PUO Jithin Joe

8/6/2019 PUO Jithin Joe

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Pyrexia Of Unknown OriginPyrexia Of Unknown Origin

RADIOLOGICALRADIOLOGICALINVESTIGATIONSINVESTIGATIONS & SKIN TESTS& SKIN TESTS



When the initial tests areWhen the initial tests are



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



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



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



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%



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



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.



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



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



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



SKIN MANIFESTATIONS



Embolic Skin Lesions «

µJaneway¶ Lesion

Skin manifestations include...

� Skin rashes� Nodules



Thank You....Thank You....

PUO Jithin Joe

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