1. Pyrexia of Unknown Origin (PUO) Approach: - identify cause – Detailed history and regular examination – Confirm temperature objectively, ?admission, ?physiological with circadian pattern – Guide investigation based on initial test results Blind investigation may be necessary – FBE, ESR, U+E, CRP, LFT, ANA, Rh Fx, TFT – Regular cultures (any fluid – blood, sputum, urine, stool, CSF) – CXR, CTA, echo – CT, IVP, MRI, PET – Treatment – ideally symptomatic prior to Dx Empirical A/B therapy may mask infectious Dx Empirical steroid therapy may mask inflammatory response w/o treating cause – Undiagnosable PUO – Sx usually spontaneously resolve, good prognosis Definition: In adults: T>38.3 for>3 weeks with no known origin despite appropriate Ix. Causes Infection Pyogenic Abscess TB IE Toxoplasmosis EBV CMV HIV Brucellosis Lyme Disease Malignancy Lymphoma Leukaemia RCC HCC CTD Adult Still’s disease RA SLE Wegener’s granulomatosis Giant cell arteritis Misc Drug Fevers Thyrotoxicosis IBD Sarcoidosis Granulomatous hepatitis Factitious fever Familial Mediterranean fever Idiopathic

2. Patterns of fever Day 1 – onset of disease – T? Day 4 – visit doctor – 36.2 Day 5 – 10am – 36.9 Day 5 – afternoon – 36.9 Day 5 – night – 38.5 *NO FEVER RECORDED* – Doesnt always follow typical pattern in all patients – Accurate recording procedure Typical malarial fever patterns - not necessarily useful diagnostically

3. Special points for an ID Ex - Note: get image from Amanda to put on this slide Gen Inspection – Room Sputum cup O2 IV – anything running Drain tube Catheter – check urine Temp chart – Patient Distress (RR, diaphoretic, conscious state) Rash – blanching/non- Track marks IVDU Any lines – sepsis? Weight loss – chronic illness Hands – Janeway – Splinters – Osler’s nodes – Erythema – Track marks – Bruising, petechiae – Phlebitis – Arthropathy, raynauds - CTD Face – Eyes – Roth spots (fundoscopy), pallor, jaundice (BW fever) – Mouth – hygeine, ginigivitis, abscess – Neck – lymphadenopathy Chest – Crepitations, consolidation Praecordium – New murmur Abdomen – Tenderness? – localised? – Organomegaly – rashes Genitourinary – Stool sample – Urinalysis – Discharge – orchitis Legs – Rash – ulcers

4. MalariaDengue FeverTyphoid FeverHepatitis A DefinitionProtozoa injected by Anopheles mosquitoes multiply in RBCs causing haemolysis, sequestration and cytokine release. RNA flavivirus (4 types) causing sudden fever, extreme myalgias and arthralgias. Bacterial infection with salmonella typhi (G- bacillus), causnig severe diarrhoea Hepatits A virus (HAV), that is not chronic or pregressive and has no permament effect on liver, acutely causes liver damage using body’s own immune response rather than viral cytotoxicity. Mode of TransmissionMosquito vector, transfusion, vertical, needlestick ‘Aedes’ mosquitoesFaecal-oral route, complicated by asymptomatic typhoid (unknowing carriers) Faecal-oral route, Incubation period (link to case) Millsy Signs and symptomsMillsy Dx/IxDavid TreatmentDobbo