Fever of Unknown Origin:

differential diagnosis

DEFINITION
Fever lasting > 3 weeks
Temperature > 38.3 C (several
measurement)
Cause still undetermined after 3 days in
hospital

30% FUO die of undetected dise

Dx FUO has to be taken SERIOUSL

The most frequent causes of

FUO

3 age groups
< 6 yo: infection of: - Upper respiratory
- Urinary tract
- Systemic viral
6-14 yo: Gastrointestinal tract &
Colagenoses
> 14 yo: -Infection,
-Neoplasm,
-Rheumatology or autoimmune
diseases

Cause of Infection
COMMON BACTERIAL INFECTIONS
Abscesses

Liver, spleen, pancreas,

subphrenic, true pelvis,
prostate, appendicitis, chrohnn
disease, diverticulitis

Endocarditis

Rheumatic fever or diagnostic

procedure

Billiary tract
infections

Cholangitis, cholecystitis, bile

empyema or infection of
pancreatic duct

Buccal cavity/
upper respiratory
tract

Dental abscesses, sinusitis

Osteomyelitis

Osteomyelitis of the spinal

column, mandible, maxilla,

Cont..
VIRAL
INFECTION

Most common
EBV
CMV
HBV
Herpes simplex
Parvovirus B19

Cont..
Less common infections
Amoebiasis

Hotter countries

Borreliosis

Tick bites

Brucellosis

Slaughterhouse workers,
veterinarians, zookeepers, cooks,
laboratory infections

Chlamydial

Handling of certain species of bird

Cat scratch
fever

Contact with cats

Leishmaniasi Asia, tropics, mediterranean countries

s
Leptospirosis
Listeriosis

Haemodialysis patients, after kidney

Cont..
Less common infections
Malaria

Travel in malaria areas

Fungal

Travel in endemic area

coccidiodomycosis
(north/
southAmerica, histoplasmosis (North
America).
Immune deficient: systemic candida
albican, aspergillosis, cryptococcosis

Rickettsiosi Tick or mite bite, Q-fever transmission

s
from pets ot airborne (infected wool)
Toxoplasmo Contact with cats, consumption of raw
sis
mwat, immunodeficiency
Tularemia

Hunters, foresters, farm workers,

deallers in game animals, fur and pelt

Neoplasms

Hodgins disease
non-Hodgin lymphoma
Myelodysplastic syndrome
Leukemia
Solid tumor (especially bronchial,
pancreas, colon, hepatic cell, renal cell
ca)

Collagenvascular diseases
Rheumatic fever
Lupus
erythematosus
Rheumatoid arthritis
Stills disease
Temporal arteritis
Periarteritis nodosa
Wegeners disease
Chrohns disease

Other causes

Drug fever
Multiple pulmonary emboli
Thrombophlebitis
Haematoma
Hepatitis
Adrenal insufficiency
Thyroiditis
Sarcoidosis
Unspecific pericarditis
Thermoregulatory disturbances
Psychogenic fever: habitual hyperthermia,
artificial fever

Diagnosis

Observation of fever course

Anamnesis
Physical examination
Laboratory parameters
Noninvasive diagnostic
measurement (e.g chest Ro)
Exclude drug fever

Definition of drug fever

Fever that arises on administration of
drug and vanishes after
discontinuation, almost always within
48-72 h, in absence of another cause.
The interval between first intake of
the drug and the onset of fever varies
widely among different groups of
drugs (AB: 8 days, cardiac medication:
45 days)

Most frequent causes of

drug fever
Antibiotics 31%:

Penicillin G 6%
Cephalosporins 4,7%
Oxacillin 1,3%
Ampicillin

Cardiovascular sustances 25%

(-Methyldopa, Quinidine, procainamide,
hydralazine, nifedipine, oxprenolol

CNS substances 20%

(diphenylhydantoin, LSD, carbamazepine,
chlorpromazine)

Important physical
examinations
Lymph nodes
Ocular investigation:
Ptosis: Wageners granulomatosis
Scleritis, uveitis: rheumatoid arthritis, SLE, & other
collagenoses
Conjonctival lessions: systemic infection viral &
chlamydial
Conjunctival petechiae: endocarditis & lymphomas
Conjunctivitis: TB, syphilis, tularemia, mycotic
infection ((histoplasmosis)
Retinitis: toxoplasmosis, CMV
Roths spot on the retinas: endocarditis, leukemias
Choroid lessions: TB, fungal

Skin & mucosae

Examination of skin &

mucosae
Oslers node & ptechiae of the gum:
endocarditis
Roseolae of the abdominal skin:
salmonellosis
Hyperpigmentation: Whipples disease
Skin metastases of various solid tumors &
lymphomas
Cutaneous vasculitis: rheumatologic
diseases

Laboratory parameters
The most important:
Differential blood count, urine
culture, electrolytes, LFT, pancreas
function test, blood culture
Sputum, tracheal secretion
Stool
Non specific parameter

Non specific parameters

BSG, Fibrinogen, Haptoglobin, CRP,
Ceruloplasmin, netrophil granulocytes
Iron, zink < N
Eosinophilia or exanthema (20% of
cases)
Imunological parameters
LDH, Cu hematological neoplasms

Other indispenables
investigations
Inspection of the head
Ocular fundus
Conjunctiva
(petechiae)
Finger & toenail
(endocarditis)
Perineal region
(fistulas)
Meningism
Lymph nods (Ca,
Hodgins disease, HIV)
Joints (arthritis)

Thyroid gland
(subacute thyroiditis)
Spleen (endocarditis,
lyphoma)
Liver (abcess)
Rectal examination
Pressure on nasal
sinuses (sinusitis)
Auscultation of the
heart (endocarditis)
The lung

Further diagnostic measures

Radiography (regular: thoracic), USG,
CT/MRI abdomen
Mone marrow biopsy
Liver biopsy
Temporal artery biopsy

Skin testing
Mantoux test: every patient with FUO