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    Fever of Unknown Origin (Fuo) : DR Budi Enoch SPPD

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    Roby Kieran
    This document discusses fever of unknown origin (FUO) and provides an updated classification system. It defines classic FUO, nosocomial FUO, neutropenic FUO, and FUO associated with HIV infection. For classic FUO, a temperature must be above 38.3°C on several occasions for more than 3 weeks, with failure to determine a diagnosis after 1 week of investigation. The causes of FUO are extensive and include infections, neoplasms, collagen vascular diseases, and other miscellaneous conditions. The diagnostic workup involves specialized studies and invasive testing if needed, with the goal of continued observation over empirical therapy to determine the underlying cause.

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    Fever of Unknown Origin (Fuo) : DR Budi Enoch SPPD

    Uploaded by

    Roby Kieran
    11 views23 pages
    This document discusses fever of unknown origin (FUO) and provides an updated classification system. It defines classic FUO, nosocomial FUO, neutropenic FUO, and FUO associated with HIV infection. For classic FUO, a temperature must be above 38.3°C on several occasions for more than 3 weeks, with failure to determine a diagnosis after 1 week of investigation. The causes of FUO are extensive and include infections, neoplasms, collagen vascular diseases, and other miscellaneous conditions. The diagnostic workup involves specialized studies and invasive testing if needed, with the goal of continued observation over empirical therapy to determine the underlying cause.

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    This document discusses fever of unknown origin (FUO) and provides an updated classification system. It defines classic FUO, nosocomial FUO, neutropenic FUO, and FUO associated with HIV infection. For classic FUO, a temperature must be above 38.3°C on several occasions for more than 3 weeks, with failure to determine a diagnosis after 1 week of investigation. The causes of FUO are extensive and include infections, neoplasms, collagen vascular diseases, and other miscellaneous conditions. The diagnostic workup involves specialized studies and invasive testing if needed, with the goal of continued observation over empirical therapy to determine the underlying cause.

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    11 views23 pages

    Fever of Unknown Origin (Fuo) : DR Budi Enoch SPPD

    Uploaded by

    Roby Kieran
    This document discusses fever of unknown origin (FUO) and provides an updated classification system. It defines classic FUO, nosocomial FUO, neutropenic FUO, and FUO associated with HIV infection. For classic FUO, a temperature must be above 38.3°C on several occasions for more than 3 weeks, with failure to determine a diagnosis after 1 week of investigation. The causes of FUO are extensive and include infections, neoplasms, collagen vascular diseases, and other miscellaneous conditions. The diagnostic workup involves specialized studies and invasive testing if needed, with the goal of continued observation over empirical therapy to determine the underlying cause.

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    of 23

    Fever of Unknown Origin

    (FUO)
    Dr Budi Enoch SpPD
    Fever of unknown origin (FUO) was
    defined by Petersdorf and Beeson in 1961
    as
    (1) temperatures of >38.3°C (>101°F)
    on several occasions;
    (2) a duration of fever of >3 weeks;
    and
    (3) failure to reach a diagnosis despite
    1 week of inpatient investigation.
    While this classification has stood for more
    than 30 years, Durack and Street have
    proposed a revised system for classification
    of FUO that better accounts for nonendemic
    and emerging diseases, improved diagnostic
    technologies, and adverse reactions to new
    therapeutic interventions.
    This updated classification includes
    ◦ (1) classic FUO,
    ◦ (2) nosocomial FUO,
    ◦ (3) neutropenic FUO, and
    ◦ (4) FUO associated with HIV infection
    Closely to the earlier definition of FUO,
    differing only with regard to the prior
    requirement for 1 week's study in the
    hospital.
    The newer definition is broader,
    stipulating three outpatient visits or 3
    days in the hospital without
    elucidation of a cause or 1 week of
    "intelligent and invasive" ambulatory
    investigation.

    Classic FUO
    In nosocomial FUO, a temperature of
    38.3°C (101°F) develops on several
    occasions in a hospitalized patient who is
    receiving acute care and in whom
    infection was not manifest or incubating
    on admission.
    Three days of investigation, including at
    least 2 days' incubation of cultures, is the
    minimum requirement for this diagnosis.

    nosocomial FUO
    Neutropenic FUO is defined as a temperature of
    38.3°C (101°F) on several occasions in a patient
    whose neutrophil count is <500/L or is expected
    to fall to that level in 1–2 days.
    The diagnosis of neutropenic FUO is invoked if a
    specific cause is not identified after 3 days of
    investigation, including at least 2 days' incubation
    of cultures. HIV-associated FUO is defined by a
    temperature of 38.3°C (101°F) on several
    occasions over a period of >4 weeks for
    outpatients or >3 days

    Neutropenic FUO
    Coincident with the widespread use of antibiotics,
    increasingly useful diagnostic technologies—both
    noninvasive and invasive—have been developed.
    Newer studies reflect not only changing patterns of
    disease but also the impact of diagnostic techniques
    that make it possible to eliminate many patients with
    specific illness from the FUO category.
    The ubiquitous use of potent broad-spectrum antibiotics
    may have decreased the number of infections causing
    FUO.
    The wide availability of ultrasonography, CT, MRI,
    radionuclide scanning, and positron emission
    tomography (PET) scanning has enhanced the detection
    of localized infections and of occult neoplasms and
    lymphomas in patients previously thought to have FUO

    Causes of Classic FUO


    Infections  Localized pyogenic
    infections:   Appendicitis  Cat-scratch
    disease Cholangitis  Cholecystitis Dental
    abscess Diverticulitis/abscess  Lesser sac
    abscess Liver abscess Mesenteric
    lymphadenitis  Osteomyelitis Pancreatic
    abscess Pelvic inflammatory disease
     Perinephric/intrarenal abscess Prostatic
    abscess  Renal malacoplakia Sinusitis
    Subphrenic abscess  Suppurative
    thrombophlebitis Tuboovarian abscess
    Causes of FUO in Adults in the
    United States
    Intravascular infections  
    Bacterial aortitis  Bacterial endocarditis
    Vascular catheter infection
    Systemic bacterial infections  
    Bartonellosis Brucellosis Campylobacter
    infection Cat-scratch disease/bacillary
    angiomatosis (B. henselae)
    Gonococcemia Legionnaires' disease
    Leptospirosis Listeriosis Lyme disease
    Melioidosis Meningococcemia Rat-bite
    fever Relapsing fever Salmonellosis
    Syphilis Tularemia Typhoid fever
    Vibriosis Yersinia infection
    Mycobacterial infections  M. avium/M. intracellulare infections
    Other atypical mycobacterial infections Tuberculosis
    Other bacterial infections  Actinomycosis Bacillary angiomatosis
    Nocardiosis Whipple's disease
    Rickettsial infections Anaplasmosis  Ehrlichiosis  Murine typhus
      Q fever Rickettsialpox Rocky Mountain spotted fever  Scrub typhus
    Mycoplasmal infections
    Chlamydial infections  Lymphogranuloma venereum  Psittacosis
    TWAR (C. pneumoniae) infection
    Viral infections
    Chikungunya fever Colorado tick fever  
    Coxsackievirus group B infection  
    Cytomegalovirus infection
    Dengue
    Epstein-Barr virus infection  
    Hepatitis A, B, C, D, and E  
    HIV infection
    Human herpes virus infection  
    Lymphocytic choriomeningitis
    Parvovirus B19 infection  
    Picornavirus infection
    Fungal infections
    Aspergillosis Blastomycosis Candidiasis
    Coccidioidomycosis Cryptococcosis
    Histoplasmosis Mucormycos
    Paracoccidioidomycosis Pneumocystis
    infection Sporotrichosis
    Parasitic infections
    Amebiasis Babesiosis Chagas' disease
    Leishmaniasis Malaria Strongyloidiasis
    Toxocariasis Toxoplasmosis Trichinellosis
    Presumed infections, agent undetermined
    Kawasaki's disease (mucocutaneous lymph
    node syndrome)
    Kikuchi's necrotizing lymphadenitis
    Neoplasms  Malignant
       Colon cancer
       Gall bladder carcinoma
       Hepatoma
       Hodgkin's lymphoma
       Immunoblastic T-cell lymphoma
       Leukemia
       Lymphomatoid granulomatosis
       Malignant histiocytosis
       Non-Hodgkin's lymphoma
       Pancreatic cancer
       Renal cell carcinoma
       Sarcoma
    Benign
       Atrial myxoma
       Castleman's disease
       Renal angiomyolipoma
    Habitual Hyperthermia    (Exaggerated circadian rhythm)
    Collagen Vascular/Hypersensitivity Diseases
       Adult Still's disease
       Behçet's disease
       Erythema multiforme
       Erythema nodosum
       Giant-cell arteritis/polymyalgia rheumatica
       Hypersensitivity pneumonitis
       Hypersensitivity vasculitis
       Mixed connective-tissue disease
       Polyarteritis nodosa
       Relapsing polychondritis
       Rheumatic fever
       Rheumatoid arthritis
       Schnitzler's syndrome
       Systemic lupus erythematosus
       Takayasu's aortitis
       Weber-Christian disease
       Granulomatosis with polyangiitis (Wegener's)
    Granulomatous Diseases
       Crohn's disease
       Granulomatous hepatitis
       Midline granuloma
       Sarcoidosis
    Miscellaneous Conditions
       Aortic dissection
    Drug fever
       Gout
       Hematomas
       Hemoglobinopathies
       Laennec's cirrhosis
       PFPA syndrome: periodic fever, adenitis, pharyngitis,
    aphthae
       Postmyocardial infarction syndrome
       Recurrent pulmonary emboli
       Subacute thyroiditis (de Quervain's)
       Tissue infarction/necrosis
    Inherited and Metabolic Diseases
       Adrenal insufficiency
       Cyclic neutropenia
       Deafness, urticaria, and amyloidosis
       Fabry disease
       Familial cold urticaria
       Familial Mediterranean fever
       Hyperimmunoglobulinemia D and periodic
    fever
       Muckle-Wells syndrome
       Tumor necrosis factor receptor–associated
    periodic syndrome (familial Hibernian fever)
       Type V hypertriglyceridemia
    Thermoregulatory Disorders  Central
       Braintumor
       Cerebrovascular accident
       Encephalitis
       Hypothalamic dysfunction
    Peripheral
       Hyperthyroidism
       Pheochromocytoma
    Factitious Fevers
    "Afebrile" FUO <38.3°C (100.94°F)
    stepwise flow chart depicting the diagnostic workup and
    therapeutic management of FUO is provided in Fig. 18-1.
    In this flow chart, reference is made to "potentially diagnostic
    clues," as outlined by de Kleijn and colleagues; these clues may
    be key findings in the history (e.g., travel), localizing signs, or
    key symptoms.
    Certain specific diagnostic maneuvers become critical in dealing
    with prolonged fevers.
    If factitious fever is suspected, temperature-taking should be
    supervised, and simultaneous urine and body temperatures
    should be measured.
    Thick blood smears should be examined for Plasmodium; thin
    blood smears, prepared with proper technique and quality
    stains and subjected to expert microscopy, should be used to
    speciate Plasmodium and to identify Babesia, Trypanosoma,
    Leishmania, Leptospira, Rickettsia, and Borrelia.
    Specialized Diagnostic Studies
    "Potentially diagnostic clues," as outlined by de Kleijn and
    colleagues (1997, Part II), may be key findings in the history,
    localizing signs, or key symptoms. bNeedle biopsy of liver as
    well as any other tissue indicated by "potentially diagnostic
    clues." cInvasive testing could involve laparoscopy. dEmpirical
    therapy is a last resort, given the good prognosis of most
    patients with FUO persisting without a diagnosis. Abbreviations:
    ANA, antinuclear antibody; CBC, complete blood count; CMV,
    cytomegalovirus; CRP, C-reactive protein; CT, computed
    tomography; Diff, differential; EBV, Epstein-Barr virus; ESR,
    erythrocyte sedimentation rate; FDG, fluorodeoxyglucose F18;
    NSAIDs, nonsteroidal anti-inflammatory drugs; PET, positron
    emission tomography; PMN, polymorphonuclear leukocyte; PPD,
    purified protein derivative; RF, rheumatoid factor; SPEP, serum
    protein electrophoresis; TB, tuberculosis; TIBC, total iron-
    binding capacity; VDRL, Venereal Disease Research Laboratory
    test.
    Approach to the patient with
    classic FUO
    The focus here is on classic FUO. Other modifiers
    of FUO—neutropenia, HIV infection, a nosocomial
    setting—all vastly affect the risk equation and
    dictate therapy based on the probability of
    various causes of fever and on the calculated
    risks and benefits of a guided empirical approach.
    The age and physical state of the patient are
    factors as well: the frail, elderly patient may
    merit a trial of empirical therapy earlier than the
    robust young adult

    Treatment: Fever of Unknown Origin


    The emphasis in patients with classic FUO is on continued
    observation and examination, with the avoidance of
    "shotgun" empirical therapy.
    Antibiotic therapy (even that for tuberculosis) may irrevocably
    alter the ability to culture fastidious bacteria or mycobacteria
    and delineate ultimate cause.
    However, vital-sign instability or neutropenia is an indication for
    empirical therapy with a fluoroquinolone plus piperacillin or the
    regimen mentioned above (see "Nosocomial FUO"), for
    example.
    Cirrhosis, asplenia, disease-modifying biologic therapy,
    intercurrent immunosuppressive drug use, or exotic travel or
    environmental exposures (e.g., cave interiors) may all tip the
    balance toward earlier empirical anti-infective therapy.
    If the TST is positive or if granulomatous hepatitis or other
    granulomatous disease is present with anergy (and sarcoid
    seems unlikely), then a therapeutic trial for tuberculosis should
    be undertaken, with treatment usually continued for up to 6
    weeks. A failure of the fever to respond over this period
    suggests an alternative diagnosis.
    sudah ya.........

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