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PUO

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Information about PUO
Education

Published on February 24, 2014

Author: manh11134

Source: authorstream.com

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APPROACH TO A CHILD WITH FEVER OF UNKNOWN ORIGIN : APPROACH TO A CHILD WITH FEVER OF UNKNOWN ORIGIN BY DR MANDAR HAVAL DCH.DNB BEST DEFINED AS: BEST DEFINED AS FEVER WITHOUT OBVIOUS SOURCE ON CLINICAL EXAMINATION ORAL R E C T A L FEVER: FEVER TEMPERATURE > 38 .0 degree C (> 100.4 degree F ) RECTAL TEMPRATURE ORAL – 0.6 C LESS AXILLARY IS 1.1 C LESS What is a PUO?: What is a PUO ? 1956 Age > 14 T > 37.4 ° C x3 or 38 ° C x1 Fever - predominant symptom Insufficient symptoms / signs to localise 1961 Days > 21, T > 38.3 ° C 1/52 hospital investigation 1968 Days > 14 No clear diagnosis Reid Petersdorf & Beeson Dechovitz & Moffet What is a PUO now?: What is a PUO now? Now + 2 hospital visits, or Hospital investigations for 3 days Neutropenic PUO Neutrophils < 1.0 Diagnosis not clear at 3 days Nosocomial PUO Admission infection screen negative Diagnosis not clear at 3 days HIV PUO HIV infected, fever for 4 weeks Diagnosis not clear after 3 days TYPES OF PUO: TYPES OF PUO ACUTE ONSET (<7 DAYS) PROLONG (> 7 to 10 DAYS) PowerPoint Presentation: The commonest cause of PUO is: A common disease presenting in an atypical way. A rare disease presenting in atypical way. A common disease presenting typically. A rare disease presenting typically . PowerPoint Presentation: The answer is ..A ..The commonest cause of PUO IS …Common disease presenting ATYPICALLY ETILOGY: ETILOGY INFECTION CONTRIBUTE TO 40 TO 50% OF FUO COLLAGEN VASCULAR DISEASE 15-20% MALIGNANCY 5-10% Causes of PUO: Causes of PUO Bacteria Tuberculosis, Salmonellosis, Brucellosis, Mycoplasma, Campylobacter Viruses Cytomegalovirus, Hepatitis, Infectious Mononucleosis, HIV Parasitic Disease Amebiasis, Toxoplasmosis, Malaria, Visceral Larva Migrans Spirochetes Leptospirosis, Lyme Disease, Relapsing Fever, Syphilis Chlamydia Lymphogranuloma Venereum Localised Infections Abscess, Endocarditis, Pyelonephritis, Sinusitis Causes of PUO – Contd..: Causes of PUO – Contd.. Connective Tissue Disorders Juvenile Rheumatoid Arthritis, Rheumatic fever, Systemic lupus erythematosus , Polyarteritis Nodosa , Hypersensitivity Pneumonia Malignancies Hodgkin disease, Leukemia, Neuroblastoma, Wilms tumor Granulomatous Disease Crohn’s Disease, Sarcoidosis Hypersensitivity Disease Drug fever, Hypersensitivity Pneumonitis Pancreatitis Miscellaneous Causes Kawasaki Disease, Pulmonary Embolism, Thyrotoxicosis , Diabetes Insipidus , Factitious fever AGE GROUP: AGE GROUP NEONATE ( 0-28 days) YOUNG INFANT ( 1-3 months) OLDER INFANT TO TODDLER (3 month To 36 month) NEONATE: NEONATE ALL TOXIC – APPEARING INFANTS AND ALL FEBRILE INFANTS LESS THAN 28 DAYS SHOULD BE HOSPITALIZED FOR EVALUATION AND INITIATION OF PROMPT PARENTAL ANTIBIOTIC THERAPY AFTER SENDING BLOOD CULTURE FLOW CHART: FLOW CHART AGE<28 days OR CLINICALLY TOXIC CHILD YES NO INVESTIGATION INCLUDE LP IV ANTIBIOTICS HOSPITALIZATION INVESTIGATE CONSIDER LP NORMAL LAB AND X RAY REACESS 24 HRS LATER CLINICALLY ABNORMAL LABS OR CXR IV ANTIBIOTICS HOSPITALIZATION WHY NEONATE ARE AT HIGH RISK:  WHY NEONATE ARE AT HIGH RISK HIGH RISK OF DEVELOPING SBI MAINLY BACTERIAL ( GRAM NEGATIVE) WHICH NEONATE ARE TOXIC: WHICH NEONATE ARE TOXIC Fever in young infants (1-3 months): Fever in young infants (1-3 months) Low risk Well appearing WBC count 5000-15000/ cmm Band : Neutrophil ≤0.2 Centrifuged urine <10 WBC/HPF No bacteria on Gram stain-urine CSF <8 WBC/ cmm High risk I ll looking WBC count <5000 or >15000/cmm Band : Neutrophil >0.2 Centrifuged urine >10 WBC/HPF Bacteria + on gram stain- urine CSF >8 WBC/cmm Risk for SBI TAKE HOME MESSAGE: TAKE HOME MESSAGE ANY NEONATE LESS THAN 28 DAYS HAS TO BE REFERRED OR ADMITTED AGE 28 DAYS TO 60 DAYS : AGE 28 DAYS TO 60 DAYS 5 – 10% INCEDENCE OF HIGH RISK INFECTION UNFORTUNATE ABOUT FEVER IN THESE AGE GROUP ROCHESTER CRITERIA APPROACH: APPROACH TOXIC OR NON TOXIC NO YES (EXAMINATION INVESTIGATION) REPEATED EVALUATION ADMIT OR REFERRED INVESTIGATION: INVESTIGATION PERIPHERAL BLOOD COUNT CRP URINE ANALYSIS BLOOD CULTURE URINE ANALYSIS/CULTURE CHEST X RAY CSF AGE 3MONTHS TO 36 MONTHS: AGE 3MONTHS TO 36 MONTHS IN THIS SUB GROUP TEMPERATURE MORE THAN 39 degree C IS DEFINED AS FEVER PowerPoint Presentation: TEMP > 39 C YES NO TOXIC Y E S N O ADMIT INVESTIGATION PARENTAL ANTI. INVESTIGATE WITH TC , DC URINE XRAY OCCULT UTI OCCULT BACTEREMIA PNEUMONIA LAB CRITERIA: LAB CRITERIA TLC (5 – 15000) ABSOLUTE BAND CELL COUNT (<1500/mm) <10 WBC PER HIGH POWER FIELD IN SPUN URINE SEDIMENT <5 WBC PER HIGH POWER FIELD IN STOOL SAMPLE PowerPoint Presentation: LP – PRESENCE OF WBC IN CSF/ GRAM STAINING 2 D ECHO – HELPS IN DIAGNOSING IE, MYOCARDITIS CT SCAN / MRI Management of Fever – Contd..: Management of Fever – Contd.. Oral antipyretics – Well tolerated , effective Parenteral antipyretics not indicated Rectal suppositories – In intractable vomiting , post-operative state Inform parents that antipyretics do not cure Fever may persist despite antipyretics , especially in first 2-3 days of even in self-limiting viral infection ANTIBIOTIC PREFFERED LESS THAN 3 MONTHS: ANTIBIOTIC PREFFERED LESS THAN 3 MONTHS AMPICILLIN + GENTAMYCIN CIFTRIAXONE CEFOTAXIME MORE THAN 3 MONTH: MORE THAN 3 MONTH CIFTRIAXONE CEFUROXIME TAKE HOME MSG..: TAKE HOME MSG.. ALL FEBRILE INFANTS WHO ARE LESS THAN 36 months WHO HAVE TOXIC MANIFESTATION HAS TO BE REFERRED LESS THAN 28 DAYS HAS TO BE REFERRED FOR PARENTRAL ANTIBIOTIC NO LAB TEST OR ANTIBIOTIC ARE NEEDED IN CHILD OVER 3 MONTHS WHO HAS TEMP LESS THAN 39 C. QUESTIONS?: QUESTIONS? THANK YOU:  THANK YOU

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