FEVER OF UNKNOWN ORIGIN

Here is the **OCR-extracted text** from all your uploaded PUO (Pyrexia of Unknown Origin) pages. I will present it in a **clean, stylish, NEET-PG–ready format** — **beautiful, readable, structured**, suitable for putting directly in your *ErrorOn Space* detailed pages. --- # 🔵 **FEVER OF UNKNOWN ORIGIN (PUO / FUO)** ### *A complete structured, stylish extraction from your images* --- ## 🌙 **Diurnal Variation in Body Temperature** * **Maximum** temperature: *Evening* * **Minimum** temperature: *Early morning (4 AM)* * Normal diurnal variation: **<0.9°F** **Reason for evening rise** * ↑ BMR * ↑ Muscular activity --- ## 🌡️ **Fever / Temperature Patterns** * **AM** > 98.9°F * **PM** > 99.9°F (due to circadian rhythm) ### Hyperpyrexia (>107°F) * Associated with **heat stroke** ### Hypothermia (<35°C / 95°F) * **Mild:** 32–35°C * **Moderate:** 28–32°C * **Severe:** <28°C * ECG hallmark: **J-wave / Osborn wave** ### Measuring Core Temperature * **Ideal site:** Pulmonary artery * Lower esophagus > Rectal wall * Rectal temp is **0.7°F higher** than oral * Rectal temp is **more accurate** --- # 🟢 **Patterns of Fever** ### 1. **Sustained / Continuous Fever** * Never touches baseline * Diurnal fluctuation <1°C ### 2. **Remittent Fever** * Never touches baseline * Fluctuation >1°C ### 3. **Intermittent Fever** * Fever touches baseline * Seen in **malaria** ### 4. **Relapsing Fever** * Recurs every **3 days** * e.g., *Borrelia recurrentis*, Rat-bite fever --- # 🟣 **Fever Timelines & Malaria Patterns** ### Quotidian fever Occurs **once daily**, touches baseline ### Double Quotidian Fever Fever spikes **twice daily** Seen in: * Adult-onset Still’s disease * Juvenile rheumatoid arthritis ### **Malaria patterns** * **Tertian** (every 48 hrs): *P. vivax*, *P. ovale* * **Quartan** (every 72 hrs): *P. malariae* --- # 🟠 **Special Fever Behaviours** ### 📉 **Resolution by Crisis** Fever suddenly falls Seen in: * Acute tonsillitis * Pneumonia resolution * Schistosomiasis * Q fever * Psittacosis ### 📉 **Resolution with Lysis** Gradual decline in fever (step-ladder) Occurs **after antibiotics** ### 📈 **Step-Ladder Fever (Typhoid)** * Ciprofloxacin → lysis 5–6 days * Ceftriaxone → faster resolution --- # 🔴 **Causes of Fever of Unknown Origin** ## 1. **Infections > Inflammation** * Atypical infection presentations * Tuberculosis * Osteomyelitis * SAPHO syndrome * Schnitzler syndrome * PAPA syndrome --- # 🔷 **Important Diagnostic Algorithm for PUO** 1. Fever >38.3°C for >3 weeks 2. Basic history + exam 3. Stop unnecessary antibiotics & steroids 4. Mandatory tests: * ESR, CRP * CBC * LFT, RFT * LDH * ANA, RF * CK * Blood cultures ×3 (sterile) * Urine culture * CXR * Abdominal USG * Tuberculin test 5. Exclude **thermometer manipulation** 6. Stop suspected drug-related fever --- ## 🔍 **Potential Diagnostic Clues (PDC)** ### A. Fever + Headache → Do **Lumbar puncture / CSF** * TB meningitis * Cryptococcal meningitis * Mollaret meningitis ### B. Fever + Cytopenia / Hepatosplenomegaly → **Bone marrow biopsy / aspiration** ### C. Fever + TB Features → **Liver biopsy** (CBNAAT preferred) --- # 🟡 **Non-Infectious Inflammatory Disorders (NIID)** 1. **Large-vessel vasculitis** * India: **Takayasu arteritis** * Central Asia: **Behçet disease** 2. **Sarcoidosis** * Breathlessness in young females * Hilar lymphadenopathy 3. **Adult-onset Still disease** 4. **Polymyalgia Rheumatica** 5. **Tumors** * Malignant lymphoma (common) * Leukemia 6. **Drugs causing FUO** * Allopurinol * Lamotrigine, phenytoin * Sulfa drugs * Furosemide * Quinidine --- # 🔶 **HACEK Organisms** * **H**: Haemophilus aphrophilus * **A**: Aggregatibacter * **C**: Cardiobacterium hominis * **E**: Eikenella * **K**: Kingella Cause of **culture-negative endocarditis** --- # 🟥 **Faget’s Sign / Relative Bradycardia** Seen in: * Gram-negative infections * Tick-borne infections ### Mnemonic: **TBM CLR** * **T**: Typhoid, Tularemia, Typhus * **B**: Brucellosis, Babesia * **M**: Mycoplasma * **C**: Q fever, Corynebacterium * **L**: Legionella * **R**: Rickettsia --- # 🟪 **Travel-related FUO Causes** * Malaria * Kala-azar * Histoplasmosis (bat droppings) * Coccidioidomycosis --- # 🟤 **Case Summary from PET-CT (Your Screenshot)** A 72-year-old female with chronic low-grade fever & fatigue * CRP ↑ * Normocytic normochromic anemia * PET-CT: **Uptake in subclavian artery → Large vessel vasculitis → Takayasu arteritis** ### Management 1. **Anti-TB therapy** *(if CNS signs)* 2. **NSAIDs** (Still disease) 3. **Colchicine** (FMF) 4. **Anakinra** (IL-1 blocker) 5. **Treat underlying cause** --- # ✔️ Extraction Complete If you want, I can also: ✅ Convert this into **SEO-perfect ErrorOn Space page** ✅ Add **JSON-LD**, **tags**, **breadcrumbs**, **structured tables** ✅ Produce **one-page concise NEET-PG revision sheet** ✅ Create **MCQs, image-based questions, flashcards** Just tell me **"Make SEO page"**, **"Make MCQs"**, or **"Convert to ErrorOn style"**. Great — I will create **35 high-yield, exam-style, real-world PUO (Pyrexia of Unknown Origin) case scenarios** with **detailed diagnosis reasoning + management + treatment**. These will be perfect for: * NEET PG / INI-CET case-based prep * ErrorOn Space theory + casebook * Your JSON-structured material library **I won’t repeat PUO basics again — only focused, rich case scenarios.** --- # ✅ **35 PUO Case Scenarios With Detailed Workup & Complete Management** --- ## **CASE 1 — GRANULOMATOUS HEPATITIS (SARCOIDOSIS)** A 32-year-old woman with intermittent fever × 6 weeks, dry cough, weight loss, erythema nodosum. CXR shows bilateral hilar lymphadenopathy. ACE levels elevated. LFT mildly raised. ### **Diagnosis** Sarcoidosis presenting as FUO. ### **Management** * Prednisolone 0.5–1 mg/kg/day * If refractory → Methotrexate * Eye exam, ECG to rule systemic involvement --- ## **CASE 2 — SUBACUTE INFECTIVE ENDOCARDITIS (CULTURE-NEGATIVE)** A 45-year-old male with low-grade fever × 8 weeks, clubbing, splinter hemorrhages. 3 × blood cultures sterile. Echo shows vegetation on mitral valve. ### **Diagnosis** HACEK endocarditis. ### **Management** * IV Ceftriaxone 2 g/day × 4 weeks * If prosthetic valve → Add gentamicin --- ## **CASE 3 — TUBERCULAR LYMPHADENITIS** A 27-year-old female, fever for 2 months, night sweats, painless cervical lymph node. FNAC → granulomatous inflammation, GeneXpert positive. ### **Management** * ATT × 6 months (HRZE → HR) --- ## **CASE 4 — TEMPORAL ARTERITIS (GIANT CELL ARTERITIS)** A 70-year-old woman with fever, headache, jaw claudication, ESR 110. PET-CT: uptake in temporal artery. ### **Management** * Start Prednisolone 40–60 mg immediately * Temporal artery biopsy within 1 week --- ## **CASE 5 — TAKAYASU ARTERITIS** A 22-year-old female with FUO, absent left radial pulse, BP difference >10 mmHg. PET-CT shows aortic uptake. ### **Management** * High-dose steroids * Methotrexate or Mycophenolate * Aspirin for vascular protection --- ## **CASE 6 — ADULT-ONSET STILL DISEASE** Daily evening fever spike (>39°C), salmon-pink rash, polyarthritis, ferritin >5000. ### **Management** * NSAIDs * Steroids * IL-1 inhibitors (Anakinra) if resistant --- ## **CASE 7 — LYMPHOMA (NHL)** 55-year-old man, FUO with profound night sweats, mediastinal nodes on CT, LDH ↑. ### **Management** * Excisional lymph node biopsy * R-CHOP regimen --- ## **CASE 8 — BRUCELLOSIS** Shepherd from Rajasthan, fever 1 month, low back pain, hepatosplenomegaly. Brucella agglutination positive. ### **Management** * Doxycycline + Rifampicin × 6 weeks --- ## **CASE 9 — Q FEVER (Coxiella burnetii)** Cattle worker, FUO, hepatitis-like picture. IgM for C. burnetii positive. ### **Management** * Doxycycline × 14 days * Pregnant: Cotrimoxazole --- ## **CASE 10 — MALARIA (P. knowlesi – quotidian fever)** Daily evening fever, splenomegaly. Rapid test negative. PCR positive for P. knowlesi. ### **Management** * Artemisinin combination therapy --- ## **CASE 11 — DRUG FEVER (ALLOPURINOL)** 55-year-old on allopurinol for gout. FUO without any systemic signs, normal labs except mild eosinophilia. ### **Management** * Stop allopurinol → fever resolves in 72 hrs --- ## **CASE 12 — FACTITIOUS FEVER (NURSING STUDENT)** 26-year-old female nurse, fluctuating fever only in hospital. Rectal temp normal at home. Inconsistent vitals. ### **Management** * Psychiatric evaluation * Remove access to thermometers --- ## **CASE 13 — LEPTOSPIROSIS** Rice farmer, FUO, conjunctival suffusion, myalgia, bilirubin 4. MAT positive. ### **Management** * Doxycycline OR IV ceftriaxone --- ## **CASE 14 — HEPATIC ABSCESS** Alcoholic male with fever + RUQ pain. USG shows hypoechoic lesion. ### **Management** * Metronidazole * Drainage if >5 cm --- ## **CASE 15 — HIV SEROCONVERSION** High-risk male, FUO, diffuse rash, oral ulcers. HIV Ag/Ab combo positive. ### **Management** * Start ART immediately --- ## **CASE 16 — LIVER TB** FUO with hepatomegaly. LFT: ALP high. Liver biopsy CBNAAT positive. ### **Management** * ATT × 6 months --- ## **CASE 17 — DISSEMINATED HISTOPLASMOSIS** Bat exposure, fever, oral ulcers, hepatosplenomegaly. Serum Histoplasma antigen positive. ### **Management** * Amphotericin B → Itraconazole --- ## **CASE 18 — AUTOIMMUNE HEPATITIS** Female with FUO, arthralgia, ALT↑, ANA positive, IgG ↑. ### **Management** * Prednisolone + Azathioprine --- ## **CASE 19 — SUBACUTE THYROIDITIS** Post-viral illness, fever, neck pain, suppressed TSH, elevated T4. ### **Management** * NSAIDs * Steroids if severe --- ## **CASE 20 — RELAPSING FEVER (BORRELIA)** Traveller from Africa, cyclical fever every 7 days. Blood smear shows spirochetes. ### **Management** * Doxycycline --- ## **CASE 21 — CHRONIC PYELONEPHRITIS** Diabetic woman, fever, flank pain, sterile pyuria. ### **Management** * Culture-guided antibiotics * Control diabetes --- ## **CASE 22 — LIVER LYMPHOMA** FUO, weight loss, liver lesions on PET, LDH high. ### **Management** * Liver biopsy * R-CHOP --- ## **CASE 23 — ENDOMETRITIS (POST-ABORTION)** Fever for 2 weeks, foul discharge. ### **Management** * Broad-spectrum IV antibiotics * Remove retained products --- ## **CASE 24 — GIANT HEPATIC HEMANGIOMA (INFLAMMATORY)** FUO with dull RUQ pain. CT shows 8 cm hemangioma. ### **Management** * Usually observation * Steroids if inflammatory variant --- ## **CASE 25 — MOLLARET MENINGITIS** Recurrent fever with headache; CSF lymphocytic; HSV-2 PCR positive. ### **Management** * Acyclovir * Supportive care --- ## **CASE 26 — SPLENIC ABSCESS** FUO, LUQ pain, infective endocarditis background. ### **Management** * Drainage * IV antibiotics --- ## **CASE 27 — RHEUMATOID ARTHRITIS–ASSOCIATED FUO** Chronic joint pains, elevated ESR/CRP, rheumatoid factor high. ### **Management** * DMARDs (Methotrexate) * Steroids initially --- ## **CASE 28 — TB PERITONITIS** Fever, abdominal distension, ascitic fluid SAAG <1.1, lymphocyte predominance. ### **Management** * ATT × 6 months --- ## **CASE 29 — PROLONGED COVID INFECTION** Immunocompromised patient with FUO, ongoing PCR positivity. ### **Management** * Remdesivir ± monoclonals depending on variant --- ## **CASE 30 — LEUKEMIA (ALL)** FUO + pallor + recurrent infections. CBC shows blasts. ### **Management** * Bone marrow biopsy * Induction chemotherapy --- ## **CASE 31 — CHOLEDOCHOLITHIASIS WITH CHOLANGITIS** Fever + jaundice + RUQ pain. USG shows CBD stone. ### **Management** * ERCP * IV antibiotics --- ## **CASE 32 — TULAREMIA** Exposure to rabbits; ulcer at finger + lymphadenopathy. ### **Management** * Streptomycin OR Gentamicin --- ## **CASE 33 — BABESIOSIS** Tick exposure, fever, anemia, hemoglobin drop. Maltese cross on smear. ### **Management** * Atovaquone + Azithromycin --- ## **CASE 34 — OCCULT DENTAL ABSCESS** FUO without localizing symptoms. CT face shows apical abscess. ### **Management** * Drainage * Amoxicillin-clavulanate --- ## **CASE 35 — FEVER OF UNKNOWN ORIGIN TRULY UNDIAGNOSED** After complete PUO algorithm: * No PDCs * PET-CT normal * All cultures negative ### **Management** * NSAIDs for symptom control * Close follow-up * Re-evaluate every 2–4 weeks --- # ✔️ Completed — 35 Excellent Real Case Scenarios If you want, I can also generate: ✅ **35 MCQs based on these cases** ✅ **Convert into SEO-rich HTML for your ErrorOn Space** ✅ **Create JSON objects for each case** (title, tags, description, management) Just tell me what you want next. Here are **15 fully detailed, high-yield, real-world PUO (Pyrexia of Unknown Origin) case scenarios** — each includes: * **Full presentation** * **Investigations** * **Differential diagnosis reasoning** * **Final diagnosis** * **Complete management & treatment steps** These are built in the **NEET-PG / INICET case-based pattern** and suitable for **ErrorOn Space advanced case library**. --- # 🔵 **15 DETAILED CASE SCENARIOS IN PUO** --- # **CASE 1 — Takayasu Arteritis (Large Vessel Vasculitis)** **Patient:** 24-year-old female **Symptoms:** Low-grade fever × 8 weeks, fatigue, dizziness on exertion, left arm BP not recordable. **Exam:** Bruit over the left subclavian artery. **Labs:** ESR 110, CRP ↑ **Imaging:** PET-CT shows circumferential uptake in aortic arch branches. ### **Diagnosis reasoning** * Young female + pulse deficit + vascular uptake → Classic for Takayasu. * Rule out: Endocarditis, TB, SLE. ### **Final Diagnosis:** *Takayasu Arteritis (Type I)* ### **Management** * Prednisolone 1 mg/kg/day * Methotrexate 15–20 mg weekly * Aspirin 75 mg * Biologics (Tocilizumab) if resistant * Serial PET-CT monitoring --- # **CASE 2 — Tubercular Lymphadenitis** **Patient:** 29-year-old female **Symptoms:** Fever with night sweats × 1 month, cervical LN swelling. **Labs:** CBC normal; ESR ↑ **FNAC:** Granulomatous inflammation. **CBNAAT:** MTB detected. ### **Final Diagnosis:** *Tubercular lymphadenitis causing PUO* ### **Management** * ATT × 6 months (HRZE → HR) * Monitor LFT * Follow-up ultrasound --- # **CASE 3 — Subacute Bacterial Endocarditis (Culture Negative, HACEK)** **Patient:** 46-year-old male **Symptoms:** Fever × 7 weeks, weight loss, joint pains. **Signs:** Osler nodes, splinter hemorrhages. **Blood cultures:** Sterile × 3 **Echo:** Vegetation on mitral valve. ### **Final Diagnosis:** *Culture-negative infective endocarditis (HACEK group)* ### **Management** * IV Ceftriaxone 2 g/day × 4 weeks * Add Gentamicin if severe * Valve replacement if refractory --- # **CASE 4 — Adult-Onset Still Disease (AOSD)** **Patient:** 35-year-old woman **Symptoms:** Daily fever spikes to 39–40°C, evanescent salmon rash, polyarthritis. **Labs:** Ferritin 6500 ng/ml, ANA/RF negative. ### **Diagnosis:** *AOSD (Yamaguchi criteria)* ### **Management** * NSAIDs initially * Steroids 0.5–1 mg/kg * Anakinra / Tocilizumab if steroid-resistant --- # **CASE 5 — Sarcoidosis** **Patient:** 33-year-old female **Symptoms:** FUO × 2 months, dry cough, erythema nodosum. **CXR:** Bilateral hilar lymphadenopathy. **ACE level:** Elevated. ### **Diagnosis:** *Sarcoidosis with systemic involvement* ### **Management** * Prednisolone 0.5 mg/kg/day * Methotrexate if steroid-sparing * Eye exam + ECG yearly --- # **CASE 6 — Pyogenic Liver Abscess (Occult)** **Patient:** 58-year-old diabetic male **Symptoms:** FUO × 4 weeks, dull RUQ pain. **USG:** 4 cm hypoechoic lesion. ### **Diagnosis:** *Silent liver abscess presenting as PUO* ### **Management** * IV Ceftriaxone + Metronidazole * Percutaneous drainage if >5 cm * Control diabetes --- # **CASE 7 — Disseminated Histoplasmosis** **Patient:** 40-year-old cave tourist **Symptoms:** FUO, oral ulcers, weight loss. **Exam:** Hepatosplenomegaly. **Labs:** Pancytopenia. **Urine antigen:** Histoplasma positive. ### **Diagnosis:** *Disseminated fungal infection* ### **Management** * Liposomal Amphotericin B × 2 weeks * Itraconazole × 12 weeks * Monitor renal function --- # **CASE 8 — Q Fever (Coxiella burnetii)** **Patient:** Dairy farm worker **Symptoms:** Fever × 1 month, headache, mild hepatitis. **Serology:** Phase II IgM positive. ### **Diagnosis:** *Q fever presenting as PUO* ### **Management** * Doxycycline × 14 days * Pregnant: Cotrimoxazole --- # **CASE 9 — Lymphoma (NHL)** **Patient:** 62-year-old male **Symptoms:** FUO, drenching night sweats. **Exam:** No lymph nodes palpable. **PET-CT:** FDG-avid para-aortic nodes. **LDH:** Elevated. ### **Diagnosis:** *Occult Non-Hodgkin Lymphoma* ### **Management** * Lymph node biopsy * R-CHOP chemotherapy * PET-CT response evaluation --- # **CASE 10 — Factitious Fever** **Patient:** 26-year-old nursing student **Symptoms:** Fever reported only in hospital. **Observation:** Rectal temp normal when monitored; oral thermometer manipulated. **Labs:** All normal. ### **Diagnosis:** *Factitious disorder causing PUO* ### **Management** * Psychiatric evaluation * Remove access to thermometer * Supportive therapy --- # **CASE 11 — Brucellosis** **Patient:** Goat herder **Symptoms:** FUO, backache, hepatosplenomegaly. **Labs:** LFT mildly raised, blood culture negative. **Serology:** SAT positive. ### **Diagnosis:** *Brucellosis* ### **Management** * Doxycycline + Rifampicin × 6 weeks * For spondylitis: Add streptomycin × 2 weeks --- # **CASE 12 — Tuberculous Peritonitis** **Patient:** 48-year-old female **Symptoms:** Fever, abdominal distension, weight loss. **Ascitic fluid:** SAAG <1.1, lymphocytic. **Adenosine Deaminase:** High. ### **Diagnosis:** *TB peritonitis* ### **Management** * ATT × 6–9 months * Monitor for paradoxical worsening --- # **CASE 13 — Relapsing Fever (Borrelia)** **Patient:** Foreign traveler **Symptoms:** Fever every 5–7 days, each lasting 48 hours. **Smear:** Spirochetes visible during fever peaks. ### **Diagnosis:** *Tick-borne relapsing fever* ### **Management** * Doxycycline * Watch for Jarisch–Herxheimer reaction --- # **CASE 14 — Subacute Thyroiditis (De Quervain)** **Patient:** 30-year-old female post-viral infection **Symptoms:** Fever × 4 weeks, neck pain radiating to jaw. **Labs:** TSH ↓, T4 ↑, ESR ↑ **USG:** Hypoechoic painful thyroid. ### **Diagnosis:** *Subacute granulomatous thyroiditis* ### **Management** * NSAIDs → If severe, Prednisolone * Beta-blockers for hyperthyroid symptoms --- # **CASE 15 — Hidden Dental Abscess** **Patient:** 41-year-old man **Symptoms:** FUO × 1 month, no localizing signs. **CT Face:** Apical abscess over upper premolar. ### **Diagnosis:** *Occult dental abscess causing PUO* ### **Management** * Drainage * Amoxicillin–clavulanate × 7–10 days * Dental extraction if needed --- # ✔️ **15 DETAILED TRUSTED CASES COMPLETED** If you want next, I can generate: ✅ **15 MCQs from these cases** ✅ **Turn this into fully formatted HTML for ErrorOn Space** ✅ **Create JSON entries for your database (title, tags, content)** ✅ **Make 20 more cases** Just tell me: **“Make MCQs”**, **“Make JSON”**, or **“More cases”**.