Structured Approach to Pts with Fever of Unknown Origin (FUO) - Flowchart

Structured Approach to Pts with Fever of Unknown Origin (FUO) - Flowchart

Structured Approach to Pts with Fever of Unknown Origin (FUO) - Flowchart

«Flowchart»

Fever 38.3°C (101°F) and illness lasting 3 weeks and no known immunocompromised state

Fever 38.3°C (101°F) and illness lasting 3 weeks and no known immunocompromised state

Fever 38.3°C (101°F) and illness lasting 3 weeks and no known immunocompromised state

and and

History and physical examination

History and physical examination

History and physical examination

End

End

End

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FDG-PET/CT, ¹⁸ F-fluorodeoxyglucose positron emission tomography combined with low-dose computed tomography; IGRA, interferon release assay; LDH, lactate dehydrogenase; NSAID, nonsteroidal anti-inflammatory drug; PDCs, potentially diagnostic clues (all localizing signs, symptoms, and abnormalities potentially pointing toward a diagnosis).

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FDG-PET/CT, ¹⁸ F-fluorodeoxyglucose positron emission tomography combined with low-dose computed tomography; IGRA, interferon release assay; LDH, lactate dehydrogenase; NSAID, nonsteroidal anti-inflammatory drug; PDCs, potentially diagnostic clues (all localizing signs, symptoms, and abnormalities potentially pointing toward a diagnosis).

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FDG-PET/CT, ¹⁸ F-fluorodeoxyglucose positron emission tomography combined with low-dose computed tomography; IGRA, interferon release assay; LDH, lactate dehydrogenase; NSAID, nonsteroidal anti-inflammatory drug; PDCs, potentially diagnostic clues (all localizing signs, symptoms, and abnormalities potentially pointing toward a diagnosis).

¹⁸

Stop antibiotic treatment and glucocorticoids

Stop antibiotic treatment and glucocorticoids

Stop antibiotic treatment and glucocorticoids

Obligatory investigations:
ESR or CRP, hemoglobin, platelet count, leukocyte count and differential, electrolytes, creatinine, total protein, protein electrophoresis, alkaline phosphatase, AST, ALT, LDH, creatine kinase, antinuclear antibodies, rheumatoid factor, urinalysis, blood cultures (n = 3), urine culture, chest x-ray, abdominal ultrasonography, and tuberculin skin test or IGRA

Obligatory investigations:
ESR or CRP, hemoglobin, platelet count, leukocyte count and differential, electrolytes, creatinine, total protein, protein electrophoresis, alkaline phosphatase, AST, ALT, LDH, creatine kinase, antinuclear antibodies, rheumatoid factor, urinalysis, blood cultures (n = 3), urine culture, chest x-ray, abdominal ultrasonography, and tuberculin skin test or IGRA

Obligatory investigations:
ESR or CRP, hemoglobin, platelet count, leukocyte count and differential, electrolytes, creatinine, total protein, protein electrophoresis, alkaline phosphatase, AST, ALT, LDH, creatine kinase, antinuclear antibodies, rheumatoid factor, urinalysis, blood cultures (n = 3), urine culture, chest x-ray, abdominal ultrasonography, and tuberculin skin test or IGRA

Obligatory investigations:

Exclude manipulation with thermometer

Exclude manipulation with thermometer

Exclude manipulation with thermometer

Stop or replace medication to exclude drug fever

Stop or replace medication to exclude drug fever

Stop or replace medication to exclude drug fever

PDCs present

PDCs present

PDCs present

PDCs absent or misleading

PDCs absent or misleading

PDCs absent or misleading

Cryoglobulin and funduscopy

Cryoglobulin and funduscopy

Cryoglobulin and funduscopy

FDG-PET/CT (or labeled leukocyte scintigraphy or gallium scan)

FDG-PET/CT (or labeled leukocyte scintigraphy or gallium scan)

FDG-PET/CT (or labeled leukocyte scintigraphy or gallium scan)

Scintigraphy abnormal

Scintigraphy abnormal

Scintigraphy abnormal

Scintigraphy normal

Scintigraphy normal

Scintigraphy normal

Guided diagnostic tests

Guided diagnostic tests

Guided diagnostic tests

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

Confirmation of abnormality (e.g., biopsy, culture)

Confirmation of abnormality (e.g., biopsy, culture)

Confirmation of abnormality (e.g., biopsy, culture)

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

Repeat history and physical examination
Perform PDC-driven invasive testing

Repeat history and physical examination
Perform PDC-driven invasive testing

Repeat history and physical examination
Perform PDC-driven invasive testing

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

Chest and abdominal CT
Temporal artery biopsy (55 years)

Chest and abdominal CT
Temporal artery biopsy (55 years)

Chest and abdominal CT
Temporal artery biopsy (55 years)

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

NO DIAGNOSIS

Stable condition:
Follow-up for new PDCs
Consider NSAID treatment

Stable condition:
Follow-up for new PDCs
Consider NSAID treatment

Stable condition

Deterioration:
Further diagnostic tests
Consider therapeutic trial

Deterioration:
Further diagnostic tests
Consider therapeutic trial

Deterioration