Pyrexia of unknown origin

RE: Pyrexia of unknown origin

Michael Woodhouse — Thu, 09 Jul 2015 09:35:39 GMT

[quote user="Martin Atkinson"] But once again I say there is a danger of this being standard protocol without due consideration which it should not be.[/quote]

Martin - you will note I say:

[quote user="Michael Woodhouse"]I'd offer investigation, but happy to try antibiotic (and usually steroid rather than NSAID) and reassess in 48 hours[/quote]

If it was my own dog, I'm not sure I'd do blood, rafiographs, ultrasound etc.

I would also say this is after a thorough clinical examination, I'm not ignoring the grumbling CBA or the moderate lymphadenopathy. It's not a case of thermometer up bum, high temperature, jab and home. These are the ones where the examination is otherwise completely normal.

RE: Pyrexia of unknown origin

Martin Atkinson — Thu, 09 Jul 2015 09:25:33 GMT

[quote user="mariette asselbergs"]Nothing to do with the use of corticosteroids. [/quote]No, and I acknowledged that but Michael suggested their use so I bundled your posts together as co-conspirators!

As said nothing wrong with 'therapeutic trials' in the right place, I might do the same at 7.00pm on a Friday night. But once again I say there is a danger of this being standard protocol without due consideration which it should not be.

RE: Pyrexia of unknown origin

mariette asselbergs — Wed, 08 Jul 2015 23:32:47 GMT

Nothing to do with the use of corticosteroids. The argument was about the lack of recognition of the fact that pattern recognition in first opinion GP practice is appropriate, as well as treatment based on the local knowledge of prevalence of disease, recognition of what is common, and the combination of treatment of symptoms in combination with the follow up consult. For the general population of first opinion practice patients it is argued that this is the correct approach, because inappropriate testing will lead to false postives since the prevalence of many diseases in the general population is low. This is not so in the population seen at referral or university practices where patients have been selected by unsuccessful initial treatments. Not only is a diagnosis of the cause here appropriate and wished for by the client, but tests will be applied to a population with a much higher prevalence of disease and therefor less false positive results.

Much of the "evidence based" stuff comes from biased populations of patients seen in referral or academic practices, and is less convincing evidence for the general population as seen in first opinion practice.

Mariette

RE: Pyrexia of unknown origin

Martin Atkinson — Wed, 08 Jul 2015 18:54:57 GMT

If he is advocating cortico-steroids before a diagnosis yes, albeit to be fair your precise of the paper did not suggest he did. I went to the 'on a budget' stream at BSAVA congress and the tone was similar - there comes a point that investigations are not a possibility then a therapeutic trial is justified. The danger is that dinovets will take this as justification of their normal practices because Stephen May or Sara Caney says its alright.

RE: Pyrexia of unknown origin

mariette asselbergs — Wed, 08 Jul 2015 17:16:26 GMT

Is Stephen May a dinovet?

Mariette

RE: Pyrexia of unknown origin

Martin Atkinson — Wed, 08 Jul 2015 17:12:57 GMT

[quote user="Michael Woodhouse"]I'd always found that investigation into these cases in dogs and cats invariably generated a large bill that cumulated in a few days worth of steroids and the animals back to normal. I'd offer investigation, but happy to try antibiotic (and usually steroid rather than NSAID) and reassess in 48 hours.[/quote]

[quote user="mariette asselbergs"]Trial treatment in combination with follow up checks are an appropriate method and should not be seen as lazy, superficial, second rate or incorrect.[/quote] Bloody hell its dinovet's corner, just need A.Todd along next!

RE: Pyrexia of unknown origin

mariette asselbergs — Wed, 08 Jul 2015 15:56:28 GMT

[quote user="Michael Woodhouse"]

[quote user="Julien Bazelle"]I do not think steroids are frequently indicated in cats as in my opinion feline cases of PUO are more frequently infectious or neoplastic. [/quote]

Is this that we are dealing with different populations in first opinion and referral practice?

I'd always found that investigation into these cases in dogs and cats invariably generated a large bill that cumulated in a few days worth of steroids and the animals back to normal. I'd offer investigation, but happy to try antibiotic (and usually steroid rather than NSAID) and reassess in 48 hours.

[/quote]

Completely agree and it would be worth reading Stephen May's Point of View ion The Veterinary Record. He gave an excellent point of view about the difference in approach between GP first opinion practices and the referral/university approach. In the first case the client expects a problem to be solved in an economical way and is less interested in the diagnosis. In the second scenario referral and university practices deal with different expectations and a very different population (animals where a treatment based on pattern recognition failed and where the client is much more interested in a diagnosis. In the first case - the GP practice, testing is often not indicated because the prevalence in the general population is very small for many diseases and hence the number of false positives will be relatively large. In referral situation, the population of animals is much smaller and the prevalence of diseases will be much higher, hence less problem with inappropriately positive tests.

Trial treatment in combination with follow up checks are an appropriate method and should not be seen as lazy, superficial, second rate or incorrect.

Mariette

RE: Pyrexia of unknown origin

Hannah Wynne Richards — Wed, 08 Jul 2015 14:04:33 GMT

I'd steer clear of steroids in case viral aetiology - either wind or fomite-borne. Of course it could be something we don't have here!

Wynne

RE: Pyrexia of unknown origin

Michael Woodhouse — Wed, 08 Jul 2015 13:42:05 GMT

[quote user="Julien Bazelle"]I do not think steroids are frequently indicated in cats as in my opinion feline cases of PUO are more frequently infectious or neoplastic. [/quote]

Is this that we are dealing with different populations in first opinion and referral practice?

RE: Pyrexia of unknown origin

Kara Gibson — Wed, 08 Jul 2015 02:37:30 GMT

I'm based in Hong Kong and have been for the past 2 and a half years and because our population is predominantly indoor I have only seen 2 cat bite abscesses since I've been here (I have to admit I rather miss them!) and indeed the cases I am thinking of were single cat household with no access to outside so no chance of a cat bite abscess. These were also long standing pyrexia of over 1 week duration and no response to antibiotics.

RE: Pyrexia of unknown origin

Martin Atkinson — Tue, 07 Jul 2015 18:30:47 GMT

[quote user="Julien Bazelle"]Regarding treatment trial, I am not against non-steroidal treatment (if there is no contraindication based on your tests[/quote]The problem with this approach is that pyrexia is there for a reason and that reason is the body's response to limit infection so you may compromise the ability to recover by just blindly giving an antipyretic. It has been shown in humans that people recover from infections more quickly if they are not treated with antipyretics. If the PUO is of less than 3-4 days duration I probably would not give NSAIDs for this reason. The trouble is people, the owner in our case, want a quick fix and want their animal to feel better immediately so we're under pressure.

RE: Pyrexia of unknown origin

Julien Bazelle — Tue, 07 Jul 2015 17:12:12 GMT

The main cause for pyrexia in cats is by far bite abscesses. I would always carefully assess/rule out skin lesions/nodules. Other causes are variable but should be identified via the investigations you listed: pyothorax, FIV/FeLV... I would add serology coronavirus or further more specific investigations to investigate the possibility of FIP in the case of a true PUO.

Regarding treatment trial, I am not against non-steroidal treatment (if there is no contradindication based on your tests) or a short course of antibiotic (as long as you use first line antibiotics) although ideally I would recommend investigations prior to these as these may interfere with the results of the tests. I do not think steroids are frequently indicated in cats as in my opinion feline cases of PUO are more frequently infectious or neoplastic.

I hope this helps

RE: Pyrexia of unknown origin

Anthony Dennison — Tue, 07 Jul 2015 11:36:34 GMT

In cats or dogs?

Dogs might get a CSF sample taken as well. Start with antibiotics & NSAIDs, possibly look at doing infectious disease PCRs, if no better, invoke the 'roid rule...