Pyrexia of Unknown Origin (PUO)

2019 ◽  
Author(s):  
Mark Melzer
Keyword(s):  
Infective Endocarditis ◽  
Lupus Erythematosus ◽  
Bacterial Infections ◽  
Unknown Origin ◽  
Coagulase Negative Staphylococci ◽  
Pyrexia Of Unknown Origin ◽  
Hospital Patients ◽  
Intravascular Devices ◽  
Abdominal Infections ◽  
Culture Negative

Petersdorf and Beeson defined pyrexia of unknown origin (PUO) in 1961. It is defined as an illness more than three weeks’ duration, with a fever > 38.3°C on several occasions and failure to reach a diagnosis after one week of in-patient investigation. Additional categories have now been added. These include: ● Nosocomial PUO in hospital patients: This is defined as fever of 38.3°C on several occasions caused by a process not present or incubating on admission, where initial cultures are negative and diagnosis remains unknown after three days of investigations. Fever is often related to hospital factors such as surgery, use of biomedical devices (e.g. intravascular devices/urinary catheters), C. difficile infection, and decubitus ulcers related to immobilization. ● HIV- associated PUO: This is defined as fever (as in Nosocomial PUO) for four weeks as an outpatient or three days as an in- patient. The commonest causes of fever are typical and atypical mycobacterial infections, cryptococcosis, and Cytomegalovirus (CMV). Lymphoma may cause fever in up to 25% of cases. ● Neutropenic PUO: This includes patients with a fever (as in Nosocomial PUO) with neutrophils < 1.0 x 109/L, with initial negative cultures and an uncertain diagnosis after three days. Bacterial infection is the commonest cause and should be treated empirically. The causes of a PUO can be categorized as infection (30–40%), neoplasia (20–30%), collagen-vascular and autoimmune diseases (10–20%), and miscellaneous (10–20%). The commonest causes of localized bacterial infections causing PUO are infective endocarditis, intra- abdominal or pelvic infections, oral cavity infections, osteomyelitis, and infected peripheral vessels. These conditions include: ● Infective endocarditis (IE): ■ Organisms associated with indolent onset (e.g. Streptococcus viridans, Enterococcus species, coagulase- negative staphylococci). ■ HACEK organisms (e.g. Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella). ■ Culture-negative endocarditis (e.g. Chlamydia, Coxiella, or Bartonella). ■ Non- infective endocarditis: ● Marantic endocarditis, associated with malignancy. ● Libman Sacks endocarditis, associated with systemic lupus erythematosus (SLE). ● Intra-abdominal infections. ■ Abscesses: ● Hepatic (GI tract or biliary in origin). ● Splenic (associated with IE). ● Sub-phrenic (associated with previous surgery). ● Pancreatic (post-pancreatitis).

Infective endocarditis as a complication of longstanding ventriculoatrial (VA) shunt: the importance of suspicion and early investigation in patients with VA shunt and pyrexia of unknown origin

2021 ◽  
Vol 14 (1) ◽  
pp. e237161
Author(s):  
Rosa Sun ◽  
Richard Warwick ◽  
Stuart Harrisson ◽  
Nageswar Bandla
Keyword(s):  
Infective Endocarditis ◽  
Fever Of Unknown Origin ◽  
Unknown Origin ◽  
Early Investigation ◽  
Window Of Opportunity ◽  
Pyrexia Of Unknown Origin ◽  
Cerebrospinal Fluid Diversion ◽  
Prompt Diagnosis

Ventriculoatrial (VA) shunts are a method of cerebrospinal fluid diversion, which nowadays are infrequently seen in medical practice. Infective endocarditis (IE) can occur as rare complications of VA shunts, through the introduction of a foreign body close to the tricuspid valve. We report a case of infective endocarditis, that is, in a patient with VA shunt for congenital hydrocephalus. We present the case to highlight the importance of early investigation for IE in patients with fever of unknown origin and shunt in situ, as rapid deterioration can occur and be fatal. We also discuss past experience reported in the literature on the role of cardiothoracic intervention. Prompt diagnosis and early cardiothoracic referral for surgery are crucial, there may only be a narrow window of opportunity for intervention before patients develop fulminant sepsis.

scholarly journals EP05 The wolf finds unusual prey

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Mithun Chakravorty ◽  
Robert Sandler ◽  
Ayman El-Nayal
Keyword(s):  
Lupus Erythematosus ◽  
Late Onset ◽  
Obstructive Uropathy ◽  
Kidney Injury ◽  
Unknown Origin ◽  
Renal Calculus ◽  
Tertiary Hospital ◽  
Haemodynamic Instability ◽  
Pyrexia Of Unknown Origin ◽  
Critical Care Admission

Abstract Background Systemic lupus erythematosus (SLE) or lupus (Latin for wolf) is a rare multi-system autoimmune disease that has usually presented by the fifth decade, with a seven-fold higher incidence in females, especially of Afro-Caribbean descent. It is a recognised cause of pyrexia of unknown origin (PUO) though infection and malignancy are far commoner causes. Lupus nephritis (LN) can be life-threatening and affects nearly one-third of patients. We highlight a surprising case of late-onset SLE in a 65-year-old Caucasian man that presented with PUO and early LN. Methods Our patient was known to have atrial fibrillation, hypertension and previous obstructing renal calculus and presented to the Emergency Department with two weeks of right flank pain and fevers. He required critical care admission due to haemodynamic instability. CT excluded obstructive uropathy but a complex right renal cyst was present with mild inflammatory stranding. Bloods showed new neutrophilia (8.31-9.50 x 109/L), anaemia (haemoglobin 93 g/L), thrombocytopenia (platelets 90 x 109/L) and acute kidney injury (creatinine 128 μmol/l from 90 μmol/l baseline). CRP persisted above 110 mg/L. Liver function and ferritin were normal. Despite escalation of antibiotics he remained febrile, creatinine peaked at 291 μmol/L with raised urine protein:creatinine ratio (PCR) of 384 mg/mmol. Repeated septic screens and blood-borne virus tests were negative. Further CT showed mild ascites and pleural effusions. Transthoracic echocardiogram revealed a small pericardial effusion only, and pleural aspirate was a transudate, without malignant cells. Results There was clinical improvement after three weeks despite persistent fevers and he was discharged. However, readmission within three days necessitated inotropic support. After stabilisation, he was transferred under Infectious Diseases in a tertiary hospital. Shortly afterwards, the autoimmune screen showed positive anti-nuclear antibody (ANA), with positive Crithidia luciliae IgG double-stranded DNA (dsDNA) and titres &gt;379 IU/mL. Concurrent hypocomplementaemia (C3 0.22 g/L, C4 0.03 g/L) raised the possibility of LN with SLE and renal biopsy demonstrated class 3 LN. Prompt treatment with intravenous glucocorticoids and mycophenylate mofetil (MMF) resulted in an excellent recovery. Almost a year later, he is taking MMF 1g twice daily with prednisolone 10mg daily. His creatinine is stable at 110 μmol/L, urine PCR around 300 mg/mmol and complements have normalised, despite persistent dsDNA titre of 150 IU/mL. He continues driving taxis and reports a good quality of life. Conclusion There was low suspicion of SLE in this case given the absence of typical symptoms and considering his age, gender and ethnicity. A literature review of male patients with SLE suggested tendency for later-onset and a worse prognosis. There appears to be less LN but when present requires prompt immunosuppression as occurred in this case. Currently, the oldest documented male patient with both SLE and biopsy-proven LN at diagnosis was 74 years old. Disclosures M. Chakravorty None. R. Sandler None. A. El-Nayal None.

scholarly journals Association between echocardiographic manifestations and bacterial infections in patients with infective endocarditis: a cohort study

2019 ◽  
Author(s):  
Anna Damlin ◽  
Katarina Westling ◽  
Eva Maret ◽  
Cecilia Stålsby Lundborg ◽  
Kenneth Caidahl ◽  
...  
Keyword(s):  
Cohort Study ◽  
Infective Endocarditis ◽  
Blood Culture ◽  
Bacterial Infections ◽  
National Registry ◽  
University Hospital ◽  
Categorical Variables ◽  
Group B Streptococci ◽  
Coagulase Negative Staphylococci ◽  
Cardiac Manifestations

Abstract Abstract Background The diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for direct visualization of IE-induced cardiac manifestations. We investigated correlations between bacterial infections and IE manifestations diagnosed by ECHO. Methods In this cohort study, data from patients aged 18 years or above, with definite or possible IE admitted at the Karolinska University Hospital between 2008-2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR were excluded. IE manifestations diagnosed by ECHO and risk factors were obtained from the registry. Chi-squared test and two-sided Fisher’s exact test was used for comparisons between categorical variables, and student’s ttest was used for continuous numerical variables; two-sided and skewed variables were log-transformed before these analyses. Multivariable analyses were performed using logistic regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P< 0.05 was considered significant. Results The most common bacteria were Staphylococcus aureus(n= 268, 47%) and viridans group streptococci (n= 127, 22%). The most common manifestations were vegetation in the mitral (n = 222, 36%), aortic (n = 214, 34%), and tricuspid valves (n = 117, 19%). Correlations were seen between aortic valve vegetation and coagulase-negative staphylococci (CoNS) and Enterococcus faecalis, between mitral valve vegetation and group B streptococci, tricuspid valve vegetation, andS.aureus, and between perivalvular abscesses and CoNS (all P< 0.05). Conclusions Correlations were found between certain bacteria and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

scholarly journals Pooled analysis of 1270 infective endocarditis cases in Turkey

2019 ◽  
Vol 13 (02) ◽  
pp. 93-100 ◽  
Author(s):  
Arman Vahabi ◽  
Funda Gül ◽  
Sabina Garakhanova ◽  
Hilal Sipahi ◽  
Oğuz Reşat Sipahi
Keyword(s):  
Infective Endocarditis ◽  
Prosthetic Valve Endocarditis ◽  
Pooled Analysis ◽  
Etiologic Agent ◽  
National Database ◽  
Coagulase Negative Staphylococci ◽  
History Of ◽  
National Databases ◽  
Culture Negative ◽  
Overall Mortality

Introduction: Despite developments in medicine, infective endocarditis (IE) is still associated with significant morbidity and mortality. In this study it was aimed to systematically review the infective endocarditis literature published or presented from Turkey. Methods: To find the published series, one national database (Ulakbim), and three international databases (Scopus, Pubmed and Sci-e) were searched between 31 October-3 November 2014. also, abstracts of congresses by three national congresses were searched for studies regarding infective endocarditis. Results: Data for 1270 patients (38.3% female, mean age 46.2, 28% prosthetic valve endocarditis) with a diagnosis of infective endocarditis were obtained from 21 reports (18 published articles and three congress abstracts). Of the 18 articles, four were in peer-reviewed medical journals indexed in national databases and 14 were in international databases. There was an underlying heart disease in 51.9% and history of dental procedure was 6.7%. Fever, heart murmur and fatigue were present in 94%, 71.4% and 69% respectively. most commonly involved site was mitral valve (43.3%), followed by aortic (33.8%) and tricuspid valve (6.4%). Staphylococcus aureus, coagulase-negative staphylococci and enterococci comprised the 22.8%, 9.7% and 7.5% of the cases while 31.1% were culture-negative. Overall mortality was 23.4%. When we compared series related to years 2008 and before and 2009 and after, the mortality rates were (24.1%-224/931) vs (20.1%-32/159), respectively (p = 0,31). Conclusion: Infective endocarditis is still associated with significant mortality. S. aureus seems to be the most common etiologic agent. There was a slight decrease in the recent years in mortality.

scholarly journals Right-sided endocarditis from Staphylococcus lugdunensis in a patient with tetralogy of Fallot

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Bradford III Becken ◽  
Jacob Kilgore ◽  
Elizabeth Thompson ◽  
M. Anthony Moody
Keyword(s):  
Staphylococcus Aureus ◽  
Infective Endocarditis ◽  
Tetralogy Of Fallot ◽  
Pediatric Patients ◽  
Coagulase Negative Staphylococcus ◽  
Coagulase Negative Staphylococci ◽  
Staphylococcus Lugdunensis ◽  
Enterococcal Species ◽  
Viridans Group Streptococci ◽  
Culture Negative

Infective endocarditis is often caused by bacterial pathogens and can affect native and prosthetic tissue. Common pathogens in pediatric patients include Staphylococcus aureus, viridans group streptococci, enterococcal species and coagulase-negative staphylococci, though culture-negative cases are not uncommon. Coagulase-negative staphylococci present a conundrum to clinicians due to the potential of culture contamination. While Staphylococcus lugdunensis is a coagulase-negative staphylococcus, it is an emerging cardiotropic pathogen that presents similarly to Staphylococcus aureus. Here we report a case of a child with repaired tetralogy of Fallot found to have right-sided infective endocarditis caused by Staphylococcus lugdunensis.

scholarly journals Associations between echocardiographic manifestations and bacterial species in patients with infective endocarditis: a cohort study

2019 ◽  
Author(s):  
Anna Damlin ◽  
Katarina Westling ◽  
Eva Maret ◽  
Cecilia Stålsby Lundborg ◽  
Kenneth Caidahl ◽  
...  
Keyword(s):  
Cohort Study ◽  
Infective Endocarditis ◽  
Blood Culture ◽  
Bacterial Infections ◽  
Electronic Device ◽  
Bacterial Species ◽  
University Hospital ◽  
Categorical Variables ◽  
Coagulase Negative Staphylococci ◽  
Cardiac Manifestations

Abstract Abstract Background The diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for visualization of IE-induced cardiac manifestations. We investigated correlations between bacterial infections and IE manifestations diagnosed by ECHO. Methods In this cohort study, data from patients aged 18 years or above, with definite IE admitted at the Karolinska University Hospital between 2008 and 2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR, and patients who did not undergo ECHO during hospital stay, were excluded. IE manifestations diagnosed by ECHO were obtained from the registry. Chi-squared test and two-sided Fisher’s exact test was used for comparisons between categorical variables, and student’s t test was used for continuous numerical variables. Multivariable analyses were performed using logistic regression. Secular trend analyses were performed using linear regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P < 0.05 was considered significant. Results The most common bacteria were Staphylococcus aureus (n = 239, 49%) and viridans group streptococci (n = 102, 21%). The most common manifestations were vegetation in the mitral (n = 195, 40%), aortic (n = 190, 39%), and tricuspid valves (n = 108, 22%). Correlations were seen between aortic valve vegetations and Enterococcus faecalis among patients with native aortic valves, between mitral valve vegetations and streptococci of group B or viridans group, between tricuspid valve vegetations and S. aureus among patients with intravenous drug abuse, and between perivalvular abscesses as well as cardiovascular implantable electronic device (CIED)-associated IE and coagulase negative staphylococci (all P < 0.05). Conclusions Correlations were found between certain bacterial species and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

Infectious diseases

2016 ◽  
Keyword(s):  
Bacterial Infections ◽  
Drug Users ◽  
Fungal Infections ◽  
Unknown Origin ◽  
Diagnostic Techniques ◽  
Needlestick Injury ◽  
Hiv And Aids ◽  
Pyrexia Of Unknown Origin ◽  
Rickettsial Infections ◽  
Immunocompromised Hosts

Chapter 12 covers the basic science and clinical topics relating to infectious disease which trainees are required to learn as part of their basic training and demonstrate in the MRCP. It begins with an overview, before covering diagnostic techniques, sepsis, antibiotics, needlestick injury, nosocomial infection, travel-related infection, immunocompromised hosts, pyrexia of unknown origin, infection in injecting drug users, bioterrorism, viral infection, HIV and AIDS, bacterial infections, mycobacterial infections, rickettsial infections, systemic fungal infections, protozoal infections, and helminthic infections.

scholarly journals Associations between echocardiographic manifestations and bacterial species in patients with infective endocarditis: a cohort study

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
A. Damlin ◽  
K. Westling ◽  
E. Maret ◽  
C. Stålsby Lundborg ◽  
K. Caidahl ◽  
...  
Keyword(s):  
Cohort Study ◽  
Infective Endocarditis ◽  
Blood Culture ◽  
Bacterial Infections ◽  
Electronic Device ◽  
Bacterial Species ◽  
University Hospital ◽  
Categorical Variables ◽  
Coagulase Negative Staphylococci ◽  
Cardiac Manifestations

Abstract Background The diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for visualization of IE-induced cardiac manifestations. We investigated associations between bacterial infections and IE manifestations diagnosed by ECHO. Methods In this cohort study, data from patients aged 18 years or above, with definite IE admitted at the Karolinska University Hospital between 2008 and 2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR, and patients who did not undergo ECHO during hospital stay, were excluded. IE manifestations diagnosed by ECHO were obtained from the registry. Chi-squared test and two-sided Fisher’s exact test was used for comparisons between categorical variables, and student’s t test was used for continuous numerical variables. Multivariable analyses were performed using logistic regression. Secular trend analyses were performed using linear regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P < 0.05 was considered significant. Results The most common bacteria were Staphylococcus aureus (n = 239, 49%) and viridans group streptococci (n = 102, 21%). The most common manifestations were vegetation in the mitral (n = 195, 40%), aortic (n = 190, 39%), and tricuspid valves (n = 108, 22%). Associations were seen between aortic valve vegetations and Enterococcus faecalis among patients with native aortic valves, between mitral valve vegetations and streptococci of group B or viridans group, between tricuspid valve vegetations and S. aureus among patients with intravenous drug abuse, and between perivalvular abscesses as well as cardiovascular implantable electronic device (CIED)-associated IE and coagulase negative staphylococci (all P < 0.05). Conclusions Associations were found between certain bacterial species and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

Sign in / Sign up

Export Citation Format

Share Document