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Patient with Fever Patient with fever Dr Förhécz Zsolt Dehydration fever Crimean-Congo hemorrhagic fever Febrile convulsions Fever of unknown origin (FUO) Jaccoud's dissociated fever Lassa fever Jamshedpur fever Metal fume fever ‘Q’ fever Rat bite fever Relapsing fever Rheumatic fever Sennetsu fever Tsutsugamushi fever Valley fever Yellow fever West Nile fever INTRODUCTION • FEVER(Pyrexia) Is an elevation of body temperature above the normal circadian range (daily variation) as a result of a change in the thermoregulatory center located in the anterior hypothalamus and pre-optic area (i.e. an increase in the hypothalamic set point of 37 C) due to infection, metabolic derangements or increased cell destruction. • Hyperthermia is a state of elevated core temperature that rises rapidly above 40°C, secondary to failure of thermoregulatio, that occurs when a body produces or absorbs more heat than it dissipates. • Hyperpyrexia — Hyperpyrexia is the term for an extraordinarily high fever (>41.5°C), which can be observed in patients with severe infections but most commonly occurs in patients with central nervous system (CNS) hemorrhages. Hyperthermia 1. • In contradistinction to fever, the setting of the thermoregulatory center during hyperthermia remains unchanged at normothermic levels, while body temperature increases in an uncontrolled fashion and overrides the ability to lose heat. Exogenous heat exposure and endogenous heat production are two mechanisms by which hyperthermia can result in dangerously high internal temperatures. It can be rapidly fatal, and its treatment differs from that of fever. • The underlying cause must be removed. Antipyretics do not reduce the elevated temperature. Rapid reduction of body temperature by physical means. Fluids. CAUSES: – Hypohydration is a major cause of hyperthermia. – Overinsulating clothing can result in elevated core temperature – Who work or exercise in hot environments –heat stroke syndromes – Hyperthyroidism Hyperthermia 2. • Neuroleptic malignant syndrome (butyrophenones(haloperidol) or phenothiazines(promethazine,chlorpromazine) are reported to be at greatest risk, dopaminergic (levodopa), antiemetic (metoclopramide), lithium. • Serotonin syndrome (SSRI) • Anesthetic agents (such as halothane) or the paralytic agent succinylcholine. • Anticholinergics • Drugs that decouple oxidative phosphorylation may also cause hyperthermia. From this group of drugs the most well known is 2,4-Dinitrophenol. • Stimulant drugs, including amphetamines and cocaine, and hallucinogenic drugs, including PCP(Angel dust), LSD, and MDMA (Ectasy) PYROGENS — The term pyrogen is used to describe any substance that causes fever. Pyrogens are either exogenous or endogenous. Endogenous pyrogens belong to the class of biologically active proteins called cytokines. • Exogenous pyrogens- mainly microbes or their products, such as toxins – lipopolysaccharide endotoxin produced by all gram-negative bacteria – Endotoxins belong to a classification of microbial products termed Toll-like receptor (TLR) ligands. – The toxic shock syndrome toxin (TSST-1) is associated with strains of Staphylococcus aureus – exotoxins from group A Streptococcus act both as direct toxins but also serve as "superantigens" • Pyrogenic cytokines -Pyrogenic cytokines are specific cytokines produced upon activation of TLR that cause fever – IL-1, TNF, and IL-6, and each or all three cytokines trigger the hypothalamus to raise the set-point to febrile levels MECHANISMS OF ANTIPYRETIC AGENTS — • The synthesis of prostaglandin E2 (PGE2) depends upon the constitutively expressed enzyme cyclooxygenase. The substrate for cyclooxygenase is arachidonic acid released from the cell membrane, and this release is the rate- limiting step in the synthesis of PGE2. • Inhibitors of cyclooxygenases (either COX-1 or COX-2) are potent antipyretics – Aspirin – Nonsteroidal antiinflammatory agents (NSAIDs), such as naproxen or ibuprofen, are excellent antipyretics – Acetaminophen is a poor cyclooxygenase inhibitor in peripheral tissue and does not display noteworthy antiinflammatory activity; however, acetaminophen is oxidized in the brain by the p450 cytochrome system, and the oxidized form inhibits cyclooxygenase activity. – Corticosteroids are also effective antipyretics, which act at two levels. • Similar to the cyclooxygenase inhibitors, corticosteroids reduce PGE2 synthesis by inhibiting the activity of phospholipase A2. • Corticosteroids block the transcription of the mRNA for the pyrogenic cytokines. FACTITIOUS FEVER • This is defined as fever engineered by the patient by manipulating the thermometer and/or temperature chart apparently to obtain medical care. • uncommon and typically presents in young women with a medical and nursing background. • Examples include The dipping of thermometers into hot drinks to fake a fever. • The factitious disorder is usually medical but may relate to a psychiatric illness with reports of depressive illness. • CLUES TO THE DIAGNOSIS OF FACTITIOUS FEVER – A patient who looks well – Absence of temperature-related changes in pulse rate – Temperature > 41°C – Absence of sweating during the period of fever – Normal ESR and CRP despite high fever • Useful methods for the detection of factitious fever include 1) Supervised (observed) temperature measurement 2) Measuring the temperature of freshly voided urine TYPES OF FEVER- The pattern of temperature changes may occasionally hint at the diagnosis: • Continuous/sustained fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid fever, urinary tract infection, brucellosis • Intermittent fever: The temperature elevation is present only for a certain period, later cycling back to normal (i.e. Normal temp. between fever episodes), e.g. pyaemia, or septicemia. • Relapsing fever: temperature returns to normal for days before rising -Tertian fever (48 hour periodicity), typical of Plasmodium vivax or Plasmodium ovale malaria • Remittent fever : Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours , e.g., infective endocarditis. • Pel-Ebstein fever : A specific kind of fever associated with Hodgkins lymphoma, being high for one week and low for the next week and so on. However, there is some debate as to whether this pattern truly exists. Presenting complaints of a patient with fever • Feeling hot- A feeling of heat does not necessarily imply fever • Rigors. profound chills accompanied by chattering of the teeth and severe shivering, implies a rapid rise in body temperature. – Can be produced by : 1) brucellosis and malaria 2) sepsis with abscess 3) lymphoma • Excessive sweating. Night sweats are characteristic of tuberculosis, but sweating from any cause is usually worse at night. • Recurrent fever. Source is often a focus of bacterial infection such as cholecystitis or cholangitis or urinary tract infection especially associated with an obstruction or calculi. • Headache. Fever from any cause may provoke headache. Severe headache and photophobia, may suggests meningitis. • Delirium. Mental confusion during fever is well described and relatively more common in young children and in old age. • Muscle pain. Myalgia is characteristic of viral infections such as influenza, Malaria and brucellosis. Symptom analysis for fever • Verify presence of fever- True or factitious fever • Duration- Acute or chronic • Mode of onset- Abrupt or gradual • Progression- Continuous or intermittent. If intermittent ask about frequency to determine the pattern. • Severity- how it affects daily work/physical activities. • Relieving and aggravating factors • Treatment received or/and outcome • Associated symptoms- Localizing symptoms may indicate the source of fever. • Respiratory tract symptoms: – 1) Sore throat, nasal discharge, sneezing-URTI – 2) Sinus pain and headache-suggests sinusitis – 3) cough, sputum, wheeze or breathlessness-suggests a LRTI • Genitourinary symptoms: – Frequency of micturition, dysuria, loin pain, and vaginal or urethral discharge- suggesting a) Urinary tract infection, b) Pelvic inflammatory disease and c) Sexually transmitted infection (STI) • Abdominal symptoms: – diarrhea, with or without blood, weight loss and abdominal pain -suggesting a) Gastroenteritis, b) Intra-abdominal sepsis, c) Inflammatory bowel disease, d) Malignancy • Skin rash: enquire about appearance and distribution as it may provide clues to the diagnosis- – 1) Macular- Measles,Rubella,toxoplasmosis – 2) Haemorrhagic- Meningococcal infections, viral haemorrhagic fever. – 3) Vesicular- Chickenpox, Shingles, herpes simplex – 4) Nodular- Erythema nodosum( TB and Leprosy) – 5) Erythematous- Drug rashes, Dengue fever – Joint symptoms: joint pain, swelling or limitation of movement is suggestive of active arthritis. – A) distribution : mono , oligo or poly arthritis – B) appearance : fleeting 1) infective arthritis- oligoarthritis 2) collagen vascular disease- fleeting 3) reactive arthritis • Constitutional symptoms: – Weakness – Fatigue – Anorexia – Change of weight – Fever/chills – Lumps – Night sweats HISTORY-Past Medical /Surgical History • Start by asking the patient if they have any medical problems • IHD/DM/Asthma/HT/RHD, TB/Jaundice/Fits e.g. if diabetic- mention time of diagnosis/current medication/clinic check up • Past surgical/operation history - E.g. time/place/ what type of operation. • Note any blood transfusion / blood grouping. • H/O dental extractions/circumcision & any excessive bleeding during
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