DEFINITION:- Oral temperature at 6 a.m. > 98.9F (37.2C) OR at 4 pm >99.9F (37.7C)

Is it a fever? Temperature chart, Document Fever by measurement.

HOW TO APPROACH? DURATION OF SYMPTOMS

Short (3 DAYS)

Look for localizing signs / symptoms ……order investigations accordingly

·       Icterus…..LFT ( Enzymes)

·       Leptospirosis……send CK

·       Throat/Teeth infection      Pus Swab smear/C/S

·       Sinus pain, Tenderness, Post nasal Drip, X ray PNS

·       Cough, Sputum, DyspnoeaX ray chest

·       Abdomen Hepatosplenomegally MP, ECR, CBC, USG, Blood C/S

·       Lymphadenopathy/Lymphangitis

·       Dysuria.............. urine Microscopy/C/S

·       Skin abcess........ Look at the perianal area, Pus smear /C/S

·       Genitalia............ Discharge smear

·       Fever with rash............ consider ricketsial fevers, typhoid, EBV infection, secondary syphilis, dengue, brucellosis, Viral exanthems, drug fevers.

No localizing signs/symptoms

·       Malaria

·       Enteric fever

·       Viral / Anicteric Hepatitis

·       UTI

·       Viral fever – Dengue

Investigations

·       TC,DC ( If low, consider possibility of viral or enteric. If neutropenic, for differentials to beconsidered ), MP/MF.

·       LFT ( enzymes, alkaline phosphatase)

·       Urine Micro, C/S

·       Blood C/S : Not to be done as a preliminary investigation in fevers of short duration unless there is strong clinical suspicion of Bacteremia/enteric fever in physical examination and lab investigations. For fevers persisting for > 1 wk..consider blood c/s.

·       Widal (If fever > 1 wk) Prolonged fevers

History

Travel, cardiac symptoms, H/o exposure, transfusions, joint pains, arthritis, Perianal Ulcers, drugsand medications.

How to use localizing signs?

Generalised Lymph Node Enlargement (LNE)

·       Infections….EBV, CMV, Toxoplasma Brucella, Syphilis, PGL of HIV.

·       Non-specific response to viral infection

·       Leukemia, Lymphoma

·       Tuberculosis

·       Sarcoidosis

·       Metastatic Disease Hepatomegaly

MILD: Not useful, very non-specific

MODERATE: malaria, tuberculosis, amoebic abscess, hydatid.Splenomegaly

MILD/MODERATE : malaria, acute viral hepatitis, typhoid, military TB, septicaemia, infectiveendocarditis.

LARGE: CML, tropical splenomegaly, Kal-azar, myelofibrosis, lymphoma.

COMBIANTIONS OF :- FEVER+HEPATOSPLENOMEGALY+GENERALISED LYMPHADENOPATHY

·       Disseminated Tuberculosis

·       Leukemias, Lymphomas

·       Immune-Stills, Systemic onset rheumatoid arthritis, SLE, MCTD, Polymyositis.

·       HIV    related    (PGL-    persistent    glandular           lymphadenopathy;                    Defined       as Lymphnodes at >2extrainguinal sites, >3mo, > 1 cmsize)

·       Metastatic Disease

·       Secondary Syphilis

·       EBV

Secondary investigations depending on the clinical findings :

DO NOT investigate too early in the phase of the disease. If already done, you may need to repeatthe first few e.g..Chest X-ray, USG, LFT, WIDAL.

Counts may need to be rechecked to look for a changing pattern. WIDAL should be repeated to lookfor increasing titres.

·       CRP ( C-reactive protein may give a clue as to whether it is infective inflammatory or neoplastic/drug related in etiology. Drug-related fevers should have normal CRP. Also usefulin the follow up of patients prior to start of empirical ATT – more sensitive marker of diseaseactivity and response to therapy than ESR.)

·       Chest X-ray

·       USG- always check for hidden abscesses. (Liver, subdiaphragmatic, perisplenic, pelvic, paraspinal, psoas, periappendiceal.) Ultrasound done too early may miss a liver abscesswhich in the process of breaking down.

·       Bone marrow for routine C/S, AFB, fungal (In neutropenic and HIV +ves),trephine biopsy,smear, NNN medium culture. (If suspecting Kala-azar)

·       Serology- ANA, LE, RF, HIV Elisa, Weil – Felix

·       Lymphnode biopsy for AFB smear, C/S, histopathology, special stains for leukemia/lymphoma

·       Thyroid function tests

·       Liver biopsy

·       Trans thoracic ECHO; if negative but strong suspicion of IE, transoesophageal can be done.Special tests :- ( Only if localizing signs are present)

UNSOLVED PUO

If still undiagnosed…………..

THERAPEUTIC TRIAL

·       Chloroquine and the, if no response

·       A.T.T

TYPES OF PUOs