Pyrexia of unknown origin

PYREXIA OF UNKNOWN ORIGIN
Dr. Arsala Mulla
Guide: Dr. Mangesh Sagale.

Old Definition(Petersdorf and
Beeson 1961)
1. Fever higher than 38.3oC
on several occasions.
2. Duration of fever > 3
weeks
3. Uncertain diagnosis after
one week of study in
hospital
New Definition:(Durack and Street
1995)
1. Fever higher than 38.3oC on
several occasions.
2. Duration of fever > 3 weeks
3. → 3 outpatient visits, or 3
days in hospital without
elucidation of the cause or 1
week of “intelligent and
invasive” ambulatory
investigation
DEFINITION

NEW DEFINITION EXPANSION
1. Classical PUO
2. Nosocomial PUO
3. Neutropenic PUO
4. HIV-Associated
5. Transplant

 Nosocomial PUO: in hospitalized patient who is receiving acute care
& in whom infection was not manifest or incubating on admission.3
days of investigation including at least 2 days incubation of cultures
minimum requirement
 Neutropenic PUO: in patient whose neutrophil count<500/ul or is
expected to fall to that level in 1-2days.Diagnosis is invoked if specific
cause is not identified after 3 days of investigations including 2 days
incubation of cultures
 HIV assoc PUO: Temp >38.3.c on several occasions over a period of
>4 weeks for outpatients or >3 days for hospitalized patients with HIV
infection. dx is invoked if appropriate inv over 3 days including 2 days
incubation of cultures reveals no source

CAUSES OF PUO
(IN INDIA)
 Infectious 53%
 #1: TB (45%)
 Neoplasm: 17%
 #1: NHL (47%)
 Collagen Vasc.: 11%
 #1 SLE: 45%
 Miscellaneous: 5%
 Undiagnosed: 14%
TB
24%
Abscess
7%
Endocarditis
5%
Other ID
17%
NHL
8%
Other Onc
9%
SLE
5%
Other Rheum
6%
Misc.
5% Unknown
14%

Infectious
31%
Malignancy
24%
Rheum
15%
Other
13%
Unknown
17%
Infectious
29%
Malignancy
16%
Rheum
25%
Other
13%
Unknown
17%
PUO BY THE DECADES
Infectious
24%
Malignancy
14%Rheum
24%Other
8%
Unknown
30%
Infectious
36%
Malignancy
19%
Rheum
18%
Other
18%
Unknown
9%
1950s 1970s
1980s
1990s

CAUSES OF CLASSIC PUO
 Infective 20-30%
 Cancer 10-20%
 Autoimmune 20-25%
 Miscellaneous 10-15%
 Undiagnosed 25-30%

INFECTIVE
 Localized pyogenic infection
 Systemic bacterial eg typhoid
 Mycobacterial MTB,MAI
 Fungal e.g. cryptococcus,histoplasmosis
 Viral e.g. HIV,CMV
 Parasitic e.g. Malaria,Toxoplasmosis,babesiosis
 Rickettsial e.g. Q fever

NEOPLASMS
 Lymphoma
 Leukaemia
 Liver, renal, colon, pancreatic
 Sarcoma
 Atrial myxomas

COLLAGEN VASCULAR DISEASES
 Adult Still’s disease
 SLE
 RA
 PAN
 Wegeners Granulomatosis
 Still’s Disease
 Polymyalgia rheumatica
 Rheumatic fever
 Behcets

MISCELLANOUS
 Granulomatous diseases i.e. Sarcoid, Crohn’s
 Drug Induced Fever
 Endocrine e.g. Thyrotoxicosis, Phaeocromocytoma
 Intracerbral e.g. SOL, Pontine CVA ,Encephalitis
 Metabolic / inherited e.g. Familial Mediterranean Fever
 Tissue infarction e.g. post MI (Dressler's syndrome), recurrent
Pulmonary Embolism
 Factitious fever

Antibiotics:
Erythromycin
Isoniazid
Nutrofurantoin
Penicillin
Antihypertensives:
Captopril
Hydralizine
Hydrochlorothiazide
Methyl Dopa
Nifedepine
DRUGS CAUSING FEVER
Others:
Allopurinol
Cimetedine
Clifibrate
Heparin
Phenytoin
Procainamide
Quinidine
Meperidine

ETIOLOGIES OF PUO
 Infection
 Tuberculosis: Disseminated
 The single most common infection in most PUO series except
in children
 Usually extrapulmonary or miliary
 Occurs in the lungs when significant pre-existing lung disease.
 Pul. TB in AIDS is often subtle (normal CXR in 15 – 30%).
 PPD is +ve < 50% of TB with PUO.
 Diagnosis often requires biopsy of LN/Liver/Bone marrow.

ETIOLOGIES OF PUO
 Abscess:
 Usually located in abdomen or pelvis.
 Secondary to appendicitis or diverticulitis.
 Pyogenic liver abscess usually follow biliary tract disease or
abdominal suppuration
 Amoebic liver abscess is similar to pyogenic → amoebic
serology is positive > 95% of cases.(IHA,ELISA)
 Splenic abscess is usually secondary to hematogenous
seeding.
 Perinephric or renal abscess is usually secondary to UTI.

ETIOLOGIES OF PUO
 Bacterial Endocarditis
 Culture remains negative in 5% of patient.
 Culture negative is likely with the following organisms:
 Coxiella burnetii → no growth.
 HACEK group → incubate blood 7 – 21 days,slow growing
 Brucella } Special media
 Legionella Long Time
 Mycoplasm/Chlamydia
 Fungal → usually sterile
 Peripheral signs may not be detected.
 Right-side endocarditis lack murmurs

ETIOLOGIES OF PUO
 Malignancy
 Lymphoma: Fever is a presenting feature
 Leukemia: M. Myeloma (fever means infection)
 Renal cell carcinoma: only rarely fever is there
 HCC or secondary metastasis to the liver

ETIOLOGIES OF PUO
 Lymphoma:
 Fever is a well-recognized manifestation.
 A Pel-Ebstein phenomenon is rare.
 Source of fever : production of cytokines.
 Fever is a negative prognostic factor
 Renal Cell Carcinoma (Adult)
 20% present with fever
 Microscopic hematuria

ETIOLOGIES OF PUO
 Wilms Tumor (Children)
 Peak incidence 2-3 years.
 Abdominal mass but FEVER can be a presentation.
 Solid Tumor
 Fever is rare except:
 Secondary metastasis to the liver
 Ductal obstruction or perforation like cholangioacarcinoma
or ampulla carcinoma
 Lung carcinoma with obstruction and pneumonia.

ETIOLOGIES OF PUO
 Collagen-Vascular-Disease
No diagnostic serology
The syndrome needs to be identified for diagnosis
 Still’s disease (young or adult)
 Giant cell arteritis } → 15% of PUO
 Polymyalgia Rheumatica }
 Behcet’s Disease
 Relapsing polychondritis

ETIOLOGIES OF PUO
 Adult Onset Still’s Disease
 Age 16 – 35 with (-ve) RF & ANA
 Fever is high and spiking with temp. up to 41.6oC (hectic)
 Fever is either intermittent or remittent (peaks typically at night)
 Most patient seek medical attention within 2 weeks.
 A distinctive evanescent macular or papular rash is typically
present during the course of the illness.
 Dx is strictly a clinical: RF is almost uniformly negative.
 Other features: myalgias, arthritis, leukocytosis (neutrophils),
hepatosplenomegaly & lymphadenopathy.
 high serum ferritin (> 2000)

ETIOLOGIES OF PUO
 Temporal Arteritis:
 Very serious condition if not diagnosed early
 Very difficult to establish the etiology of fever without high index of
suspicion
 Fever and malaise may be the only manifestation. Headache is
the most common.
 Common cause of puo in elderly >70 yrs
 Tenderness or decreased pulsation guide the selection of site of
bx
 “blind biopsy” of one or both temporal arteries may yield to
diagnosis

ETIOLOGIES OF PUO
 Polymyalgia Rheumatica:
 Can cause fever, arthralgia, myalgia & ↑ ESR > 50.
 Characteristic muscle complaints: symmetrical pain and stiffness
that are typically worse at morning
 Affects lumbar spine and large proximal muscles
 Other vasculitides that cause PUO:
 Polyarteritis nodosa → Mononeuritis multiplex (60%)
 Wegener’s Granulomatosis
 Mixed Cryoglobulinemia

ETIOLOGIES OF PUO
 Miscellaneous Causes: (Non-Infectious)
 Vascular Causes:
 Pulmonary Emboli
 50% are febrile
 Fever is characteristic (< 39oC)
 Patient typically has predisposing factors : cancer or recent
immobility.
 Hematoma in closed space
 Hemorrhage in the retroperitoneal space
 Within the wall of an aneurysm or dissection of the thoracic or
abdominal aorta.

ETIOLOGIES OF PUO
 Factitious Fever
In a study 9% of cases of PUO were factitious
 False fever:
 Thermometer manipulation using external heat or substitute
thermometer.
 Genuine fever (self induced)
 Administration of pyrogenic substances (bacterial suspensions)
 Generally young women with connection to health care often
NURSES.

It is axiomatic that as the duration of fever
increases, the likelihood of an infectious
cause decreases even for the more
indolent infections (brucellosis,
paracoccidiomycosis, etc.)

PYREXIA OF UNKNOWN ORIGIN
The majority of disease remaining after an initial NEGATIVE
workup are:
1. Neoplasm
2. Seronegative collagen vascular disease
3. Progressive Tuberculosis
4. Increasing Drug Addition
5. Elderly with Endocarditis
6. HIV with or without infection or malignancy
7. Prosthetic devices / implants
8. Travel

CLINICAL
 History
 Travel:
 Travel to an area known to be endemic for certain disease:
 Name of the area, duration of stay
 Onset of illness (incubation period)
1 – 10 Days 10 – 21 Days Weeks - Months
Malaria Malaria Kala Azar
Plague Typhoid Amoebiasis
Dengue Brucella HIV
Salmonella Hepatitis A Hepatitis
EVALUATION OF PUO

 Physical examination
 Localizing Symptoms may Indicate the source of fever:
Back Pain TB Spondylitis
Bone Metastasis
Headache Chronic Meningitis/GCA
RUQ Pain Liver Abscess
LUQ Pain Splenic Abscess
Oral & Genital Ulcer Behcet’s Disease
Jaw Claudication Temporal Arteritis
Subtle changes in behavior Granulomatous Meningitis
EVALUATION OF PUO

ROLE OF LAB INVESTIGATIONS
MINIMAL DIAGNOSTIC CRITERIA
 History & Physical
examination
 CBC & DLC, TLC
 U/A and Microscopy
 Chest X-ray
 Blood Cultures x 3
 Urine culture
 LFTs
 Hepatitis serologies (if
abnormal LFTs)
 Chem10

OTHER TESTS
 ESR/CRP
 Peripheral Smear
 Anti Nuclear Antibody
 Rheumatoid Factor
 HIV
 CMV IgM
 Mono Spot
 PPD

 Complete Blood Count
 Anemia suggests a serious underlying disease
 Leukocytosis with bands → occult bacterial infection
 Lymphocytosis & atypical lymphocyte → Infectious
mononucleosis
 Leucopenia and lymphopenia → advanced HIV, typhoid
 Leukoerythroblastic Anemia → Disseminated TB
 Thrombocytopenia → Malaria/Leukemia
 Peripheral Blood → Malaria and other parasites
CRITICAL EVALUATION
ROUTINE

ROUTINE
 ESR & CRP is elevated in:
1. Bacterial Infection
2. Neoplasm
3. Immunological-mediated inflammatory states
4. Tissue infarction
58%: malignancy like Lymphoma/myeloma
25% Infection: Endocarditis, Giant cell arteritis

ROUTINE
 ↑ High ESR → lacks specificity:
 Drug Reaction
 Thrombophlebitis may cause very high ESR
 Nephrotic Syndrome
 Normal ESR → significant inflammatory process is absent with
exception.
 CRP-level may be useful cross reference for ESR
 More sensitive and specific indicator of an “acute
phase”inflammatory metabolic response.

MARKERS OF INFLAMMATION
 Acute Phase Proteins
Proteins Increased Proteins Decreased
Fibronogen Albumin
Ferritin Transferrin
Plasminogen
Fetoprotein
Protein S
Ceruloplasmin

LAB EVALUATION
 Blood Testing
 Anti-nuclear Antibodies
 Rheumatoid Factor
 CMV Antibody: IgM
 Heterophile Antibody Test in children and young adult
 Thyroid Function Test
 HIV Screening
 Angiotensin converting enzyme
 Febrile agglutinins

LAB EVALUATION
 Cultures
 Blood
 Obtain more than 3 blood cultures from separate sites over 24 hr
period prior to antibiotics if Infective Endocarditis is suspected
 Lysis centrifugation blood culture techniques
 Sputum: For Tuberculosis
 Any normal sterile: CSF/urine/pleural or peritoneal fluid
 Bone marrow aspirate → Tuberculosis/Brucellosis
 Lymph node aspirate → TB

Detection of mycobacterial agents
 Stains
 Carbol fuschin (classic ZN stain, cold Kinyoun stain)
 Fluorochrome stain ( auramine-rhodamine & auramine O)
 Culture
 Broth culture: BACTEC 460TB,SEPTI-CHEK AFB
 Solid medium-: LJ;Middlebrook 7H10,7H11
 Currently most rapid method: nucleic acid amplification test
 Amplified mycobacteriym TB direct test (Gen Probe)
 AMLICOR mycobacterium tuberculosis test (Roche)

 Hepatomegaly or Abnormal LFT
 Hepatic Granuloma
 Non-caseating: Tuberculosis/Sarcoidosis & Brucellosis
 Caseating: Tuberculosis
 Bone Marrow
 Granuloma ± Tubercle Bacilli → Tuberculosis
 Aplastic Cells → Leukemia
 Leishmania Bodies → Kala-Azar
 Atypical Cells → Lymphoma
 Atypical Plasma Cells → Multiple myeloma
 Pleural or pericardial fluid→ Extrapulmonary Tuberculosis
 Temporal artery biopsy→ Giant Cell Arteritis
LAB EVALUATION - BIOPSY

OTHER INVESTIGATION
 Imaging Studies: to localize abnormalities for definite tests or
treatment
 Chest x-ray:
 Miliary shadows → disseminated tuberculosis
 Atelectasis
 ↑ Hemi diaphragm
 Pleural Effusion
 Mediastinal mass → Lymphoma/Tuberculosis/ Sarcoid
 If CXR is WNL → Repeat on weekly basis
 Ultra sonography
Hepatic, Splenic, Pancreatic or
Subphrenic Abcess

IMAGING STUDIES
 CT-Scan → CT scan chest
 Mediastinal mass → Tuberculosis/Lymphoma/ Sarcoidosis
 Dorsal Spine → Spondylitis and disc space disease
 CT-Scan Abdomen → very effective to visualize
 All types of abscesses
 Retroperitoneal tumor, lymph node or haematoma
 MRI: spleen, lymph node and the brain

Radionuclear Scanning
 Bone TC-scan → osteomyelitis (skeletal),bony metastasis
 Gallium scan → occult inflammation, pneumocystis
 Indium labeled WBC-scan → occult abscesses
 Fluorodeoxyglucose F18(FDG)PET scanning appears to be
superior to other forms of nuclear imaging
FDG used in PET scans accumulates in tumour and at sites of
inflammation
NEWER TECHNIQUES

A radiograph of the right humerus (a part of skeletal survey) shows no
abnormality in a 69-year-old man recently diagnosed with multiple
myeloma.
FDG-PET shows
multiple areas of
hypermetabolism,
including in the right
humerus where the
radiograph was negative.
The majority of lesions in
the ribs, scapulae and
spine are not visualized
on the skeletal survey.

RADIONUCLEAR STUDIES
 Radionuclear Scanning
 Overall Assessment:
 Non-specific tests to localize a site for more specific
evaluation (such as CT-scan)
 Impressive no. of false (+) and false (-) results
 True positive scan only indicates an area of increased
uptake → no anatomic detail

GALLIUM SCAN
 Will be hot if there is:
 Increased blood flow
 Uptake by bacteria (lactoferrin)
 Uptake by WBC
 Sensitive but not specific
 Not recommended for abdomen or pelvis: false +ves are common
 Effective in:
 Chronic Infection
 Lymphoma

INDIUM-LABELED LEUKOCYTE
 Uptake by WBC
 Only for acute problem (less than 4 weeks)
 Study in the UK has found the sensitivity for infective PUO: 25%
and specificity was 100%
 Recommended for strongly suspected infective PUO if done within
the 1st 2-4 weeks
 False positive: post op wound, mastitis
Retroperitoneal angiosarcoma demonstrating mild uptake of
In111-WBC.

 Laparoscopy
 To visualize and biopsy the pathology in the abdomen
e.g. Tuberculous peritonitis
Peritoneal carcinomatosis
 Biopsy
 Enlarged lymph node
 Granulomatous disease (Tuberculosis)
 Others
 Metastatic carcinoma
HISTOPATHOLOGICAL EVALUATION
Lymph node biopsy showing tumor cells, which have either
vacuolated or pale mucin filled cytoplasm. Many signet ring
cells are seen and occasional mitoses are present. Also seen
are tiny pools of mucin along with the tumor cells. Normal
lymph node tissue is seen at the right upper corner

Pyrexia of unknown origin

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