4mb clinical problem-solving dr. gerard flaherty dept. of medicine
TRANSCRIPT
![Page 1: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/1.jpg)
4MB Clinical Problem-Solving
Dr. Gerard FlahertyDept. of Medicine
![Page 2: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/2.jpg)
42-yr-old ♂Presenting Complaint: Pyrexia of Unknown Origin
![Page 3: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/3.jpg)
Definition
“Illness of more than three weeks’ duration, fever higher than 38.3°C (101°F) on several occasions, and diagnosis uncertain after one week of study in hospital.” (Petersdorf and Beeson, 1961)
![Page 4: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/4.jpg)
Definition
“Fever that does not resolve spontaneously in the period expected for self-limited infection and whose cause cannot be ascertained despite considerable diagnostic effort.” (Arnow and Flaherty, 1997)
![Page 5: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/5.jpg)
History ?Night sweats ?Weight loss ?Pruritus Symptoms of underlying illness Previous illnesses Medications Occupational exposures Pets Foreign travel Family history
![Page 6: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/6.jpg)
Physical Examination Vital signs (?relative
bradycardia) ?Jaundice Anaemia ?Hyperpigmentation Abdominal tenderness Hepatosplenomegaly Abdominal mass ENT examination Examine teeth ?Murmurs ?Wounds Auscultate chest
Lymphadenopathy Clubbing Joint swelling Rash Thickened temporal artery Iritis Mouth ulcers Leg swelling (?DVT) Thyroid tenderness Signs of thyrotoxicosis Gouty tophi Tender prostate on PR
exam Testicular tenderness
![Page 7: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/7.jpg)
76-yr-old ♂ with headache and scalp tenderness.Give the diagnosis.
![Page 8: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/8.jpg)
Minimum diagnostic work-up to qualify as PUO
Full history Repeated examination FBC SMAC, including LDH ESR Antinuclear antibodies Rheumatoid factor HIV serology MSU
ACE Blood cultures ×3 CMV serology Monospot Mantoux test Chest radiograph Ultrasound Abdomen CT Abdomen
![Page 9: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/9.jpg)
Further Investigations Discontinue as many medications as possible Tumour markers Echocardiogram Gallium-67 or indium-111-labelled white cell
scan Excision biopsy Laparotomy Temporal artery biopsy Sputum for acid-fast bacilli Bone marrow biopsy
![Page 10: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/10.jpg)
Infective endocarditis
![Page 11: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/11.jpg)
Differential Diagnosis
Disease categories1. Infection2. Neoplasia3. Collagen vascular diseases
![Page 12: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/12.jpg)
The causes of Pyrexia of Unknown Origin are usually familiar diseases with uncommon presentations rather than rare disorders.
![Page 13: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/13.jpg)
Failure to utilise findings correctly, delay in requesting appropriate tests, and misinterpretation of results all contribute to missed diagnoses.
![Page 14: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/14.jpg)
Infection (a partial list!) Intraabdominal abscess; Appendicitis; Cholecystitis; Cholangitis; Mesenteric lymphadenitis; Tubo-ovarian abscess; Intracranial abscess; Sinusitis; Mastoiditis; Otitis media; Dental abscess; Chronic pharyngitis; Tracheobronchitis; Lung abscess; Septic jugular phlebitis; Mycotic aneurysm; Endocarditis; IV catheter infection; Vascular graft infection; Wound infection; Osteomyelitis; Infected joint prosthesis; Pyelonephritis; Prostatitis; TB; Lyme disease; Relapsing fever; Syphilis; Q fever; Legionella; Salmonella; Listeria; Campylobacter; Brucellosis; Psittacosis; Chlamydia pneumoniae; Gonorrhoea; Meningococcaemia; Actinomycosis; Whipple’s disease; Candidaemia; Cryptococcus; Histoplasma; Coccidioidomycosis; Blastomycosis; Aspergillosis; Pneumocystis carinii; Visceral leishmaniasis; Malaria; Babesiosis; Toxoplasmosis; Schistosomiasis; Toxocariasis; Amoebiasis; Hydatid cyst; Trypanosomiasis; CMV; HIV, Herpes simplex; Epstein-Barr virus.
![Page 15: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/15.jpg)
Hepatic abscess
![Page 16: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/16.jpg)
Neoplasia
Pyrexia of unknown origin has been reported in association with 46 different malignancies.
e.g. Lymphoma Renal-cell carcinoma
![Page 17: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/17.jpg)
Collagen vascular diseases
Adult Still’s disease; SLE; Cryoglobulinaemia; Reiter’s syndrome; Rheumatic fever; Giant cell arteritis / Polymyalgia rheumatica; Wegener’s granulomatosis; Ankylosing spondylitis; Behçet’s disease; Polyarteritis nodosa; Sjögren’s syndrome; Polymyositis; Rheumatoid arthritis; Erythema multiforme; Erythema nodosum; Relapsing polychondritis; Mixed connective-tissue disease; Takayasu’s arteritis; Felty’s syndrome; Eosinophilic fasciitis.
![Page 18: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/18.jpg)
Rheumatoid arthritis
![Page 19: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/19.jpg)
30-yr-old ♀ with arthralgia and pleuritic chest pain.Give the diagnosis.
![Page 20: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/20.jpg)
Miscellaneous Haematoma; Thrombosis; Aortic dissection; Femoral aneurysm; Dressler’s syndrome; Atrial myxoma; Drug fever; Familial Mediterranean fever; Familial Hibernian fever; Inflammatory bowel disease; Sarcoidosis; Subacute thyroiditis; Hyperthyroidism; Addison’s disease; Hypothalamic hypopituitarism; Gout; Pseudogout; Cirrhosis; Chronic active hepatitis; Alcoholic hepatitis; Kawasaki’s disease; Gaucher’s disease; Fabry’s disease; Cholesterol emboli; Sickle cell disease; Cyclic neutropenia; Hamman-Rich syndrome; Hypersensitivity pneumonitis; Extrinsic allergic alveolitis; Stroke; Brain tumour; Encephalitis; Psychogenic fever; Factitious fever.
![Page 21: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/21.jpg)
24-yr-old ♂ with dyspnoea and a painful red eye.Give the diagnosis.
![Page 22: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/22.jpg)
38-yr-old ♀ with bloody diarrhoea and arthralgia.Give the diagnosis.
![Page 23: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/23.jpg)
Management of underlying conditions
![Page 24: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/24.jpg)
References
1. Arnow PM, Flaherty JP (1997) Fever of unknown origin. Lancet 350: 57-80.
![Page 25: 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine](https://reader030.vdocument.in/reader030/viewer/2022032722/56649ce45503460f949b1500/html5/thumbnails/25.jpg)
Next week….
Headache