جديد Flashcards
(47 cards)
FUO
Definition
Old definition: 3حاجات مع بعض
* Fever > 38^\circ C on several occasions
* > 3 weeks duration
* And No diagnosis established despite 1 week of intensive evaluation test
FUO
Recent definition and categories
- Classic FUO: The original criteria of FUO + evaluation of at least 3 days in hospital or 3 outpatient visits or 1 week of logical & intensive outpatient tests.
- Nosocomial FUO: Fever occurring in hospitalized patients who was admitted for at least 24 hours and hasn’t been manifested by any signs of infection before admission, 3 days of evaluation at least are needed.
- Neutropenic (immunodeficient) FUO: ANC < 500/mm+ Recurrent fever and has been evaluated for 3 days & no established diagnosis.
- HIV - Associated FUO: Recurrent fever over 4 week duration in an outpatient or for 3 days in a hospital admitted HIV+ patient
Cause of fuo
Infections
Infections (30-40%)
* T.B especially Extra-Pulmonary
* Typhoid Fever - Mal treated
* Abdominal abscess (Amebic Liver abscess, Pyogenic Liver abscess, Subphrenic)
* Pelvic abscess
* Dental abscess
* Brucellosis
* CMV
* EBV
* HIV
* Septic arthritis
* Osteomyelitis
* Lyme disease
* Infective endocarditis
* Leptospira
* Histoplasmosis
* Malaria (no falciparum)
Causes of fuo
Malignancies
Lymphoma
* Leukemia (chronic)
* Metastatic Cancer
* Multiple myeloma
* Myelodysplastic Syndrome
* Hepatoma
*Cancer colon
* Sarcoma
* Bronchogenic Carcinoma
* Renal cell Carcinoma
Causes of FUO
Autoimmune
Autoimmune
* SLE
* Sjogren’s
* Rheum. Fever
* Still’s disease
* Rheum. arthritis
* Temporal arteritis
* Reiter’s $
Causes of FUO
Misselenous
Sarcoid
* FMF
* Thyrotoxicosis
* Hemolytic blood diseases
* Factitious fever? ازاي؟
1- Ingestion of pyrogenic material
2-Hot drinks/keep before temp. reading
3-Switching thermometer
Role aof animal contact in diagnosis of FUO
1-Cats:
* Cat scratch disease (Bartonella henselae).
*toxoplasmosis
2-Dogs :
*Leptospirosis.
* echinococcosis.
* rabies
3-Farm animals (cattle, sheep, goats)
*Brucellosis,.
*Q fever (Coxiella burnetii).
* anthrax
4-Rodents:
*Leptospirosis,.
*hantavirus.
* plague (Yersinia pestis)
5-Birds:
*Psittacosis (Chlamydia psittaci).
*avian influenza
6-Bats:
*histoplasmosis (via guano)
*Nipah virus
Role aof travel history in diagnosis of FUO
1-Sub-Saharan Africa :
Malaria, typhoid, African trypanosomiasis, Ebola.
2-Central/South America: Chagas disease,
عشان المناجم histoplasmosis
3-Caves/mines (bat exposure) Histoplasmosis
4-South/Southeast Asia Dengue, typhoid fever, leptospirosis, TB
5-Middle East:
Brucellosis, leishmaniasis
6-Rural/freshwater exposure worldwide Schistosomiasis
Ag shift
*Sudden major change leading to new Subtype .
*May cause Pandemic
*There is exchange of gene segment.
*occur in A Subtype only
Ag drift
*minor, gradual change leading to Point mutations of the Same Subtype.
*May cause epidemic.
*There is Point Mutation.
*occur in A & B Subtypes
Plan management after needle stick injury
في الجون
- Immediate First Aid
*Wash the site with soap and water.
*Do not squeeze or apply bleach/disinfectants directly.
*If mucous membrane exposure (eyes, mouth): irrigate thoroughly with water or saline. - Report and Document
3-Risk Assessment:
Test for HBV, HCV, HIV
4-Post-Exposure Prophylaxis
*HIV Start within 1–2 hours, ideally <72 hours. Use 3-drug ART (TDL)(e.g., Tenofovir + Lamivudine + Dolutegravir) for 28 days.
*HBV :
Depends on vaccination and antibody status:
1-If Vaccinated + titre Anti-HBs >10 mIU/mL….no action
2-if Unvaccinated → HBIG + HBV vaccine series
*HCV:
No post exposure prophylaxis.
5- Follow-up Testing
Time Tests
6 weeks :HIV, HCV RNA
3 months :HIV, Anti-HCV
6 months :Final HIV, Anti-HCV
A 20-year-old woman went to her doctor complaining of a sore throat. It started 4 days previously with associated episodes of fever and chills. On examination her doctor noticed that her tonsils and uvula were red and slightly swollen and that she had cervical lymphadenopathy. Suspecting a bacterial infection her doctor prescribed a course of ampicillin and suggested that she took a couple of days off work. The patient returned a week later with worsening symptoms. She was now very lethargic with a temperature of 38.5°C and a widespread maculopapular rash. On the second visit to her doctor, she had patches of white exudate on her tonsils, petechial hemorrhages on the soft palate, and generalized lymphadenopathy. The doctor could also palpate an enlarged spleen and noticed that she was slightly tender over the right hypochondrium.
A: What is the most likely diagnosis?
EBV
B: What are the remote complications?
1-Splenic rupture – due to splenomegaly (avoid contact sports)
2. Autoimmune hemolytic anemia and thrombocytopenia
3. Hepatitis or cholestatic jaundice
4. Neurological complications:
Guillain-Barré syndrome
Meningitis, encephalitis
Bell’s palsy
5. Airway obstruction from severe tonsillar enlargement
6. Reactivation in immunocompromised individuals
7. Association with malignancies:
*Hodgkin lymphoma
*Nasopharyngeal carcinoma
*Burkitt lymphoma (especially in endemic areas)
C: How is this disease diagnosed?
*Seology
*Pcr
*Monospot test (heterophile antibody test): positive in most cases after 1 week
A 31-year-old Sudanese male sanitation worker in a municipality was referred to the emergency department with complaints of difficulty in opening his mouth and swallowing and painful stiffness in his back and chest that started three days prior to his admission. Symptoms were aggravated by breathing and movement. The general stiffness in his body increased gradually. The spasms of the back muscles were compatible with opisthotonus. The patient had no known medical history, did not take any medications, and was unvaccinated. Physical examination was significant for an unhealed wound on his right hand that was caused by a metal cut approximately a month prior to his admission.
A: What is the most likely diagnosis and what is the causative agent?
Tetanus,cl.tetani
B: What is the appropriate management strategy?
Management
1-Supportive care:
*Admit to ICU due to risk of respiratory failure.
*Airway support may be needed (intubation or tracheostomy).
*Minimize external stimulation (quiet, dark room).
2. Neutralize the toxin:
Administer Tetanus Immune Globulin (TIG) intramuscularly – to neutralize circulating toxin.
Dose: typically 3000–6000 IU IM (once)
3. Halt toxin production:
Begin antibiotics:
Metronidazole (preferred) than Penicillin G
Note: Metronidazole is often favored to avoid GABA antagonism of penicillin.
4. Control muscle spasms:
Benzodiazepines (e.g., midazolam or diazepam) – to reduce spasms and anxiety.
*Consider neuromuscular blockers if severe spasms threaten airway.
5. Care of the wound:
Wound debridement to remove necrotic tissue and reduce bacterial load.
6. Immunization:
Start the tetanus vaccination series (toxoid) as the patient is unvaccinated
Pathogenesis & Treatment of Malignant Malaria
Pathogenesis:
* Malignant malaria (due to Plasmodium falciparum) is usually severe and occurs due to Clumping of parasitized RBCs and adherence to specific receptors on endothelial wall of capillaries of internal organs which lead to hypoxia, ischemia, and necrosis. This may lead to:
1-Anemia
2-Bleeing tendency.
الاتنين مع بعض اخوان
3-Altered mental status
4-Cerebral malaria: Altered mental status +seizures + coma
الاتنين الاخوات
5-Dysentric malaria
6-Choleretic malaria..(watery diarrhea)
الاتنين اخوات
7-Renal failure
8-Pulmonary edema
الاتنين اخوات
9-Hypoglycemia
اللي هيموت العيان
10-Black water fever
Hemolysis + Hemoglobinuria + Renal failure (it may occur due to hemolysis precipitated by a drug or dietary factor in patients with G6PD deficiency or high level of parasitemia>100.000).
Malaria Paroxysm
*Recurrent febrile episodes of fever with peroids free of fever in between.
*Its duration is according to the type of Plasmodium:
1- P. falciparum: Irregular
2- P. malariae: every 72h
3- P. ovale, P. vivax: every 48 h
*stages:
1- Cold stage (chills)
2- Hot stage (fever)
3-Sweating stage
* Cause:
1-Cytokines released due to rupture of parasitized RBCs. 2-Parasites produce schizont which rupture in plasma of patients.
Malaria Relapse
Recurrence of illness after previous complete parasite clearance due to rupture of hypnozoites.
* Usually occurs in P. vivax & P. ovale (الأنواع الكامنة) 8-24 weeks after clearance
Malaria Recrudescence
- ” is the term for recurrence of infection with all malaria species including P. falciparum, P. malariae and P. knowlesi, which lack hypnozoites.
This occurs when the infection
has persisted in the blood at undetectable levels
يعني العدوي موجودة بس ال parasitemia قليل ومش مرصود… - relapse …
Relapse is when symptoms reappear after the parasites have been eliminated from blood but persist as dormant hypnozoites in liver cells. Malaria relapse occurs commonly seen with P. vivax and P. ovale infections
Diagnosis of complicated malaria
Malignant Malaria. فاكر
قولهم وقول تشخصهم ازاي؟
1-Cerebral malaria:
DCL +Convulsions.
* CT Brain
* CSF analysis
2-Black water fever: Hemolysis + Renal failure + Hemoglobinuria.
اطلب
* Urine analysis
* Renal function tests
3-Severe Anemia:
* CBC
4-Hypoglycemia:Blood glucose level
5-Renal failure:
* Renal function tests
6-Pulmonary edema:
* Dyspnea, Bilateral fine crepitations
7- Bleeding tendency:
* CBC → ↓ Platelets
* Fibrinogen degradation product ↑, INR ↑
8- Blood film to diagnose malaria
9-Detect level of parasitemia:
* If 5- 10%: ICU admission.
* If > 15%: For exchange transfusion
10- Other tests to detect malaria:
* Rapid dipstick to detect aldolase (present in all malaria species)
* HRP2 gene specific for P. falciparum
* PCR
* IFAT
Investigations of Malaria
A-Clinical Suspicion:
* Traveler from or resident in endemic area
+
* Fever or flu-like symptoms
* Jaundice
* Splenomegaly
* DCL
* Anemia
* History of exposure to mosquitoes
B-Labs:
1-Blood film:
* Thin film (Giemsa or Leishman stain): Detect only malaria parasite.
* Thick film (Giemsa or Leishman stain): Detect type of malaria and Parasitemia (Percentage of infected RBCs): Which helps in making decision if patient needs ICU or not.
* 5-10%: For ICU
* >15%: → Exchange transfusion
2-ELISA
3-IFT
4-PCR
5-HRP2 gene specific for P. falciparum
6-Rapid dipstick to detect aldolase (present in all malaria species)
Guidelines of treatment of malaria
A-Uncomplicated:
* Chloroquine sensitive : use Chloroquine
* Chloroquine resistant : use Artemisinin based Combination:
1- artemether + lumefantrine
اللي هو الكوارتم
2-artesunate + amodiaquine
3-artemether + mefloquine
B-Complicated:
Quinine IV OR Artesunate based Combination therapy for at least 24 h, once the Patient received the IV therapy & he is tolerable for oral therapy, he can receive Artemisinin based Combination Therapy.
C- p vivax,oval :Receive primaquine
الجرعات
Artesunate \ 2.4 mg/kg/dose
At 0, 12, 24 then daily for 5-7 days
Artemether - lumefantrine) =Coartem
< 15 kg … 1 tab
15 - 25 kg … 2 tab
25 - 35 kg …… 3 tab
> 35 kg …… 4 tab
0,8,24,36,48,60 hour
1st trimester of pregnancy
pregnant women with uncomplicated P. falciparum during 1st trimester by Quinine + Clindamycin
Prophylaxis
*Doxycycline 2 days before travel & continue 1 week after return
*Chloroquine, mefloquine
2w before travel & continue
4 w after return
