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Fever of Unknown Origin

Fever of Unknown Origin. Domenick Roma 7/31/2009. Types. Classic FUO Nosocomial FUO Immune-deficient FUO HIV-related FUO. Definition. Fever higher than 38.3ºC on several occasions Duration of fever for at least three weeks Uncertain diagnosis after one week of study in the hospital

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Fever of Unknown Origin

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  1. Fever of Unknown Origin Domenick Roma 7/31/2009

  2. Types • Classic FUO • Nosocomial FUO • Immune-deficient FUO • HIV-related FUO

  3. Definition • Fever higher than 38.3ºC on several occasions • Duration of fever for at least three weeks • Uncertain diagnosis after one week of study in the hospital • Uncertain diagnosis after 3 outpatient visits or three days of study in the hospital.

  4. History

  5. Physical Exam • Facial/Sinus Tenderness  Sinusitis • Temporal Artery Tenderness Temporal Arteritis • Tenderness of a Tooth  Periapical Dental Abscess • Roth Spots on Fundoscopic Exam Endocarditis • Enlarged Tender Thyroid  Thyroiditis • Murmur  Endocarditis • Perirectal Tenderness/Fluctuance  Perirectal Abscess • Prostatic Tenderness  Prostatitis or Prostate Abscess • Splenomegaly  Lymphoma, Endocarditis, Leishmaniasis • Lymphadenopathy  Lymphoma, HIV, Tuberculosis • Calf Tenderness  DVT

  6. Comprehensive History Physical Examination Complete blood count, including differential and platelet count Blood cultures (three sets drawn without administering antibiotics) Routine blood chemistries, including liver enzymes and bilirubin Hepatitis serologies (if liver tests abnormal) Urinalysis, including microscopic examination, and urine culture Chest radiograph Erythrocyte sedimentation rate (and/or C-reactive protein) Antinuclear antibodies Rheumatoid factor Angiotensin-converting enzyme Cytomegalovirus IgM antibodies or virus detection in blood Heterophile antibody test in children and young adults Mantoux skin test CT scan of abdomen (or radionuclide scan) HIV antibody test Approach to Diagnosis

  7. Invasive Testing • Liver Biopsy • Lymph Node Biopsy • Bone Marrow Biopsy/Culture • Temporal Artery Biopsy • Exploratory Laparotomy

  8. Causes

  9. Causes • Infectious (16%) • TB, Abscess, Endocarditits, Osteomyelitis, Dental Abscess • Malignancies (7%) • Lymphoma, Leukemia, Renal Cell Carcinoma, Liver (HCC or metastases) • Connective Tissue Disease (22%) • Adult Stills Disease, Temporal Arteritis, polyarteritis nodosa, Takayasu's arteritis, Wegener's, mixed cryoglobulinemia • Other (4%) • DVT, Drugs, Factitious, Hypothalmic Dysfunction, Hereditary Fever Syndromes • Undiagnosed (51%)

  10. Treatment & Prognosis • Treatment • Empiric antibiotics? • Trial of Steroids? • Prognosis • Depends on final diagnosis • Undiagnosed generally have good prognosis

  11. References • Clinical Medicine 2008 Oct 8 (5): 526-530. • Arch Intern Med. 2003 Mar 10;163(5):545-51. • Am Fam Physician. 2003 Dec 1;68(11):2223-8. • Up-to-Date

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