| I
was very amused to see the definition of ‘acute ever’ as
‘PUO’ in the latest edition of a textbook of medicine. The
original PUO has been now labelled as ‘chronic fever’.
This definition was long overdue. I have always been teaching that when
a patient comes for acute fever, the doctor should openly tell the patient
that he is not sure of the diagnosis and suggest that the fever could
be due to this or that, etc (explain the differential diagnosis).
The fact is that many of the acute fevers cannot be diagnosed on the
first or second day and sometimes even upto a week or so. In some situations,
the accompanying symptoms help to make a slightly accurate diagnosis,
e.g. symptoms of nasal cold, sore throat and cough go in favour of viral
fever, but the only symptom of cough can be present in malaria or typhoid
as well.
True rigors are very suggestive of malaria, but chills can occur in
all fevers. History of eating contaminated food, accompanied by vomiting
and diarrhoea will favour gastro-enteritis. (Note that in this case
the symptoms of vomiting and diarrhoea are more than the fever). Only
diarrhoea (and sometimes vomiting) can occur in malaria or typhoid or
viral hepatitis. The presence of chest pain on one side makes the diagnosis
easier, especially because X-ray chest will pick up the disease.
The fact is that on many occasions, it is impossible to exclude malaria,
mild dengue fever, mild leptospirosis, viral hepatitis, typhoid, etc.
and yet, these patients can suddenly become serious and even die. The
following case of a colleague of mine is a good example.
This doctor, who is a very famous super specialist had been out of Mumbai,
2 days earlier for a lecture tour. Even on the previous day he had lectured
in a medical meeting. The next day, after delivering another lecture,
while travelling in a car with a colleague of his, he complained of
feeling feverish during the last 3 days and a little weakness. He was
worried because he had to conduct another lecture tour after a week.
Hence, his colleague suggested that he should get all the tests and
a complete check up done before leaving. The investigations showed that
his platelet count was only 6000 and dengue IgM antibodies were strongly
positive. He was immediately admitted to a hospital and given a platelet
transfusion. He survived.
Does this case not convince you that all acute fevers should be labelled
as PUOs? The next lesson to be learnt from this case is, that whenever
a patient has acute fever (low or high) with no straight forward symptoms
of a common fever, then such a patient needs a full investigation.
With the presence of mild anaemia, severe leucopenia, raised LDH, thrombocytopenia,
very high SGPT, dengue IgM and leptospira IgM AB, presence of MPs, results
of 2-3 blood cultures and malarial antigen tests, in addition to X-ray
chest and sonography of the abdomen, it is often easy to pick up the
disease. If not, at least a serious disease will not be missed.
As against this, a non-affording patient with straight forward symptoms
need not be investigated during the first 2-3 days of fever. |
