Scribd
Upload
13 views

Syndrome -Lecture 7

The document outlines definitions and classifications of Fever of Unknown Origin (FUO) and sepsis, including classic and nonclassic FUO types, their etiologies, and diagnostic workups. It details the management strategies for FUO and sepsis, emphasizing the importance of avoiding unnecessary treatments and conducting thorough evaluations. Additionally, it highlights common sources and risk factors for sepsis, along with clinical manifestations and initial management protocols.

Uploaded by

Velma Pranay Reddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
13 views

Syndrome -Lecture 7

The document outlines definitions and classifications of Fever of Unknown Origin (FUO) and sepsis, including classic and nonclassic FUO types, their etiologies, and diagnostic workups. It details the management strategies for FUO and sepsis, emphasizing the importance of avoiding unnecessary treatments and conducting thorough evaluations. Additionally, it highlights common sources and risk factors for sepsis, along with clinical manifestations and initial management protocols.

Uploaded by

Velma Pranay Reddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 18

Fever of Unknown Origin, Sepsis

Anzor Gogiberidze
Definitions

•Classic FUO: temperature of > 38.3°C (100.9°F) recorded on multiple occasions that lasts
for > 3 weeks with no clear etiology despite investigations on 3 outpatient visits, 3 days in
the hospital, or 1 week of invasive ambulatory investigation
•Nonclassic FUO is characterized by temperature > 38.3°C recorded on multiple occasions
with no clear etiology after at least 2 days of culture incubation in addition the following
specific features:
• Neutropenic FUO (immunodeficient FUO): neutrophil count of < 500/mm3 or an
anticipated fall in neutrophil count to < 500/mm3 within 1–2 days
• HIV-associated FUO: fever that lasts for > 4 weeks (or > 3 days if hospitalized) in a
patient with HIV
• Nosocomial FUO: fever that lasts for > 3 days in a hospitalized patient who was
afebrile on admission
Classic FUO-Etiology

•Most etiologies of classic FUO can be grouped into four major


categories:
• Infection
• Inflammatory (e.g., rheumatic conditions, autoimmune
conditions)
• Malignancy
• Miscellaneous
•In 7–51% of cases, the underlying etiology remains undiagnosed.
Healthcare-associated
FUO
In addition to the common causes of fever, consider the following in
this group of patients:
•Drug fever
•Intravascular catheter-related infection
•Venous thromboembolism (DVT, pulmonary embolism)
•Clostridioides difficile colitis
•Inflammatory response to major surgery
•Occult abscess
•Transfusion reactions
•Sinusitis
•Candidemia (if critically ill)
Immunodeficiency-associated
FUO

In addition to the common causes of fever, consider the following in this group of
patients:
•Opportunistic infections (e.g., candidiasis, aspergillosis, CMV infection)
•Drug fever (more common in neutropenic patients) [1]
•Malignancy
•In people living with HIV, also consider HIV-associated conditions (e.g.,
Pneumocystis pneumonia, MAC infection, Kaposi sarcoma) and
immune reconstitution inflammatory syndrome.
Minimum diagnostic workup

•Laboratory studies
• CBC with differential
• Acute phase reactants : erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP)
• Liver chemistries
• Serum electrolytes
• LDH
• Creatine kinase
• Urinalysis and urine culture
• Blood culture (three sets) if bacteremia is suspected [3][8]
•Imaging
• X-ray or CT chest
• Ultrasound or CT abdomen and pelvis
Treatment

•Avoid antipyretics if feasible.


•Avoid empiric therapy (e.g., antibiotics, glucocorticoids) unless
there is rapid clinical deterioration or if a life-threatening etiology
is suspected.
•If the underlying etiology remains undiagnosed and FUO persists
despite advanced diagnostics:
• Specialist consultation (e.g., infectious diseases,
rheumatology, oncology, and/or hematology) is advised.
• Consider a trial of anakinra in patients with a
suspected autoinflammatory condition and rapid clinical
deterioration. [4][25]
•Once a likely cause has been identified, manage accordingly (see
dedicated articles for details).
Sepsis - Definitions

•Sepsis: a severe, life-threatening condition that results from a


dysregulation of the patient's response to an infection, causing tissue and
organ damage and subsequent organ dysfunction [1]
•Septic shock: a sepsis syndrome accompanied by circulatory and
metabolic abnormalities that can significantly increase mortality [1]
• Diagnostic criteria
• Persistent hypotension: Vasopressors are required to maintain
mean arterial pressure (MAP) ≥ 65 mm Hg.
• Persistent lactic acidosis: lactate > 2 mmol/L (18 mg/dL)
despite adequate fluid resuscitation
Other definitions of sepsis syndromes

•Systemic inflammatory response syndrome (SIRS) : a group of


physiological and immune-mediated reactions that are triggered in
response to an infectious or noninfectious insult (e.g., an acute
inflammatory process or trauma) [1][3]
• SIRS is diagnosed if ≥ 2 of the following 4 criteria are fulfilled:
• Temperature: > 38°C or < 36°C
• Heart rate: > 90/min
• Respiratory rate: > 20/min or PaCO2 < 32 mm Hg
• White blood cell count: > 12,000/mm3, < 4000/mm3,
and/or > 10% band cells
•Sepsis: ≥ 2 SIRS criteria PLUS a suspected or confirmed underlying
infection [1]
•Severe sepsis: sepsis PLUS dysfunction of at least one organ or
system [1]
•Multiple organ dysfunction syndrome (MODS) : [1]
• Progressive, but potentially reversible, dysfunction of several
organs and/or systems [7]
• The more organs that are affected, the greater the mortality
risk.
•Bacteremia: the presence of viable bacteria in the bloodstream, with
Common sources of sepsis

• Respiratory: pneumonia (most common cause of


sepsis)
• Abdominal infections (e.g., intraabdominal abscess)
• Genitourinary: pyelonephritis
• Skin and soft tissue infections
• Implanted devices (e.g., central venous catheter,
port-a-cath, urinary catheter, endotracheal tube)
•Pathogens
• Bacterial: gram-positive bacteria (most common in the
US); gram-negative bacteria
• Fungal, viral, or parasitic infection (rare)
Common risk factors

•Age: < 1 year or > 75 years


•Primary comorbidities (diabetes mellitus, cirrhosis,
community acquired pneumonia, bacteremia, alcohol use disorder)
•Immunosuppression (neutropenia, corticosteroid treatment)
•Intensive care or prolonged admission (nosocomial infections)
•Recent antibiotic or corticosteroid treatment
•Invasive medical devices (e.g., endotracheal tubes, intravenous lines,
urinary catheters)
Clinical Manifestation

•General features
• Fever , chills, and diaphoresis
• Tachycardia
• Tachypnea
• Generalized edema (capillary leak)
•Features of organ dysfunction (see SOFA score)
• CNS impairment: altered mental status
• Cardiovascular failure: hypotension
• Coagulopathy → disseminated intravascular coagulation → petechiae, purpura
• Liver failure: jaundice
• Kidney failure: oliguria
• Respiratory failure: symptoms of acute respiratory distress syndrome (ARDS)
•Features of septic shock
• Hypotension (MAP < 65 mm Hg)
• Altered skin and soft tissue perfusion
• Early presentation: warm skin and normal capillary refill time (warm shock)
• Late presentation: cold, cyanotic, pale, and/or mottled skin and
prolonged capillary refill time (cold shock)
•Features of the primary infection: e.g., clinical features of pneumonia, meningismus
, peritonitis, clinical features of pyelonephritis, clinical features of infective endocarditis
Management
•Initial evaluation
• Perform a clinical evaluation using the ABCDE approach.
• Establish IV access.
• Obtain the following initial studies immediately:
• Serum lactate: Elevated lactate predicts sepsis severity and
helps guide resuscitation.
• Two sets of blood cultures (aerobic and anaerobic) prior to
antibiotics (if possible)
•Initial management
• Fluid resuscitation: Infuse 30 mL/kg of crystalloid fluid in 3
hours.
• Vasopressors for septic shock: Administer if hypotension
persists (during or after fluid resuscitation); target MAP ≥ 65
mm Hg. [2]
• Antibiotics for sepsis: Begin empiric broad-spectrum or
directed antibiotics within 1–3 hours.
•Next steps
• Continuous reassessment of hemodynamic parameters
• Supportive care for sepsis.
• Begin source control for sepsis
Thank you! 

You might also like