Download Pou And Pneumoia

D efinit ion
Petersdorf and Beeson defined pyrexia of
unknown origin (PUO) in 1961. It is defined as:
 A temperature greater than 38.3°C on several
occasions.
 This should be accompanied by more than 3 weeks of
illness.
 There should also be failure to reach a diagnosis, after
1 week of inpatient investigation.
Pathophysiology
• Fever is a natural response of the body that helps in fighting
off foreign substances, such as microorganisms, toxins, etc.
• Body temperature is set by the thermoregulatory center,
located in an area in the brain called hypothalamus.
cytokines cause the thermoregulatory center in the
hypothalamus to reset the normal temperature level.
• The body's initial response is to conserve heat by
vasoconstriction, a process in which blood vessels narrow
and prevent heat loss from the skin and elsewhere. This
alone will raise temperature by two to three degrees.
• Fever is a body defense mechanism. It has been shown that
one of the effects of temperature increase is to slow
bacterial growth.
Common causes of PUO
Most cases are unusual presentations of
common diseases e.g. tuberculosis, endocarditis,
gallbladder disease and HIV infection, rather than
rare or exotic diseases.
• In adults: infections and cancer (25-40% of cases
each) account for most of PUOs.
• Children: 30-50% of cases are due to infections, 510% cancer, autoimmune disorders 10-20%.
Bacterial
• Abscesses
– There may be no localising symptoms.
– Previous abdominal or pelvic surgery, trauma .
– Most commonly in the subphrenic space, liver,
right lower quadrant, retroperitoneal space or the
pelvis in women.
• Tuberculosis (TB)
– caused by Mycobacterium tuberculosis in humans.
Most infections in humans result in an asymptomatic.
– The classic symptoms are a chronic cough with bloodtinged sputum, fever, night sweats, and weight loss.
Infection of other organs .
– More people in the developed world are contracting
tuberculosis because their immune systems are
compromised by immunosuppressive drugs, substance
abuse, or AIDS.
• Urinary tract infections (UTIs) are rare causes.
Perinephric abscesses occasionally fail to
communicate with the urinary system
resulting in a normal urinalysis
• Hepatobiliary infections e.g. cholangitis can
occur without local signs and with only mildly
elevated or normal liver function tests
especially in the elderly.
• Osteomyelitis Subacute in onset, there is
dull, constant pain and soft tissue
swelling/tenderness over the involved bone,
with low-grade fever.
• Brucellosis should be considered in patients with
persistent fever and a history of contact with
cattle, swine, goats or sheep, or patients who
consume raw milk products.
• Giant cell arthritis Consider when an elderly
patient develops a new headache associated with
a tender, ropy, or nodular temporal artery and/or
fever.
• Other spirochetal diseases that can cause PUO
include Spirillum minor (Rat-bite fever), Borrelia
burgdorferi (Lyme disease), and Treponema
pallidum (syphilis).
Viral
Herpes viruses such as cytomegalovirus and EpsteinBarr virus (EBV) can cause prolonged febrile illnesses
with constitutional symptoms and no prominent
organ manifestations, particularly in the elderly.
• HIV:
– Prolonged febrile episodes are frequent in patients with
advanced HIV infection.
– Suspect tuberculosis in high-risk patients such as HIVinfected persons, tuberculosis is usually extra pulmonary
(bones, nodes, renal, genitals, or liver).
– Over 80% of patients with AIDS and lymphomas have
involvement of extranodal sites - usually the brain.
Fungi
• Immunosuppression, the use of broad-spectrum
antibiotics, the presence of intravascular devices
and total parenteral nutrition all predispose
people to disseminated fungal infections.
Parasites
• Toxoplasmosis: This should be considered in
patients who are febrile with lymph node
enlargement.
• Trypanosoma, leishmania and amoeba species
may rarely cause PUO.
Rickettsial organisms
Coxiella burnetii may cause chronic infections, chronic Q
fever or Q fever endocarditis may be identified in patients
with a PUO.
Psittacosis
• Infection by the causative organism, Chlamydophila
should be considered in a patient with PUO who has a
history of contact with birds.
Lymphogranuloma venereum
• This should also be considered, but is rare.
Drug fever
• The most common are beta-lactam antibiotics,
procainamide (now discontinued) and isoniazid.
Stopping the drug generally leads to recovery
within 2 days.
• may be due to serum sickness, allergy, or
immune-mediated vasculitis.
• It is usually accompanied by a rash.
Collagen vascular and autoimmune diseases
• Systemic-onset juvenile rheumatoid arthritis.
High-spiking fevers, non-pruritic rashes, arthralgias
and myalgias, pharyngitis and lymphadenopathy
typically are present.
• Polyarteritis nodosa (PAN), rheumatoid arthritis
and mixed connective-tissue diseases should be
considered.
Neoplasms
• Hodgkin and non-Hodgkin lymphomas may cause
PUO.
• Leukaemias may also be responsible.
• Among solid tumours, renal cell carcinoma is most
commonly associated with PUO.
Vasculitides
• Giant cell arteritis and also the related polymyalgia
rheumatica
• Polyarteritis nodosa
• Behcet's has also been reported
Inherited diseases
• Familial mediterranean fever a hereditary
disease usually seen in Armenians and Sephardic
Jews, with short recurrent attacks of fever, pain in
the abdomen, chest, or joints, and erythema like
that of erysipelas; it may be complicated by
amyloidosis.
Hyperthyroidism and subacute thyroiditis
• These are the most common endocrine causes of
PUO.
Diagnosis
•
•
•
•
•
•
•
•
when a fever over 101°F (38.5°C) remains unexplained for
longer than 3 weeks, is usually a result of infection (40%),
neoplasm (20%), or collagen-vascular disease (20%).
Record all complaints even if not currently present.
Discuss nutrition including consumption of products and
source of these products.
Drug history should be recorded, to include over-thecounter medications,
Immunization status should be documented.
Enquire about family history of illness.
Occupational history should include illicit substances.
Sexual history should be recorded.
Take a history of travel and recreational habits
Examine for subtle clues & Clinical Findings
•Extreme elevations of fever (40°C )
it is found in heat stroke,
hypothalamic dysfunction,
meningitis,
midbrain hemorrhage,
falciparum malaria.
• Relative bradycardia occurs
typhoid fever,
meningitis with increased ICT,
factitious fever, tularemia,
brucellosis, mumps,
hepatitis, and
with concomitant beta blockers.
•Relapsing fever
(days of fever alternating with days without)
occur in
brucellosis (fever with physical activity),
Hodgkin's disease,
extrapulmonary tuberculosis,
malaria, and Lyme disease.
Hectic fever.
• FUO lasts longer than 6 months,
consider factitious fever,
granulomatous hepatitis,
neoplasm, Still disease,
infection,
collagen-vascular disease.
Jwara samprapti
• Jirna Jwara
च. चच. ३
त्रिसप्ताहे व्यतीते तु ज्वरो यस्तनुताम ् गतााः।
प्प्िहोप्ननसादम ् कुरुते स जीर्णोज्वरमच्य
ु यते।मा.नन. मधुकोष
च. चच. ३
• त्रिसप्ताहे
Fever continuous after 21 days ,indicating chronicity
& long duration of fever may be due to failure in
diagnosis or in treatment.
• मन्दज्वरा : it may be due to failure of immune
system to control infections.
• प्प्िहावद्
ृ धी: Angnimandya lead to disturbance in
Dhatupotion
Dhatukshaya
Vataprakopa
Medakshaya
Pliharuddhi.
Pneumonia is an abnormal inflammatory condition of the lung.
it is often characterized as including inflammation of the
parenchyma of the lung (that is, the alveoli) and abnormal alveolar
filling with fluid (consolidation and exudation).
• Classification
• Early classification schemes
Initial descriptions of pneumonia focused on the anatomic or
pathologic appearance of the lung, either by direct inspection at
autopsy or by its appearance under a microscope.
• Lobar pneumonia
• Interstitial pneumonia
• Bronchial pneumonia
• Multilobar pneumonia
Traditionally, clinicians have classified
pneumonia by clinical characteristics, dividing them
into "acute" (less than three weeks duration) and
"chronic" pneumonias.
1. Chronic pneumonias, on the other hand, mainly
include those of Nocardia, Actinomyces and
Blastomyces as well as the granulomatous
pneumonias (Mycobacterium tuberculosis and
atypical mycobacteria, Histoplasma capsulatum.
2. Acute pneumonias are further divided into the
classic bacterial bronchopneumonia's (such as
Streptococcus pneumoniae),
The atypical pneumonias (such as the interstitial
pneumonitis of Mycoplasma pneumoniae ), and the
aspiration pneumonia syndromes.
* There are two broad categories of pneumonia ;
1) Community-acquired pneumonia (CAP)
2)Hospital-acquired pneumonia. A recently introduced type
of healthcare-associated pneumonia lies between these two
categories.
1) Community-acquired pneumonia (CAP):it is
infectious pneumonia in a person who has not recently
been hospitalized. CAP is the most common type of
pneumonia. Streptococcus pneumoniae is the most
common cause of CAP The term "walking pneumonia" has
been used to describe a type of community-acquired
pneumonia of less severity usually caused by the atypical
bacterium, Mycoplasma pneumoniae.
2)Hospital-acquired pneumonia, also called
Nosocomial pneumonia, is pneumonia acquired
during or after hospitalization for another illness or
procedure with onset at least 72 hrs after admission.
Hospital-acquired microorganisms may include
resistant bacteria such as MRSA, Pseudomonas,
Enterobacter, and Serratia.
Ventilator-associated pneumonia (VAP) is a subset of
HAP, VAP is pneumonia which occurs after at least 48
hours of intubation and mechanical ventilation
Other types of pneumonia
1)Severe acute respiratory syndrome(SARS) .
2) Bronchiolitis obliterans organizing
pneumonia(BOOP) .
3)Eosinophilic pneumonia.
4)Chemical pneumonia.
5)Aspiration pneumonia.
6)Dust pneumonia.
7)Necrotizing pneumonia,
Signs and symptoms
People with infectious pneumonia often have
1) cough producing greenish or yellow sputum or phlegm.
2)High fever that may be accompanied by shaking chills.
3)Shortness of breath is also common.
4) A pleuritic chest pain, a sharp or stabbing pain, either
experienced during deep breaths or coughs or worsened
by them.
5) People with pneumonia may cough up blood.
6)experience headaches, or develop sweaty and clammy
skin.
pneumonia caused by Legionella may cause
abdominal pain and diarrhea, while pneumonia caused by
tuberculosis or Pneumocystis may cause only weight loss
and night sweats.
Cause
The symptoms of infectious pneumonia are caused by the
invasion of the lungs by microorganisms and by the immune
system's response to the infection The most common causes
of pneumonia are viruses and bacteria
Viruses
A virus reaches the lungs when airborne droplets are inhaled
through the mouth and nose. virus directly kills the cells.
When the immune system responds to the viral infection,
even more lung damage occurs lymphocytes, activate certain
chemical cytokines which allow fluid to leak into the alveoli.
This combination of cell destruction and fluid-filled alveoli.
Viral pneumonia is commonly caused by viruses such as influenza
virus, respiratory syncytial virus (RSV), adenovirus, and
metapneumovirus.
Bacteria
. Streptococcus pneumoniae, often called
"pneumococcus", is the most common bacterial cause of
pneumonia . Bacteria enter the lung when airborne droplets
are inhaled, but can also reach the lung through the
bloodstream through infection in another part of the body.
The neutrophils engulf and kill the offending organisms, and
also release cytokines, causing a general activation of the
immune system. This leads to the fever, chills, and fatigue .
fluid from surrounding blood vessels fill the alveoli and
interrupt normal oxygen transportation.
Less common causes of infectious pneumonia are fungi,
parasites & Idiopathic interstitial pneumonias (IIP) are a class of
diffuse lung diseases
• Investigations
• An important test for pneumonia in
unclear situations is a chest x-ray.
Chest x-rays can reveal areas of opacity
(seen as white) which represent
consolidation.
• chest CT (computed tomography) can
reveal pneumonia that is not seen on
chest x-ray. X-rays can be misleading,
because other problems, like lung
scarring and congestive heart failure
• Sputum cultures take at least two to
three days.
• Heamogram ,RFT,LFT, ect.
Pneumonia as seen on
chest x-ray. A: Normal
chest x-ray. B: Abnormal
chest x-ray with
shadowing from
pneumonia in the right
lung (white area, left side
of image).
Differential diagnosis
• . Chronic obstructive pulmonary disease (COPD) or
asthma can present with a polyphonic wheeze, similar to
that of pneumonia.
• Other diseases to be taken into consideration include
bronchiectasis, lung cancer and pulmonary emboli.
Complications
• Respiratory and circulatory failure ,Pneumonia can also
cause respiratory failure by triggering acute respiratory
distress syndrome (ARDS).
• Pleural effusion. Chest x-ray showing a
pleural effusion. The A arrow indicates
"fluid layering" in the right chest.
• empyema, and abscess
1
2
3
4
1. Normal AP CXR.
2. Normal lateral CXR.
3. AP CXR showing left lower lobe
pneumonia associated with a small left
sided pleural effusion.
4. AP CXR showing right lower lobe
pneumonia.
5. A lateral CXR showing right lower lobe
pneumonia