原因不明熱 FUO

WordNet

the source of somethings existence or from which it derives or is derived; "the rumor had its origin in idle gossip"; "vegetable origins"; "mineral origin"; "origin in sensation"
properties attributable to your ancestry; "he comes from good origins" (同)descent, extraction
an event that is a beginning; a first part or stage of subsequent events (同)origination, inception
the point of intersection of coordinate axes; where the values of the coordinates are all zero
not known; "an unknown amount"; "an unknown island"; "an unknown writer"; "an unknown source"
a variable whose values are solutions of an equation (同)unknown_quantity
an unknown and unexplored region; "they came like angels out the unknown" (同)unknown region, terra_incognita
not known to exist; "things obscurely felt surged up from unknown depths"
a rise in the temperature of the body; frequently a symptom of infection (同)febrility, febricity, pyrexia, feverishness
intense nervous anticipation; "in a fever of resentment"
highly excited; "a fevered imagination"

PrepTutorEJDIC

《所有・所属》…『の』,…のものである,…に属する・《材料・要素》…『でできた』,から成る・《部分》…『の』[『中の』] ・《数量・単位・種類を表す名詞に付いて》…の・《原因・動機》…『で』,のために(because of) ・《主格関係》…『の』,による,によって・《目的格関係》…『を』,の・《同格関係》…『という』・《関係・関連》…『についての』[『の』],の点で・《抽象名詞などと共に》…の[性質をもつ] ・《『It is』+『形』+『of』+『名』+『to』 doの形で,ofの後の名詞を意味上の主語として》・《分離》…『から』・《起原・出所》…『から』[『の』](out of) ・《『名』+『of』+『a』(『an』)+『名』の形で》…のような・《『名』+『of』+『mine』(『yours, his』など独立所有格)の形で》…の…・《時》(1)《副詞句を作って》…に《形容詞句を作って》…の・《時刻》《米》…前(to,《米》before)
〈U〉〈C〉(…の)『起源』発端;もと,原因《+『of』+『名』》 / 〈U〉『生まれ』,素性,血統 / 〈U〉〈C〉(数学で,座標の)原点
『知られていない』,不明の,無名の / 『未確認の』,未発見の,未知の
〈U〉《しばしばa fever》(身体の異常な)『熱』,発熱 / 〈U〉『熱病』 / 〈U〉〈C〉(…に対する)『興奮』,熱狂《+『for』+『名』》
(比較変化なし)《名詞の前にのみ用いて》熱のある,熱病にかかった / 熱にうかされたような,興奮した / (憎しみなどが)異常に強い

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/04/08 20:54:54」(JST)

wiki en

Fever of unknown origin (FUO), pyrexia of unknown origin (PUO) or febris e causa ignota (febris E.C.I.) refers to a condition in which the patient has an elevated temperature but despite investigations by a physician no explanation has been found.^[1]^[2]^[3]^[4]^[5]

If the cause is found it usually is a diagnosis of exclusion, that is, by eliminating all possibilities until only one explanation remains, and taking this as the correct one.

Definition

In 1961 Petersdorf and Beeson suggested the following criteria:^[1]^[2]

Fever higher than 38.3°C (101°F) on several occasions
Persisting without diagnosis for at least 3 weeks
At least 1 week's investigation in hospital

A new definition which includes the outpatient setting (which reflects current medical practice) is broader, stipulating:

3 outpatient visits or
3 days in the hospital without elucidation of a cause or
1 week of "intelligent and invasive" ambulatory investigation.^[2]

Presently FUO cases are codified in four subclasses.

Classic FUO

This refers to the original classification by Petersdorf and Beeson. Studies show there are five categories of conditions:

infections (e.g. abscesses, endocarditis, tuberculosis, and complicated urinary tract infections),
neoplasms (e.g. lymphomas, leukaemias),
connective tissue diseases (e.g. temporal arteritis and polymyalgia rheumatica, Still's disease, systemic lupus erythematosus, and rheumatoid arthritis),
miscellaneous disorders (e.g. alcoholic hepatitis, granulomatous conditions), and
undiagnosed conditions.^[1]^[3]

Nosocomial

Nosocomial FUO refers to pyrexia in patients that have been admitted to hospital for at least 24 hours. This is commonly related to hospital associated factors such as, surgery, use of urinary catheter, intravascular devices (i.e. "drip", pulmonary artery catheter), drugs (antibiotics induced Clostridium difficile colitis, and drug fever), immobilization (decubitus ulcers). Sinusitis in the intensive care unit is associated with nasogastric and orotracheal tubes.^[1]^[2]^[3] Other conditions that should be considered are deep-vein thrombophlebitis, and pulmonary embolism, transfusion reactions, acalculous cholecystitis, thyroiditis, alcohol/drug withdrawal, adrenal insufficiency, pancreatitis.^[2]

Immune-deficient

Immunodeficiency can be seen in patients receiving chemotherapy or in hematologic malignancies. Fever is concomitant with neutropenia (neutrophil <500/uL) or impaired cell-mediated immunity. The lack of immune response masks a potentially dangerous course. Infection is the most common cause.^[1]^[2]^[3]

Human immunodeficiency virus (HIV)-associated

Further information: Human immunodeficiency virus

HIV-infected patients are a subgroup of the immunodeficient FUO, and frequently have fever. The primary phase shows fever since it has a mononucleosis-like illness. In advanced stages of infection fever mostly is the result of a superimposed infections.^[1]^[2]^[3]

African hantavirus (Sangassou virus)

In 2010, the first indigenous African hantavirus, Sangassou virus (SANGV) was isolated from an African wood mouse in a forest in Guinea, West Africa. A retrospective seroepidemiological analysis revealed the presence of Sangassou virus-specific neutralizing antibodies in the sera of patients suffering from fever of unknown origin. ^[6]^[7]

Some important causes

Extrapulmonary tuberculosis is the most frequent cause of FUO.^[2] Drug-induced hyperthermia, as sole symptom of an adverse reaction to medication, should always be considered. Disseminated granulomatoses such as Tuberculosis, Histoplasmosis, Coccidioidomycosis, Blastomycosis and Sarcoidosis are associated with FUO. Lymphomas are the most common cause of FUO in adults. Thromboembolic disease (i.e. pulmonary embolism, deep venous thrombosis) occasionally shows fever. Although infrequent, its potentially lethal consequences warrant evaluation of this cause. Endocarditis, although uncommon, is another important etiology to consider. An underestimated reason is factitious fever. Patients frequently are women that work, or have worked, in the medical field and have complex medical histories.^[1]^[8] Bartonella infections are also known to cause fever of unknown origin.^[9]

Diagnosis

A comprehensive and meticulous history (i.e. illness of family members, recent visit to the tropics, medication), repeated physical examination (i.e. skin rash, eschar, lymphadenopathy, heart murmur) and myriad laboratory tests (serological, blood culture, immunological) are the cornerstone of finding the cause.^[1]^[3]

Other investigations may be needed. Ultrasound may show cholelithiasis, echocardiography may be needed in suspected endocarditis and a CT-scan may show infection or malignancy of internal organs. Another technique is Gallium-67 scanning which seems to visualize chronic infections more effectively. Invasive techniques (biopsy and laparotomy for pathological and bacteriological examination) may be required before a definite diagnosis is possible.^[1]^[3]

Positron emission tomography using radioactively labelled fluorodeoxyglucose (FDG) has been reported to have a sensitivity of 84% and a specificity of 86% for localizing the source of fever of unknown origin.^[10]

Despite all this, diagnosis may only be suggested by the therapy chosen. When a patient recovers after discontinuing medication it likely was drug fever, when antibiotics or antimycotics work it probably was infection. Empirical therapeutic trials should be used in those patients in which other techniques have failed.^[1]

Therapy

Unless the patient is acutely ill, no therapy should be started before the cause has been found. This is because non-specific therapy rarely is effective and mostly delays diagnosis. An exception is made for neutropenic patients in which delay could lead to serious complications. After blood cultures are taken this condition is aggressively treated with broad-spectrum antibiotics. Antibiotics are adjusted according to the results of the cultures taken.^[1]^[2]^[3]

HIV-infected persons with pyrexia and hypoxia, will be started on medication for possible Pneumocystis jirovecii infection. Therapy is adjusted after a diagnosis is made.^[3]

Prognosis

Since there is a wide range of conditions associated with FUO, prognosis depends on the particular cause.^[1] If after 6 to 12 months no diagnosis is found, the chances diminish of ever finding a specific cause.^[3] However, under those circumstances prognosis is good.^[2]

References

^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l Mandell's Principles and Practices of Infection Diseases 6th Edition (2004) by Gerald L. Mandell MD, MACP, John E. Bennett MD, Raphael Dolin MD, ISBN 0-443-06643-4 · Hardback · 4016 Pages Churchill Livingstone
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Harrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j The Oxford Textbook of Medicine Edited by David A. Warrell, Timothy M. Cox and John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press, ISBN 0-19-262922-0
^ Cecil Textbook of Medicine by Lee Goldman, Dennis Ausiello, 22nd Edition (2003), W.B. Saunders Company, ISBN 0-7216-9652-X
^ Irwin and Rippe's Intensive Care Medicine by Irwin and Rippe, Fifth Edition (2003), Lippincott Williams & Wilkins, ISBN 0-7817-3548-3
^ Klempa B, Koivogui L, Sylla O et al. Serological evidence of human hantavirus infections in Guinea, West Africa. J Infect Dis 2010; 201: 1031–1034. | Article | PubMed |
^ Strecker, Jan ter Meulen and Detlev H. KrügerAuste, et al. Sangassou virus, the first hantavirus isolate from Africa. Journal of Virology2012, 86(7):3819. DOI: 10.1128/JVI.05879-11.
^ Fever of Unknown Origin at Mount Sinai Hospital
^ Florin TA, Zaoutis TE, Zaoutis LB (2008). "Beyond cat scratch disease: widening spectrum of Bartonella henselae infection". Pediatrics 121 (5): e1413–25. doi:10.1542/peds.2007-1897. PMID 18443019.
^ Meller J, Altenvoerde G, Munzel U, Jauho A, Behe M, Gratz S, Luig H, Becker W (2000). "Fever of unknown origin: prospective comparison of [18F]FDG imaging with a double-head coincidence camera and gallium-67 citrate SPET.". Eur J Nucl Med. 27 (11): 1617–25. doi:10.1007/s002590000341. PMID 11105817.

UpToDate Contents

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1. 成人における不明熱に対するアプローチ approach to the adult with fever of unknown origin
2. 小児の不明熱に対するアプローチ fever of unknown origin in children evaluation
3. 成人における不明熱の病因 etiologies of fever of unknown origin in adults
4. 小児における不明熱の病因 etiologies of fever of unknown origin in children
5. 高齢者の感染症評価 evaluation of infection in the older adult

English Journal

PMID 26086302

FDG PET/CT in infection and inflammation-current and emerging clinical applications.

Vaidyanathan S1, Patel CN1, Scarsbrook AF1, Chowdhury FU2.
Clinical radiology.Clin Radiol.2015 Jul;70(7):787-800. doi: 10.1016/j.crad.2015.03.010. Epub 2015 Apr 25.
Integrated positron emission tomography/computed tomography (PET/CT) with the glucose analogue, 2-[18F]-fluoro-2-deoxy-d-glucose (FDG), is an evolving hybrid imaging technique in the evaluation of an important and diverse group of pathological conditions, which are characterised by infection and ase
PMID 25917543

Arteriovenous fistula stent infection diagnosed with radiolabelled leucocyte scintigraphy.

Yoo JR1, Heo ST, Kim M, Kim HW, Chang JW, Song H.
Infectious diseases (London, England).Infect Dis (Lond).2015 Jul;47(7):510-4. doi: 10.3109/00365548.2014.1002108. Epub 2015 Mar 13.
Infectious complications of haemodialysis in patients with arteriovenous fistula stent are rare. In addition, patients with low-grade infection are more difficult to diagnose. Here, we report the first case of low-grade infection of an arteriovenous fistula stent diagnosed using (99m)Tc-hexamethylpr
PMID 25768230

Japanese Journal

症例リウマチ性多発筋痛症との鑑別が困難であった感染を伴った褥瘡の1例

菱田雅之
日本褥瘡学会誌 : 日本褥瘡学会機関誌 17(1), 31-38, 2015
NAID 40020379271

症例急性巣状細菌性腎炎との鑑別に苦慮した慢性間質性腎炎の14歳男児例

多田憲正,田中絵里子,元吉八重子
The Japanese journal of
NAID 40020351614

Diagnostic Value of Percutaneous Liver Biopsy in Fever of Unkown Origin in Patients with Human Immunodeficiency Virus Infection

Wiboonchutikul Surasak,Manosuthi Weerawat,Kowadisaiburana Boonchai,Sungkanuparph Somnuek
Japanese Journal of
… Fever of unknown origin (FUO) poses a major diagnostic challenge in patients infected with human immunodeficiency virus (HIV). … In this retrospective study, we sought to assess the clinical utility of percutaneous liver biopsy as a diagnostic aid for FUO in HIV-infected patients and identify the factors associated with a greater likelihood of a positive diagnostic yield form this procedure. …
NAID 130005088805

Related Pictures

★リンクテーブル★

リンク元	「不明熱」「古典的不明熱」「FUO」「原因不明発熱」
関連記事	「unknown」「origin」

「不明熱」

Fever of unknown origin
	Classification and external resources
ICD-10	R50
ICD-9	780.6
MedlinePlus	003090
MeSH	D005335

　　[★]

英: fever of unknown origin FUO
同: 原因不明熱
関: 発熱、体温; ジェネラリスト診療が上手になる本 p.9

定義

3週間以上の発熱。38.3℃以上、1週間の入院精査でも原因不明

鑑別疾患

3大疾患

1. 感染症(深部腫瘍、心内膜炎、結核、寄生虫、腸チフスなど)
2. 悪性疾患(悪性リンパ腫、白血病など)
3. 膠原病(血管炎、側頭動脈炎、成人still病など)
4. その他：薬剤性など

ジェネラリスト診療が上手になる本 p.9

感染症

(各種病原体)感染性心内膜炎、骨髄炎、伝染性単核球症、副鼻腔炎、齲歯

(細菌)結核、腸チフス、リケッチア感染症

(ウイルス)HIV感染症、サイトメガロウイルス感染症

(真菌)ニューモシスチス肺炎、クリプトコッカス症

(寄生虫)マラリア

悪性腫瘍：リンパ腫、肝転移、腎細胞癌、心房粘液腫
膠原病・血管炎：側頭動脈炎、全身性エリテマトーデス、血管炎、リウマチ熱、スチル病、炎症性腸疾患
そのほか：熱中症、薬剤熱、悪性高熱、詐熱、詐病

UCSF.44

感染症26%, 腫瘍13%, 非感染性炎症疾患24%

感染症：背臥位結核、心内膜炎、膿瘍(肝臓、脾臓、腎臓、後腹膜、骨、脳、耳、脊椎)、HIV感染症、サイトメガロウイルス感染症、カンジダ感染症、その他(尿路感染症、副鼻腔、骨髄炎)、入院患者(尿路感染、カテーテル感染症、偽膜性腸炎、褥瘡、蜂窩織炎)
腫瘍：悪性リンパ腫、白血病、腎細胞癌、肝癌、心房粘液腫、VAHS(ウイルス関連性血球貪食症候群)、LAHS(リンパ腫関連性血球貪食症候群)
非感染性炎症疾患：成人スティル病、SLE(全身性エリテマトーデス)、顕微鏡的多発血管炎(MPA)/多発性結節性動脈周囲炎(PN)/高安病、側頭動脈炎、リウマチ性多発筋痛症、サルコイドーシス、炎症性腸疾患(クローン病、潰瘍性大腸炎)
その他：薬剤熱、詐熱、肺塞栓症/深部静脈血栓症、脊椎損傷/頭蓋内疾患、副腎機能不全/甲状腺機能亢進症、家族性地中海熱、組織球性壊死性リンパ節炎(菊地病)

感染症専門医テキスト第1部解説編 p.53

不明熱の最終診断

診断			診断診断例 n=192	早期診断例 n=67	中期診断例 n=38	後期診断例 n=87
感染症			57(29.7)	25(37.3)	12(31.6)	20(23.0)
	細菌性		43	1.8	8	17
		心内膜炎	11	9	1	1
		結核	8	0	0	8
		尿跨感染症(1)	6	3	1	2
		腹腔内膿瘍	5	2	2	1
		骨・関節感染	4	2	1	1
		その他の細菌感染	9	2	3	4
	ウイルス性		10	5	3	2
		CMV	6	2	3	1
		EpsteinーBarrウイルス	3	3	0	0
		HIV	1	0	0	1
	寄生虫性(2)		4	2	1	1
悪性新生物			29(15.1)	5(7.5)	6(15.8)	18(20.7)
	血液疾患		22	2	6	14
		非Hodgkinリンパ腫	9	0	2	7
		Hodgkin病	5	1	1	3
		白血病	6	0	3	3
		血管免疫芽球性リンパ酔症	2	1	0	1
	固形癌		7	3	0	4
		腺癌	5	2	0	3
		その他(3)	2	1	0	1
非感染性炎症性疾患			68(35.4)	22(32.8)	.6)	34(39.1)
	結合織疾患		35	15	6	14
		成人Still病	18	5	4	9
		SLE	8	5	1	2
		リウマチ性多発性筋痛症	3	3	0	0
		関節リウマチ	2	0	0	2
		Sjogren症候群	2	1	0	1
		その他(4)	2	1	1	0
	血管炎症候群		19	5	3	11
		巨細胞性動脈炎	11	4	3	4
		Wegener肉芽腫症	2	1	0	1
		結節性多発性動脈炎	2	0	0	2
		その他(5)	4	0	0	4
	肉芽腫性疾患		14	2	3	9
		サルコイドーシス	10	0	2	8
		Crohn病	4	2	1	1
その他			39(18.1)	15(22.4)	8(21.1)	15(17.2)
	亜急性甲状腺炎		6	3	1	2
	Addison病		2	0	1	1
	心筋梗塞後症候群		2	1	0	1
	肺動脈塞栓症		2	1	0	1
	習慣性高体温症		11	6	3	2
	薬剤熱		4	3	0	1
	詐熱		1	1	0	0
	その他(6)		10	0	3	7

数値は症例数で( )内は比率. %表示

1) 膿瘍を除く実質感染
2) マラリア(2例)、ジアルジア症、トリパノソーマ症を含む
3) germinoma, hypernephromaを含む
4) Reiter症候群, 多発性筋炎を含む
5) Behcet病, Schönlein-Henoch紫斑病, Schnitzler症候群, 分類不能型血管炎を含む
6) Sweet症候群, 原発性硬化性胆管炎, アルコール性肝炎, 出血を伴う巨大肝血管腫, 間質性肺炎, 特発性胸膜心膜炎, 特発性好酸球増多症候群, リンパ節の炎症性偽腫瘍, 後腹膜線維症, 線状IgA水疱症

(Vanderschueren S. Knockaert D. et al. : From prolonged febrile illness to fever of unknown origin: the challenge continues. Arch Intern Med. 2003 : 163 : 1033-1041)