puo jithin joe
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Pyrexia Of Unknown OriginPyrexia Of Unknown Origin
RADIOLOGICALRADIOLOGICALINVESTIGATIONSINVESTIGATIONS & SKIN TESTS& SKIN TESTS
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When the initial tests areWhen the initial tests are
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Radiological ModalitiesRadiological Modalities
Chest XChest X--RayRay Plain XPlain X--Ray AbdomenRay Abdomen CT AbdomenCT Abdomen
Nuclear Nuclear Imaging Imaging EchocardiographyEchocardiography MRIMRI
Positron EmissionPositron EmissionTomography (PET)Tomography (PET) USG AbdomenUSG Abdomen
Intravenous PyelogramIntravenous Pyelogram
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Chest XChest X--RayRay
Chest radiography is indicated when theChest radiography is indicated when the
patient has tachypnea, retractions, focal patient has tachypnea, retractions, focal
auscultatory findings, or oxygen saturationauscultatory findings, or oxygen saturation
level (SO2) on room air of less than 95%.level (SO2) on room air of less than 95%. Also, Also, itit should be obtained if WBC is >20,000should be obtained if WBC is >20,000..
PulmonaryPulmonary TuberculosisTuberculosis
M Malignancalignanciesies
PneumocystisPneumocystis cariniicarinii pneumonia pneumonia
HistoplasmosisHistoplasmosis
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CComputedomputed TTomographyomography Chest CT:Chest CT:
Mediastinal mass Tuberculosis/Lymphoma/ Mediastinal mass Tuberculosis/Lymphoma/
SarcoidosisSarcoidosis
Dorsal Spine Spondylitis and disc spaceDorsal Spine Spondylitis and disc space
diseasedisease
Abdominal CT Abdominal CT::
Useful to look for abdominalUseful to look for abdominal lymphomalymphoma,,
malignancies malignancies and and most most abscessabscesseses Diagnostic yield Diagnostic yield iis almosts almost 19%19%
Clinical followClinical follow--upup showshowss that only 1/32that only 1/32
patients with normal scans had an intra patients with normal scans had an intra--
abdominal cause forabdominal cause for PPUOUO
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EchocardiographyEchocardiography
Done if endocarditisDone if endocarditisor atrial myxoma isor atrial myxoma issuspected suspected
Duke criteria forDuke criteria forendocarditis:endocarditis:
Endocarditis: 1Endocarditis: 1--5%5%of all cases ofof all cases of PPUOUO
Sensitivity 82%,Sensitivity 82%,specificity 99%specificity 99%
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Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)
Enlarged lymphnodesEnlarged lymphnodes
Organomegaly (eg. Spleen)Organomegaly (eg. Spleen) BBrainrain malignancies malignancies
Automimmune conditions Automimmune conditions
Spinal cord visualisationSpinal cord visualisation
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UltrasonographyUltrasonography
Leg DopplerLeg Dopplers:s:
DDeepeep V Veinein TThrombosis causehrombosis cause of FUO ~of FUO ~22--6% of6% of pt ptss
SafeSafe;; easy to doeasy to do;; recommended recommended
Ultrasound Heart/AbdomenUltrasound Heart/Abdomen::
TTo look foro look for effusioneffusions,s, lymph nodes,lymph nodes,hepatic and splenic lesionshepatic and splenic lesions and and pelvic masses. pelvic masses.
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Nuclear ImagingNuclear Imaging
For localizing inflammatory orFor localizing inflammatory orinfectious focusinfectious focus
Technetium scans likely have best testTechnetium scans likely have best test
characteristics overall and should becharacteristics overall and should bethethe test of choicetest of choice (Specificity 93%,(Specificity 93%,Sensitivity 40Sensitivity 40--75%)75%)
Technetium studiesTechnetium studies:: Acute infection and Acute infection and inflammation of bones and softinflammation of bones and soft tissuetissue
Indium Indium--labeled WBC scanslabeled WBC scans:: Occult abscessesOccult abscesses
Gallium scans:Gallium scans: Occult inflammationOccult inflammation
BoneBone TCTC--scanscan:: Skeletal OSkeletal Osteomyelitissteomyelitis
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Gallium ScanGallium Scan
The site wThe site will beill be thermogenicthermogenic if there is:if there is:
Increased blood flowIncreased blood flow
U ptake by bacteria (U ptake by bacteria (LLactoferrinactoferrin))
U pU pttaakke by WBCe by WBC
Sensitive but not specificSensitive but not specific
Not Not adviced foradviced for abdomen or pelvisabdomen or pelvis ((FalseFalse
positivity) positivity)
Effective in:Effective in:
Chronic InfectionChronic Infectionss
LymphomaLymphoma
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IndiumIndium--LabelledLabelled LeukocyteLeukocyte
U ptake by WBCU ptake by WBC
Only for acute problem Only for acute problems,s, less than 4 wless than 4 wksks
Stud Studies fies found ound the sensitivity for infectivethe sensitivity for infective
PUOPUO asas 25% and specificity as 100%25% and specificity as 100% Not sensitive enough Not sensitive enough
Recommended for strongly suspected Recommended for strongly suspected
infective PUO if done within theinfective PUO if done within the initialinitial 22--
4 weeks4 weeks
False positiveFalse positives in:s in:
PPostost--opoperativeerative wound wound
M Mastitisastitis
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SKIN MANIFESTATIONS
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Embolic Skin Lesions «
µJaneway¶ Lesion
Skin manifestations include...
� Skin rashes� Nodules
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Thank You....Thank You....
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