and culture, and
microscopy and culture for mycobacteria Blood culture x 3 Chest X-Ray Ultrasound examination of abdomen Electrocardiogram (ECG)
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TreatmentTreatment
In the seriously ill or rapidly deteriorating patient, empiric therapy is often given. Once definitive culture results return, streamlining therapy to the most narrow spectrum antimicrobial should take place
An empiric course of antimicrobials should also be considered if a diagnosis is strongly suspected.
However, if there is no clinical response in several weeks, it is imperative to stop therapy and re-evaluate the patient.Antituberculosis medications (particularly in the elderly) and broad-spectrum antibiotics are reasonable in this setting.
Empiric administration of corticosteroids should be discouraged; they can suppress fever if given in high enough doses, but they can also exacerbate many infections, and infection remains a leading cause of FUO.