EDITORIAL CHANGING TRENDS IN PATTERN OF PRESENTATION WITH DIFFERENT TYPES OF PYREXIA AND APPROACH TO BE MADE PROF. KHAN ABUL KALAM AZAD Editor, Journal of Dhaka Medical College

J Dhaka Med Coll. 2011; 20(1) : 1-3.

With increasing number of patients with infectious diseases have common and pyrexia, doctors are often faced with the overlapping clinical features. Due to diagnostic dilemma of a febrile patient who has emergence of many new infectious diseases different types of manifestations. is an e.g.viral haemorrhagic fever, yellow fever important and common presentation of tropical Chikungunya, Nipah encephalitis pattern of diseases and may sometimes be the only fever is changing. Besides the same infectious presentation of a serious illness. Diagnosis is agent can also change presentation of clinical often difficult because of the many diagnostic features after a time interval, the most possibilities, symptoms and signs which may common example is Dengue hemorrhagic often be non-specific and because of doctors’ fever. Now dengue is commonly associated with unfamiliarity with many tropical diseases. liver and renal function impairment and Fever is a manifestation of an illness but not associated respiratory tract which was an illness itself. By far, the most common cause very uncommon in previous years. of fever is infection. However, other causes of Continued are those that are constant fever should always be kept in mind, such as with only slight remissions and can be seen in malignancy (especially lymphoma and such diseases as lobar pneumonia and leukaemia), connective tissue diseases, drugs, rickettsial disease. An intermittent fever is pulmonary embolism and other less common one with wide fluctuations, usually normal in causes. the morning and peaking in the afternoon or Fever patterns are rarely diagnostic but can evening. This fever pattern can be seen in be helpful in certain . As for example, many viral diseases as well as endocarditis or Dengue virus infection typically presents with localized pyogenic infections such as an two febrile periods separated by an afebrile abscess. A diurnal pattern also known as typhus interval of one to three days (saddle back fever). inversus, is the reverse of normal circadian Fevers that occur at regular intervals of 42-78 pattern in which the highest temperature is hours are virtually pathognomic of P.vivax, in the morning. It can be found in milliary TB, P.ovale, P.malariae infections. Although hepatic abscesses and endocarditis. untreated typhoid fever classically presents Saddleback or biphasic fevers are those that with a continued fever associated with relative are constant for several days, spontaneously bradycardia, almost any fever pattern can reduce for 1 to 2 days, and then increase again. develop. Nowadays the pattern of fever is Saddleback fevers can be seen in such changing. The common associated infections as dengue, yellow fever and presentations are also changing which include influenza. A Pel-Ebstein fever is one that myalgia, headache, backache, pain in other site occurs daily for a period of about one week, of the body, vomiting, cough, diarrhoea, runny resolves for about an equal time, and then nose, arthralgia, burning sensation of recurs. Pel-Ebstein fevers are often seen in micturition, different types of rashes. Many lymphomas. The Jarisch-Herxheimer reaction J Dhaka Med Coll. Vol. 20, No. 1. April, 2011 is a fever (and sometimes more systemic marrow such as malignancy, TB, or symptoms such as hypotension) that occurs histoplasmosis. Lymphocytosis may be several hours after treatment with antibiotics. seen in viral infections, typhoid fever, It is a classic reaction for syphilis, but can also , or TB, and atypical lymphocytes be seen in leptospirosis, and are frequently seen in infections with brucellosis. Epstein-Barr virus, cytomegalovirus or HIV. A history of specific exposure should be sought Monocytosis may be seen with typhoid fever, from the patients. Eliciting unique exposure TB, or lymphoma. Eosinophilia can be seen may help to point to a specific diagnosis. For with certain parasitic infestations, a example, a patient with a history of tick bite hypersensitivity drug reaction, or presenting with fever, rash, regional lymphoma. lymphadenopathy, and a painless skin eschar • Urine analysis with examination of the suggests tick typhus due to rickettsia. urinary sediment is indicated when Traditional cultural restraints on sexual symptoms suggest involvement of the behavior may not be present during travel, and genitourinary system or when another therefore a history of sexual exposure is exclusive diagnosis is not really apparent. important when evaluating the febrile traveler. A history of unprotected sexual intercourse, for • Electrolytes, glucose, BUN, and creatinine example, may point to the diagnosis of an acute should be checked as a general measure retroviral syndrome with HIV, which often of the patient’s condition. Liver function manifests as fever and mononucleosis like tests are also generally indicated if other illness one to six weeks after exposure. As signs and symptoms do not specifically point many tropical diseases have overlapping and away from hepatic involvement. non-specific signs and symptoms, a unique • Smears and cultures of specimens from exposure is often the only clue to correct the throat, urethra, anus, cervix, or vagina diagnosis. should be obtained when symptoms or signs A thorough physical exam is very important in indicate involvement of those systems. the diagnosis of febrile illnesses and should be Cultures of blood and urine are indicated repeated during the course of illness to whenever the illness is thought to be more evaluate for changes. While the exam is often than a simple viral infection, especially if directed by symptoms, special attention should the diagnosis is unclear and empiric be paid to the skin, lymph nodes, eyes, nail antibiotics are being considered. beds, cardiovascular system, chest, abdomen, joints and neurological system. A genital or • Cerebrospinal fluid should be examined and pelvic exam and rectal exam should be cultured if there is an associated severe considered as a part of complete evaluation. headache, meningismus, a change in mental status. If signs of increased Symptoms and physical findings should guide intracranial pressure, such as focal the laboratory evaluation. Often, no lab studies neurological deficit or papilloedema, are are required to make the diagnosis of a simple present, a CT of the head should be viral illness. When the diagnosis is not clear- performed to rule out a mass lesion before • A should almost performing a lumber puncture. always be ordered, with special attention • Any abnormal fluid collection (pleural, paid to the differential. The presence of peritoneal or joint) found in the presence increased neutrophils and band forms (as of fever should be examined and cultured. well as toxic granulations and Dohle bodies) may indicate a bacterial infection, while • if a fever is severe or prolonged, it is neutropenia might be seen in viral appropriate to order an erythrocyte infections or infiltrative process of the bone sedimentation rate (ESR) or C- reactive

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protein (CRP) as a baseline. These tests are References: too non-specific to use for diagnostic l Fortnightly Review: Evaluating fever in travellers purposes, but can be used to follow the returning from tropical countries Atul Humar, fellow in infectious diseases, Jay Keystone patient’s progress. ([email protected]), professor of medicine Author Affiliations a Tropical Disease Unit, • A chest X-ray should be considered standard Division of Infectious Diseases, Department of in any patient with an unclear diagnosis Medicine, Toronto Hospital, University of Toronto, or if signs and symptoms point to the chest. ENG212, 200 Elizabeth Street, Toronto, Ontario X-rays of other areas, such as the abdomen M5G 2C4 or an extremity, may be indicated by the 2. Operational Medicine 2001 Health Care in patient’s symptoms. Military Settings, The Brookside Associates Medical Education Division. • A CT scan abdomen, CT chest or MRI brain 3. Fever: Basic Mechanisms and Management, may also be considered according to site of Second Edition. Edited by Philip A Mackowiak. involvement and suspicious lesion. Lippincott-Raven Publishers, Philadelphia. 4. Gelfand JA and Dinarello CA. Fever and A stepwise and rational approach to febrile Hyperthermia. Harrison’s Principles of Internal patients will allow for correct diagnosis and Medicine, 14th edition. Edited by Anthony Fauci, optimal management in most patients. When et al. McGraw-Hill Companies, Inc. USA, 1998: evaluating fever in a tropical country, the doctor 84-89. 5.Mackowiak PA, et al. Concepts of fever: recent advances and lingering dogma. Clinical must first determine if the patient has a Infectious Diseases 1997; 25:119-138. tropical disease or any other illness. If a tropical infection is suspected doctors should consider 6. A Comprehensive Evidence-Based Approach to Fever of Unknown Origin Ophyr Mourad, MD, which illnesses are potentially fatal, which are FRCPC; Valerie Palda, MD, MSc; Allan S. Detsky, treatable and which infections are potentially MD, PhD transmissible and may therefore pose a public 7. Etiology and Outcome of Fever After a Stay in the health risk. Such an approach needs a clear Tropics Emmanuel Bottieau, MD; Jan Clerinx, understanding of tropical illnesses and their MD; Ward Schrooten, MD, PhD; Erwin Van den presentation and epidemiological background. Enden, MD; Raymond Wouters, MD; Marjan Van A working differential diagnosis can be Esbroeck, MD; Tony Vervoort, MD; Hendrik formulated from a complete history, physical Demey, MD; Robert Colebunders, MD, PhD; Alfons Van Gompel, MD; Jef Van den Ende, MD, PhD examination, knowledge of the most common diseases affecting travelers and of the 8. Changing patterns of communicable disease in incubation periods of these diseases, and England and Wales Part ]-Newly recognised diseases N S GALBRAITH, PAT FORBES, R T appropriate laboratory investigations. MAYON-WHITE

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