विवरण
Pyrexia of unknown origin (PUO) is a condition that has long put physicians' diagnostic skills to the test. Patients with this illness will, by definition, be more challenging to identify because they resisted categorization during initial studies. Additionally, researching PUO necessitates familiarity with a wide range of illnesses from various clinical specialities as well as specialized investigative techniques. The etiology and epidemiology of the illnesses that cause PUO vary as society and medicine both continue to evolve. These factors make it crucial for doctors to address PUO logically and for the causes and treatment of PUO to be regularly examined.
सारांश
- Dr. Kwasa, Senior Director of Pediatrics and Udology at Medanta Hospital, discusses Parachsia Phanonology, defining it as a fever exceeding 101 degrees Fahrenheit for at least eight days despite OPD or IPT treatment and thorough investigation. He highlights the challenge in diagnosing and treating this condition, contrasting it with typical pediatric upper and lower respiratory tract infections.
- Etiology of Parachsia Phanon origin is divided into infectious and non-infectious categories. Infectious etiologies include generalized infections like malaria, salmonella, tuberculosis, and less common ones such as leptospirosis, toxoplasmosis, and rare viral/fungal infections. Localized infections involve specific organs, such as infective endocarditis, intra-abdominal abscesses, liver infections, osteomyelitis, septic arthritis, chronic otitis media, and recurrent urinary tract infections.
- Rheumatoid diseases and malignancies also contribute to Parachsia Phanon origin. Key examples include juvenile idiopathic arthritis (JIA), SLE, vasculitis, leukemia, lymphoma, and hepatoblastoma. Miscellaneous causes include drug fever, hemophagocytic lymphohistiocytosis (HLH), histiocytosis associated with COVID-19, immune deficiency, inflammatory bowel disease (IBD), Kawasaki disease, and sepsis.
- Dr. Kwasa outlines a standard investigative protocol for patients with persistent high-grade fever lasting more than eight days. This includes a complete hemogram with ESR, CRP, peripheral smear, tuberculosis testing, viral serology (including EBV, CMV, HIV, Hepatitis B and C), urine examination, and echocardiogram. Further investigations encompass CT scans of the chest and abdomen, ultrasound of the neck, and FNAC for enlarged lymph nodes, alongside immunodeficiency panels and ANA titers.
- Brusulosis is often a differential diagnosis, exhibiting non-specific symptoms such as persistent fever (15-20 days), lethargy, osteoarticular complaints, hepatosplenomegaly, elevated liver enzymes, and lymphocytopenia. History of consuming infected animal products, particularly unpasteurized goat milk, or exposure to animal fluids can support the diagnosis. Brusulosis is typically suspected after a fever duration exceeding 15 days due to its incubation period of up to four weeks. Diagnosis involves checking brusulosis IgM levels, with titers above 1:160 considered positive. Treatment consists of doxycycline and rifampicin, often for an extended period of approximately six weeks.
- Scrub typhus, common in tropical climates, is another consideration for persistent fever beyond 8-10 days. Symptoms include fever, myalgia, mild headache, cough, and potential gastrointestinal issues. Treatment involves doxycycline, or azithromycin for children under eight years old. Malaria, with treatment options like artemether and chloroquine, should also be considered.
- Tuberculosis is ruled out through sputum testing, chest X-ray, QuantiFERON-TB Gold test, and CT scan. Salmonella, manifesting as enteric fever, is treated with ceftriaxone. Viral infections, including CMV and Epstein-Barr virus, require viral marker testing and tailored treatment. Localized infections require careful physical examination, review of reports, ultrasounds, and X-rays for diagnosis.
- Bone and joint infections like septic arthritis and osteomyelitis should be investigated with CT, ultrasound, or MRI. Infective endocarditis, often caused by staph and strep, is treated with penicillin or other antibiotics. Intra-abdominal abscesses require ultrasound or CT scans. Upper respiratory tract infections and UTIs also need exclusion through cultures and appropriate antibiotic treatment.
- HLH, often associated with previous COVID-19 infection, presents with prolonged fever, hepatosplenomegaly, hyperferritinemia, and cytopenias. Diagnostic markers include serum triglycerides, ferritin levels, liver function tests, coagulation studies, and D-dimers. Investigation involves bone marrow, blood, urine, and CSF cultures, along with PCR for viral infections. Diagnosis is based on fever, splenomegaly, peripheral blood cytopenia, hypertriglyceridemia, ferritin levels above 500, and elevated CD25 levels.
- Kawasaki disease, a multi-system vasculitis, is diagnosed using criteria such as bilateral bulbar conjunctival injection, oral changes, extremity changes, rash, and cervical lymphadenopathy. Elevated CRP, ESR, and coronary artery involvement on echocardiogram are key indicators. Treatment includes IVIG and aspirin, with steroids used for coronary involvement.
- Peripheral lymphadenopathy can be caused by lymphoma, leukemia, or tuberculosis, requiring ultrasound of the neck and abdomen. A detailed patient history, thorough physical examination, and appropriate laboratory tests are crucial for diagnosing fever of unknown origin. The differential diagnosis includes infectious, connective tissue disorders, and neoplastic diseases.
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डॉ. विनीत क्वात्रा
Senior Consultant Department of Paediatrics and Neonatology Medanta Hospital
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