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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 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 • Uncertain diagnosis after 3 outpatient visits or three days of study in the hospital.
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
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
Invasive Testing • Liver Biopsy • Lymph Node Biopsy • Bone Marrow Biopsy/Culture • Temporal Artery Biopsy • Exploratory Laparotomy
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%)
Treatment & Prognosis • Treatment • Empiric antibiotics? • Trial of Steroids? • Prognosis • Depends on final diagnosis • Undiagnosed generally have good prognosis
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