PUO

Question 1

What criteria define the classic PUO? Give 3 aetiologies

Answer 1

Temp >38.3
>3w
>,3 OP evaluations/ >,3d IP
Infection, Malignancy, Collagen vascular disease

Question 2

What criteria define the nosocomial PUO? Give 3 aetiologies

Answer 2

Temp >38.3
Patient hospitalised >24h but no fever or incubating on admission
>,3d evaluation
C. diff enterocolitis, Drug induced, PE

Question 3

What criteria define the immune deficient PUO? Give 4 aetiologies

Answer 3

Temp >,38.3
Neutrophils ,<500/mm3
>,3d evaluation
Opportunistic bacterial infections, Aspergillosis, Candidiasis, HSV

Question 4

What criteria define the HIV-associated PUO? Give 3 aetiologies

Answer 4

Temp >38.3
>4w OP / >3d IP
HIV+
CMV, Mycobacterium avium complex, PCP

Question 5

What is the trend in the number of patients with no identified diagnosis presenting with PUO? Why?

Answer 5

Increasing
Ageing populaiton
Development of immunosuppressive drugs
Increasingly survivable chronic conditions

Question 6

How does PUO differ with geographic trends?

Answer 6

European: 11-26% due to infectious cause
India: 55% due to infectious cause

Question 7

What broad causes predominate in children with PUO?

Answer 7

Infection 44%
No diagnosis 43%

Question 8

Which 7 features should not be missed in taking a PUO history?

Answer 8

B-Sx
Localising Sx
DH: doses + initiation
Contact hx, Pets, Animal exposure
IVDU
Sexual hx
Travel, accommodation + activities abroad

Question 9

Give 5 example risk activities that should be enquired about in PUO

Answer 9

White water rafting: water borne pathogens
Caving: bat poo
Safari: Tick bites
Prostitutes: STIs
Medical elective: sick contacts

Question 10

Give 6 aspects of examination in PUO

Answer 10

Head to toe
Fundoscope: infective endocarditis
ENT: oral thrush- HIV seroconversion
Erythema migraines: Rickettsias
Thump Spine: many infections have predilection for vertebrae
Temporal artery palpation: Temporal arteritis

Question 11

What 7 basic investigations may be taken in A+E for PUO?

Answer 11

FBC
U+Es
LFT
CRP
Urine dip
Blood cultures
CXR

Question 12

What is the most useful test to confirm EBV infection 2 weeks after exposure in an immunocompetent patient?

Answer 12

EBV IgM
Rises in 1-2w, stays high for 2-4w, then decreases

Question 13

What does and FDG-PET CT scan show?

Answer 13

Radiolabelled glucose accumulates in hyper metabolic cells (infection, inflammation, malignancy)
Identifies focus (doesn’t determine cause)

Question 14

Which criteria is used in diagnosing infective endocarditis? Give the 3 major criteria

Answer 14

Duke’s criteria
Persistent bacteraemia >2 BC +ve
Echo: vegetation
+ve serology for Bartonella, Coxiella or Brucella

Question 15

Give the 6 minor criteria in Duke’s criteria

Answer 15

Predisposition (murmur, IVDU)
Inflammatory markers (Fever, CRP high)
Immune complexes: splinters, RBCs in urine
Embolic phenomena: Janeway lesions, CVA
Atypical echo
1 +ve BC

Question 16

When suspecting an infective cause of PUO, what blood tests do you request?

Answer 16

Rare + Imported Pathogens Laboratory bloods (RIPL)

Question 17

What go to inflammatory cause of PUO should be considered in young patients and old patients?

Answer 17

Young: Adult-onset Stills
Old: GCA

Question 18

What are 4 major criteria of adult-onset stills disease?

Answer 18

Temp >39 for >1w
Leukocytosis >10,000
Salmon pink rash
Arthralgias >2w

Question 19

What measurement may be high and help diagnose adult onset Stills disease?

Answer 19

Serum ferritin
Due to macrophage activation syndrome

Question 20

What is adult onset stills disease?

Answer 20

Rare inflammatory arthritis
Monophonic, Intermittent or Chronic

Question 21

Give 5 minor criteria for adult onset stills disease

Answer 21

Sore throat
Lymphadenopathy
Splenomegaly/ hepatomegaly
Abnormal LFT
ANA + RF -ve

Question 22

Give 3 investigations for GCA

Answer 22

High ESR + CRP
Duplex US
Temporal Artery Biopsy (GS)

Question 23

How should suspected GCA be treated?

Answer 23

High dose glucocorticoids STAT e.g. Prednisolone
Involve rheumatology

Question 24

Give 4 malignant causes of PUO

Answer 24

Lymphoma esp. non Hodgkins
Leukaemia: BM biopsy
Renal cell carcinoma +/- haematuria
Hepatocellular carcinoma/ liver mets

Question 25

Why is PUO in lymphoma a difficult diagnosis?

Answer 25

Often advanced disease with aggressive subtype Presentation overlaps with infectious causes e.g. TB Raised LDH, weight loss, lymphadenopathy

Question 26

Give a miscellaneous cause of PUO

Answer 26

Drug fever (ADR) Idiosyncratic reaction / affect on thermoregulation +/- Eosinophilia +/- rash

Question 27

Give 5 causes of PUO which warrant urgent treatment pre-confirmation

Answer 27

Infective endocarditis Disseminated TB CNS TB GCA Sepsis

Question 28

Give 3 features raising suspicion of infective endocarditis and 3 investigations

Answer 28

New cardiac murmur Splinter haemorrhages Hx of valvular pathology /IVDU BC Echo Serology for Brucella, Bartonella, Q fever

Question 29

Give 4 features raising suspicion of disseminated TB and 4 investigations

Answer 29

Weight loss Drenching night sweats Cough Travel/ time spent in endemic region Mycobacteria BC Sputum culture for acid-fast bacilli HIV test CXR

Question 30

Give 3 features raising suspicion of CNS TB and 3 investigations

Answer 30

Headaches Reduced level of consciousness Travel/ time spent in endemic region Cerebral MRI/ CT with contrast LP HIV test

Question 31

Give 3 features raising suspicion of GCA

Answer 31

Unilateral headache Jaw claudication Scalp tenderness Polymyalgia rheumatica Visual loss ESR Temporal artery biopsy Visual acuity assessment

Question 32

Give 4 features raising suspicion of sepsis. What investigations/ management is necessary?

Answer 32

Resp rate >20 SBP <100 HR > 90 Altered mental status Blood cultures Urine output: measure- catheter Fluids Abx Lactate O2