PUOPUO Illness of at least 3 weeks duration. Fever over 38.3 °C on several occasions. Diagnosis has not been made after three outpatient

visits or 3 days of hospitalization.

CAUSES OF PUO

Infections 45 % Malignancy 20 %Connective Tissue

Diseases15 %

Other causes

20%

COMMON CAUSESCOMMON CAUSES

Most cases represent unusual manifestations of common diseases and not rare or exotic diseases eg tuberculosis, endocarditis, gallbladder disease and hepatitis are more common causes of PUO or FUO than Whipple disease or familial Mediterranean fever

Infectious Causes of PUOInfectious Causes of PUOSepsisAbscess at any site: cholecytic/ cholangitisUrinary tract infection: prostatitis Dental and sinus infectionBone and Joint infection Malaria, dengue, brucellosisEnteric Fever, Infective endocarditisTuberculosis (particularly extrapulmonary) Viral infections, Fungal infection

VIRAL CAUSES OF PUOVIRAL CAUSES OF PUO

CMV infection Infectious mononucleosisHIV infection Arbovirus infection Hepatitis A, B, C infection Erthrovirus infection

BACTERIALBACTERIAL

Chlamydial infection Q Fever Brucellosis Mycoplasma infection Syphilis Rickttsial infection Melioidosis

Leptospirosis Lyme disease Yersinia infection Relapsing fever Bartonoellosis

FUNGAL FUNGAL

Crytococcosis Histoplasmosis Coccidioidomycosis

PROTOZOAL AND PARASITICPROTOZOAL AND PARASITIC

Toxoplasmosis Schistosomiasis Amoebiasis Leishmaniasis trypanosomiasis

MALIGNANCYMALIGNANCY Lymphoma Multiple myloma Leukaemia Solid tumours

- renal

- liver

- colon

- stomach

- pancreas

CONNECTIVE TISSUE CONNECTIVE TISSUE DISORDERSDISORDERS

Vasculitic disorders ( including polyatertis nodosa and rheumatiod diseases with vasculitis )

Temporal arteritis/ polymyalgia rheumatica

Systemic lupus erthematosus (SLE)

Still’s disease

Polymyositis

Rheumatic fever

MISCELLANEOUS MISCELLANEOUS

Inflammatory bowel disease Liver disease: cirrhosis and garnulomatous Hepatitis Sarcoidosis Drug reaction Atrial myxoma Thyrotoxicosis Hypothalamic Familial Mediterranean fever

NO DIAGNOSIS OR RESOLVE SPONTANEOUSLY

EARLY TESTS IN THE INVESTIGATION EARLY TESTS IN THE INVESTIGATION OF PUOOF PUO

Full blood count (FBC) and differential counts Erythrocyte sedimentation rate (ESR)and C-reactive

protein (CRP) Serum ferritin Urea, ceratinine and electrolytes Liver functions tests (LFTs)and r-glutmayl transferase Blood glucose Bone Biochemistry Creatine phosphokinase Malaria blood films

Other testsOther tests

Urinalysis Midstream urine(MSU)for microscopy and culture Faeces culture Sputum for routine microscopy and culture, and

microscopy and culture for mycobacteria Blood culture x 3 Chest X-Ray Ultrasound examination of abdomen Electrocardiogram (ECG)

TreatmentTreatment

In the seriously ill or rapidly deteriorating patient, empiric therapy is often given. Once definitive culture results return, streamlining therapy to the most narrow spectrum antimicrobial should take place

An empiric course of antimicrobials should also be considered if a diagnosis is strongly suspected.

However, if there is no clinical response in several weeks, it is imperative to stop therapy and re-evaluate the patient.Antituberculosis medications (particularly in the elderly) and broad-spectrum antibiotics are reasonable in this setting.

Empiric administration of corticosteroids should be discouraged; they can suppress fever if given in high enough doses, but they can also exacerbate many infections, and infection remains a leading cause of FUO.