Pyrexia - PACT - ESICM

Task 2. Determining the cause of fever in the critically ill patient
Konen E, Faibel M, Kleinbaum Y, Wolf M, Lusky A, Hoffman C, et al. The value of
the occipitomental (Waters’) view in diagnosis of sinusitis: a comparative
study with computed tomography. Clin Radiol 2000; 55(11): 856–860.
PMID 11069741
Vargas F, Bui HN, Boyer A, Bébear CM, Lacher-Fougére S, De-Barbeyrac BM, et
al. Transnasal puncture based on echographic sinusitis evidence in
mechanically ventilated patients with suspicion of nosocomial maxillary
sinusitis. Intensive Care Med 2006; 32(6): 858–866. Epub 2006 Apr 14.
PMID 16614810
Q. Considering the risks involved in transporting a critically ill
patient to the radiology department, in what circumstances might it
be justified to perform a CT examination to confirm a diagnosis of
sinusitis
A. If the patient has to be transported for investigation of another major problem. Some
institutions may also perform a CT scan when sinusitis persists or recurs despite
adequate treatment (drainage and lavage) for 72h.
Opacification or fluid-air levels necessitate needle aspiration, microscopy and
culture of secretions to confirm a radiologic diagnosis. Only half the patients
with a radiological diagnosis are confirmed to have sinusitis on aspiration. A
radiological diagnosis is confirmed on aspiration if staining and culture yield
neutrophils and micro-organisms at a concentration >10 3 CFU/ml. Gramnegative
bacteria are often involved, and polymicrobial infections are relatively
common. Treatment of maxillary sinusitis includes needle aspiration, lavage
and, sometimes, systemic antibiotics. The clinical and radiographic features of
infection should abate within a few days, following the start of appropriate
treatment. Rarely, persistent or recurrent sinusitis may necessitate surgical
exploration.
Q. Examine this CT scan from a 54-year-old male admitted because
of respiratory insufficiency in the course of Legionella pneumonia.
Day 11 of mechanical ventilation was complicated by fever,
leukocytosis, and purulent nasal discharge, in spite of systemic
antibiotics. What is your presumptive diagnosis and how would you
prove it
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