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MCD - Fever Flashcards

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1
Q

Etiology of Fever - Respiratory infections?

A
  1. Acute bronchitis.
  2. Pneumonia.
  3. Influenza.
  4. Empyema.
  5. Infective exacerbation of bronchiectasis/COPD.
  6. TB.
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2
Q

Etiology of fever - GI causes?

A
  1. Gastroenteritis.
  2. Appendicitis.
  3. Biliary sepsis.
  4. Viral hep.
  5. Diverticulitis.
  6. Intra-abdominal TB.
  7. Hepatic abscess.
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3
Q

Etiology of fever - Skin/soft tissue?

A
  1. Cellulitis.
  2. Erysipelas.
  3. Necrotizing fasciitis.
  4. Pyomyositis.
  5. Infected pressure sore.
  6. Wound infection.
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4
Q

Etiology of fever - Musculoskeletal causes?

A
  1. Septic arthritis (native and prosthetic joint).
  2. Osteomyelitis.
  3. Discitis.
  4. Epidural abscess.
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5
Q

Etiology of fever - Genitourinary tract?

A
  1. Lower UTI, e.g. cystitis, prostatitis.
  2. Upper UTI (pyelonephritis).
  3. Perinephric collection.
  4. Pelvic inflammatory disease.
  5. Epididymo-orchitis.
  6. Syphilis.
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6
Q

Etiology of fever - CNS?

A
  1. Meningitis (bacterial, viral, fungal, TB).
  2. Encephalitis.
  3. Cerebral abscess.
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7
Q

Etiology of fever - ENT?

A
  1. Upper RTI, eg tonsillitis.
  2. Otitis media.
  3. Quinsy.
  4. Dental abscess.
  5. Mumps/Parotitis.
  6. Glandular fever (EBV).
  7. Sinusitis.
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8
Q

Etiology of fever - Immunocompromised patients?

A
  1. Pneumocystis jiroveci (carinii) pneumonia.
  2. Aspergillosis.
  3. TB.
  4. Atypical mycobacterial infection, eg MAI.
  5. CMV infection.
  6. Toxo.
  7. Cryptococcal meningitis.
  8. Nocardia.
  9. Disseminated herpes/fungal infection.
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9
Q

Etiology of fever - Returning travelers?

A
  1. Malaria.
  2. Typhoid.
  3. Infective diarrhea, eg cholera, amebiasis, Shigella.
  4. Amebic liver disease.
  5. Strongyloides infection.
  6. Schistosomiasis.
  7. Dengue.
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10
Q

Etiology of fever - Other infectious causes?

A
  1. Leptospirosis.
  2. Brucellosis.
  3. Lyme.
  4. Q fever.
  5. HIV.
  6. Toxo.
  7. Fungal infection.
  8. Measles.
  9. Rubella.
  10. Herpes zoster infection (chickenpox or shingles).
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11
Q

Etiology of fever - Malignancy?

A
  1. Hematological malignancy - Lymphoma/leukemia/myeloma.

2. Solid tumors - Renal, Liver, colon, pancreas.

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12
Q

Etiology of fever - Connective tissue disease?

A
  1. Giant cell arteritis/Polymyalgia rheumatica.
  2. RA.
  3. SLE.
  4. Polymyositis.
  5. Polyarteritis nodosa.
  6. Wegener.
  7. Churg-Strauss.
  8. Cryoglobulinemia.
  9. Adult-onset Still’s disease.
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13
Q

Etiology of fever - Drugs?

A
  1. Drug fever (almost any drug).
  2. Antipsychotics (neuroleptic malignant syndrome).
  3. Anesthetics (malignant hyperthermia).
  4. Cocaine, amphetamines, ecstasy.
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14
Q

Etiology of fever - Miscellaneous causes?

A
  1. Transfusion-associated.
  2. Thyrotoxicosis, thyroiditis.
  3. Pheochromocytoma.
  4. DVT/PE.
  5. Pancreatitis.
  6. Alcoholic hep/ delirium tremens.
  7. Rheumatic fever.
  8. IBD.
  9. Sarcoidosis.
  10. Atrial myxoma.
  11. Familial Mediterranean fever.
  12. Erythroderma/Stevens-Johnson syndrome.
  13. Factitious (fever or apparent fever surreptitiously engineered by the patient).
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15
Q

Fever overview - Step 1?

A 
Exposure to blood products, anesthetic, antipsychotics or stimulants.
If YES:
1. Transfusion reaction.
2. Malignant hyperthermia.
3. Neuroleptic malignant syndrome.
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16
Q

Fever overview - Step 2?

A

HR>90, RR>20, or abnormal WBC/CRP.

If YES –> SIRS/sepsis.

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17
Q

Fever overview - Step 3?

A

Specific risk factor for infection.

If YES –> Further targeted investigation.

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18
Q

Fever overview - Step 4?

A

Clinical findings/initial tests suggest a likely source.

If YES –> Confirm diagnosis +/- empirical treatment.

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19
Q

Fever overview - Step 5?

A

Positive cultures.

If YES –> Seek source +/- specific antimicrobial therapy.

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20
Q

Fever overview - Step 6?

A

Persistent fever.

If YES –> See further assessment of pyrexia of unknown origin.

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21
Q

Fever caused by transfusion - What to do?

A
  1. Stop the transfusion.
  2. Ensure compatibility.
  3. Contact the blood bank and seek immediate Hematology input if there is any suspicion of ABO incompatibility or other major transfusion reaction.
  4. Otherwise, monitor temperature and vital signs, and consider restarting the transfusion at a slower rate if observations are stable, the patient is systemically well and the rise in temperature is <1.5C.
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22
Q

Fever due to neuroleptic malignant syndrome - When to suspect?

A

If the patient has received neuroleptics, eg haloperidol, within the past 1-4weeks and exhibits muscular rigidity, tremor and excessive sweating and/or altered mental status, especially in association with incr. CK.

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23
Q

Fever due to toxic hyperthermia?

A
  1. Ask about cocaine, ecstasy, amphetamines.
  2. Temperature >39.
  3. UP BP, UP HR, dilated pupils, aggression, psychosis or serotonin syndrome eg rigidity, hyper-reflexia.
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24
Q

Fever due to rhabdomyolysis, ARF, arrhythmia, DIC, acute liver failure - What to measure?

A
  1. CK.
  2. U+E.
  3. LFTs.
  4. Coagulation.
  5. Monitor ECG, HR, BP, urine output.
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25
Fever due to malignant hyperthermia - When to assume?
Severe pyrexia with tachycardia +/- rhabdomyolysis during administration of, or within 1-2 hrs of exposure to, a volatile anesthetic, eg halothane, or succinylcholine.
26
Fever with HR>90, RR>20 or abnormal WBC/CRP - What to think?
Assess the patient for SIRS/sepsis.
27
SIRS/Sepsis - What is ESSENTIAL to minimize mortality?
EARLY + APPROPRIATE antibiotic treatment.
28
Criteria for determining SIRS:
2 or more of: 1. Temperature >38C or 90. 3. RR>20. 4. WBC>12.000 or <4.000 or 10% immature forms; or UP CRP.
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Criteria for determining sepsis:
SIRS + suspected or proven infection.
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Criteria for determining SEVERE sepsis:
Sepsis + Organ dysfunction or hypotension.
31
Criteria for determining septic shock:
Severe sepsis that persists despite adequate fluid resuscitation.
32
What is the septic screen?
1. Combines clinical assessment with lab analysis and imaging studies to identify a source of infection. 2. It may also reveal non-infectious causes of pyrexia, eg malignancy. 3. Full septic screen may NOT be required in all patients, especially if there is an OBVIOUS focus of infection.
33
Septic screen - General?
1. >2sets of blood cultures. 2. Urinalysis. 3. FBC. 4. U+E. 5. LFTs. 6. CRP. 7. CXR.
34
Septic screen - Respiratory:
1. Assess suspected RTI - eg new/worsening cough with purulent sputum or CXR consolidation. 2. Perform a pleural tap and send fluid for biochemical, microbiological and cytological analysis if unilateral pleural effusion. 3. If other respiratory features - eg Hemoptysis, non-specific CXR hypoxia, consider further investigation - eg CT, bronchoscopy to exclude atypical infection, lung cancer and PE.
35
Septic screen - Abdominal?
1. Stool --> Microscopy, culture, C.difficile toxin if acute diarrhea. 2. IBD --> Flexible sigmoidoscopy, if persistent bloody diarrhea. 3. Fever + ASCITES --> Treat empirically SBP, pending culture, if >250Neutros. Consider TB/malignancy if cultures(-) and fluid exudative.
36
Septic screen - Abdominal - New-onset jaundice?
Arrange an abdominal USS and serology for viral hep. 1. Empirically for biliary sepsis and arrange surgical review. 2. Blood + urine samples for LEPTOSPIROSIS and serology +/- PCR if symptoms include purpura/down platelets/conjunctival congestion or recent exposure to potentially contaminated water eg freshwater sports, sewage worker.
37
Septic screen - Abdominal - Amylase?
Check amylase and assess accordingly.
38
Septic screen - Abdominal - Palpable mass?
If palpable abdominal mass investigate for infective eg diverticular or appendiceal abscess, non-infective eg carcinoma, lymphoma, causes with USS or CT +/- aspiration or biopsy.
39
Septic screen - Urinary tract - Step 1:
Send a mid-stream urine (MSU) specimen if new-onset urinary tract symptoms, an indwelling catheter, or leukocytes/nitrites on urinalysis (Highly unlikely in the absence of either nitrites or leukocytes).
40
Septic screen - Urinary tract - Step 2:
Arrange USS to exclude renal obstruction, calculus, or a perinephric collection if loin pain or renal angle tenderness.
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Septic screen - Urinary tract - Step 3:
Exclude urinary tract cancer +/- inflammatory renal disease if peristent hematuria (visible or non-visible) or loin pain with repeated negative MSU.
42
Septic screen - Urinary tract - Step 4:
Send swabs for N.gonorrhea and Chlamydia if urethral or PV discharge.
43
Septic screen - Skin and soft tissue - Steps:
1. Swabs from any wounds or sites discharging pus. 2. Suspect cellulitis if there is an area acutely hot, erythematous, painful - Look for potential entry sites. 3. Severe necrotizing infection --> Immediate surgery + Antibiotics. 4. DVT may produce low grade fever. 5. Osteomyelitis eg bone scan, persistent non-healing ulcer. 6. Whole body for rashes - urgent dermatology advice if blistering, mucosal involvement or pustules.
44
Septic screen - CNS - Steps:
1. Assume CNS infection, initially, if severe meningism, purpuric rash etc. 2. Immediate empiric treatment after blood cultures. 3. Arrange neuroimaging. 4. If no contraindications - Perform LP. 5. If meningitis suspected, send a throat swab for Neisseria meningitidis PCR.
45
Septic screen - Cardiovascular - Steps:
1. Endocarditis investigations - See criteria. | 2. Consider TE echo if transthoracic images equivocal or persistent high clinical suspicion.
46
Septic screen - ENT - Steps:
1. Autumn/winter --> Throat swab for influenza. 2. Pustular exudates --> Swab for S.pyogenes. 3. Parotitis/Tender lymphadenopathy --> Throat swab for mumps, PCR and, if age-appropriate, check EBV serology (>95% of patients >35yr will have evidence of previous exposure).
47
Septic screen - Musculoskeletal - Steps:
1. If acutely swollen, painful joint, seek urgent orthopaedic assessment and perform diagnostic aspiration to exclude septic arthritis. 2. If unexplained back pain with no other obvious source for fever, take >3 blood cultures + arrange spinal MRI to exclude discitis.
48
Modified Duke Criteria for the diagnosis of infective endocarditis - Major criteria:
A. Positive blood culture: 1. Typical organism from 2 cultures. 2. Persistent positive blood cultures taken >12hrs apart. 3. >3 positive cultures taken over >1hr. B. Endocardial involvement: 1. Positive echocardiographic findings of vegetations. 2. New valvular regurgitation.
49
Modified Duke Criteria for the diagnosis of infective endocarditis - Minor Criteria:
1. Predisposing valvular or cardiac abnormality. 2. IV drug misuse. 3. Pyrexia >38C. 4. Embolic phenomenon. 5. Vasculitic phenomenon. 6. Blood cultures suggestive - organism grown but NOT achieving major criteria. 7. Suggestive echocardiographic findings.
50
Modified Duke - DEFINITE endocarditis?
2M 1M + 3m 5m
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Modified Duke Criteria - POSSIBLE endocarditis?
1M + 1m | 3m
52
Septic screen in specific patient groups - Recent travel or residency abroad:
1. Exact travel/ location/ activities. 2. Ask about vaccinations/malaria prophylaxis. 3. Consult an ID specialist. 4. Exclude malaria if recent travel to an endemic region. 5. If fever + diarrhea --> Isolate the patient and note all recent travel history on stool specimen requests. 6. Send blood and stool cultures for typhoid (and start empirical treatment) if high fever. 7. Consider acute schistosomiasis. 8. Arrange US to exclude amebic abscess. 9. Check dengue fever serology if recent return from the tropics/subtropics and an acute febrile illness.
53
Septic screen in specific patient groups - Immunocompromised HIV(+):
1. HIV(+) - Check the most recent CD4 count and repeat if >3months ago. 2. Fungal and viral infections are more likely if CD4 is PCP.
54
Further assessment of PUO - Step 1:
Discuss the significance of any positive serology with the ID/microbiology team and a positive ANA, ENA, ANCA with the Rheumatology team.
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Further assessment of PUO - Step 2:
1. Biopsy any suspicious masses or lymphadenopathy (incl. bilateral hilar lymphadenopathy) detected clinically or radiologically. 2. If an abscess is identified, request a surgical opinion regarding drainage.
56
Further assessment of PUO - Step 3:
Discuss with Hematology and consider bone marrow exam if Bence-Jones protein, paraproteinemia or a significant blood film abnormality, eg atypical lymphocytes.
57
Further assessment of PUO - Step 4:
Arrange muscle biopsy if CK UP to exclude inflammatory myositis.
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Further assessment of PUO - Step 5:
Perform a radioisotope bone scan to look for evidence of malignancy or osteomyelitis if persistent bony pain, UP Ca, UP PSA, UP ALP (with otherwise normal LFTs).
59
Further assessment of PUO - Step 6:
If LFTs persistently deranged or hepatomegaly without an obvious cause, request a liver biopsy (with material for culture) to look for TB, sarco, and granulomatous hep.
60
Further assessment of PUO - Step 7:
If persistent hematuria/proteinuria with negative MSU, discuss with the Renal team and consider renal biopsy to exclude GN.
61
Further assessment of PUO - Step 8:
Use the Duke and Jones criteria to confirm or refute a suspected diagnosis or endocarditis or RF respectively.
62
Further assessment of PUO - Step 9:
1. Consider an ANCA(-) systemic vasculitis if palpable purpura, skin ulceration, or livedo reticularis. 2. Measure serum cryoglobulins (cryoglobulinemic vasculitis). 3. Consider arteriography eg renal, mesenteric, or tissue biopsy if PAN is suspected.
63
Further assessment of PUO - Step 10:
If ESR UP in a patient >50: A. Treat for giant cell arteritis + biopsy. B. Diagnose polymyalgia rheumatica if there is any proximal joint pain or stiffness - review the diagnosis if no response to steroids within 72hr.
64
Further assessment of PUO - Step 11:
Suspect adult-onset Still's disease if microbiological and autoimmune investigations are consistently negative, and there are recurrent joint pains or a transient, non-pruritic, salmon-pink maculopapular rash that coincides with fever, especially if UP ferritin.
65
Further assessment of PUO - Step 12:
Review all drugs - Discontinue one at a time for 72hr and then reinstate if fever persists.
66
Jones criteria for the diagnosis of RF - Major:
1. Carditis. 2. Polyarthritis. 3. Chorea. 4. Erythema marginatum. 5. Subcutaneous nodules.
67
Jones criteria for the diagnosis of RF - Minor:
1. Fever. 2. Arthralgia. 3. Previous RF. 4. UP ESR or CRP. 5. Leucocytosis. 6. 1st-degree AV block.
68
Jones criteria for the diagnosis of RF - PLUS:
Supporting evidence of preceding strep. infection: 1. Recent scarlet fever. 2. UP Anti-Strep O. 3. Other strep antibody titre. 4. Positive throat culture. - --> Particularly important if there is only one major manifestation.
69
Definition of fever?
Core body temperature >38. | If it persists >3weeks without explanation it is termed pyrexia of unknown origin (PUO).
Internal Medicine
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