Presented in IMA Perambra by Dr.Jithesh.K,MD(c).Senior consultant Physician

1. Dr.Jithesh.K, MD (Gen. Medicine)
Consultant Physician
Baby Memorial Hospital
1

2. 2

3.  Mean oral temperature
 36.8 ± 0.4 °C or 98.2 ± 0.7 °F
 low levels at 6 A.M. and higher levels at 4 to 6 P.M.
 Maximum normal oral temperature
 37.2 ° C or 98.9 ° F at 6 A.M.
 37.7 ° C or 99.9 ° F at 4 P.M.
 Normal daily temperature variation
 0.5 ° C or 0.9 ° F
Reference: Harrison’s Principles of Internal Medicine, 16th ed.
3

4.  Oral temperature
 Accurate and convenient
 usually quoted at 37°C (98.6°F)
 Place thermometer under tongue, then close
both lips
 Mercury: 3-5 minutes ; Electric: 10 seconds
Reference: Bates’ Guide to Physical Examination and History Taking4

5.  Axillary temperature
 Reads 1°C lower than oral temperature
 Takes 5-10 minutes to register
 Lower accuracy
 Place the thermometer under the armpit and
fold the arm across the chest to hold the
thermometer in place.
Reference: Bates’ Guide to Physical Examination and History Taking5

6.  Rectal temperature
higher than oral temperatures by 0.4 to 0.5°C
patient lies on one side with the hip flexed
Select a rectal thermometer with a stubby tip,
use a lubricant, and insert it about 3-4 cm into
the anal canal for about 3 minutes
Reference: Bates’ Guide to Physical Examination and History Taking6

7.  Tympanic Membrane temperature
measures core body temperature
higher than the normal oral temperature by 0.8°C
measure radiant heat energy from the tympanic
membrane and nearby ear canal
Position the probe in the canal and wait 2 to 3
seconds
7

8. Range °C
Hypothermia <36
Normal 37
Low Grade or Mild 38.2-39
Moderate or Average 39 – 40
High-Grade 40 – 41.5
Severe > 41.5
8

9.  Fever
is an elevation of body temperature
that exceeds the normal daily
variation and occurs in conjunction
with an increase in the
hypothalamic set point.
a protective mechanism of the body

10.  FEVER is a Diagnostic Clue
 It is an essential host defense mechanism
 Associated with or without localizing signs
 It can be due to Infection, inflammation or neoplasm

11.  Fever may not be present despite infection,
inflammation and neoplasm in:
Newborn
Elderly
Uremia
Significant malnourished
individual
Taking corticosteroids

12. INCREASE IN HYPOTHALAMIC
SETPOINT
 Feeling of cold despite an
increase in body temperature
 Vasoconstriction in hands and
feet
 Shivering
 Increase in heart rate &
muscle tone
(increases about 18 beats per
minute for each degree
Celsius increase in temp.)
 Behavioral adjustments

13. WHEN HYPOTHALAMIC SET
POINT IS AGAIN RESET
DOWNWARD
 Intense sweating
 Hot skin (vasodilatation)

14. Harrison’s Principles of Internal Medicine, 16th
Edition
Infection, microbial toxins,
mediators of inflammation,
immune reactions
Microbial toxins
FEVER
Monocytes/macrophages,
endothelial cells, others
Pyrogenic cytokines IL-1, IL-
6, TNF, IFN
Cyclic
AMP
PGE₂
Hypothalamic
endothelium
Elevated
thermoregulatory set
point
Heat conservation,
heat production
Circulation
14

15. Reference: Fever: From Symptom to Treatment (1978) 15

17.  Sustained (Continuous)
Fever:UTI,Pneumonia,Typhus,brucellosis
 Intermittent Fever (Hectic
Fever);Malaria,Kalaazar,septicaemia..
 Remittent Fever:IE
 Relapsing Fever:
Tertian Fever;P.Vivax
Quartan Fever;P.Ovale,P.Malariae
Pel Ebstein Fever (Days of Fever Followed by a
Several Days Afebrile);Hodgkins Lymphoma

20.  Infection,Inflammation and Neoplasm
 Exogenous pyrogens: derived from outside an
individual and may include LPS and toxins.
 Endogenous pyrogens: originating inside the body
and may include pyrogenic cytokines,IL-1, IL-6,
TNF.
 Brain lesions
 Compression of the hypothalamus by a brain
tumor.
 Operations in the region of the hypothalamus

21.  Below 97 degree F – Hypothermia
 98.4 degree F - Normal
 98 to 102 degree F – INFECTIONS
 102 degree to 105 degree F – “NO MAN’S LAND”
 106 degree and above – Non- infectious fever (Hyperpyrexia)

22.  Heat production exceeds
heat loss, and the
temperature exceeds the
individuals set point

23.  Heat stroke: Exercise, Anticholinergic
 Drug induced: Cocaine,
Amphetamine,MAO inh.
 Neuroleptic malignant
syndrome:Phenothiazine
 Malignant hyperthermia:
Inhalational anesthetics
 Endocrinopathy: thyrotoxicosis,
pheochromocytoma

24.  History
 Antipyretics are not effective
 Skin is hot but dry

25. “THERE IS NO SUBSTITUTE
FOR OBSERVING THE PATIENT,
TALKING TO HIM AND
THINKING ABOUT HIM.”

26. 26

27. 27

28.  RESPIRATORY SYMPTOMS – URTI ,LRTI,PTB etc
 URINARY SYMPTOMS – UTI,APN,CYSTITIS
 ABDOMINAL SYMPTOMS – DYSENTRY,ABSCESS,ACUTE
ABDOMEN
 ARTHRITIS SYMPTOMS –RA,SLE,AS
 CARDIOVASCULAR SYMPTOMS- IE,pericarditis
 TRAVEL HISTORY
 DIETARY HISTORY
 OCCUPATIONAL HISTORY

29.  MALARIA
 DENGUE FEVER
 VIRAL FEVERS
 TYPHOID
 TUBERCULOSIS
 SCHISTOSOMIASIS - eg Egypt
ENDEMIC AREAS

30.  BIRDS – SARS, PSITTACOSIS
 ANIMALS CONTACT- TOXOPLASMOSIS (CAT),
BRUCELLOSIS (CATTLE),LEPTOSPIROSIS (RAT)
 UNCOOKED MEAT/SEA FOOD/ -
HEPATITIS –A & E,SALMONELLA
 UNPASTEURIZED MILK – SALMONELLA,Instestinal
TB,BRUCELLOSIS
 HIGH RISK BEHAVIOURS - STDS,HIV,HBV,HCV,IV
ABUSE

31. Fever

32.  Physical Examination:
Vital Signs
Skin Lesions,Mucous Membrane
Lymphadenopathy
Eyes
Lungs and Heart
Abdominal Region
(Hepatomegaly,Splenomegaly)
Neurological Exam.
ENT
Musculoskeletal

33. 33

34.  VIRAL FEVERS – LEUCO & THROMBO CYTOPENIA
 INFLUENZA – URTI SYMPTOMS
 POLYMYOSITIS – PROXIMAL M WEAKNESS, MUSCLE
PAIN & TENDERNESS, CPK HIGH
 MENINGOCOCCAL INFECTION -Rash
 SEPSIS

35.  TUBERCULOSIS
 LYMPHOMA
 ABSCESS
 BRUCELLOSIS
 INFECTIVE ENDOCARDITIS
 ALCOHOL WITHDRAWAL SYNDROME

36.  RELATIVE
BRADYCARDIA
 TYPHOID FEVER
 MALARIA
 MENINGITIS
 LEPTOSPIROSIS
 VIRAL
 DRUG FEVER
 RELATIVE
TACHYCARDIA
 TOXINS

37.  EYE PAIN – TEMPORAL ARTERITIS
 WATERY EYES- PAN,CONJUNCTIVITIS
 DRY EYES – SLE,RA
 SC HGE –Leukaemias,SBE
 CONJUNCTIVITIS – TB,SLE
 CONJUNCTIVAL SUFFUSION- LEPTOSPIROSIS
 UVEITIS- TB,SLE,SARCOIDOSIS

38.  DENGUE
 RICKETTSIAL INFC.
 LYME’S DISEASE
 JRA
 MEASLES/RUBELLA
 CHICKEN POX/HZ
38

39.  LEPTOSPIROSIS
 HEPATITIS- DRUGS (ATT) ,VIRAL
 ALCOHOLIC HEPATITIS
 CIRRHOSIS OF LIVER
 HEPATOMA
 VIRAL FEVERS
 MALARIA

40.  LEUKEMIA – ALL , CLL
 LYMPHOMA – MEDIASTINAL INVOLVEMENT
 HIV INFECTION – ORAL CANDIDIASIS,THIN
BUILT,
 TOXOPLASMOSIS- WITH LIVER,SPLEEN
 DISSEMINATED TUBERCULOSIS – WITH
LIVER ,SPLEEN
 BRUCELLOSIS- WITH LIVER,SPLEEN

41.  MILIARY TB
 LYMPHOMA
 HIV INFECTION
 SYPHILIS
 Local infections

42.  MALARIA
 TYPHOID
 LYMPHOMA
 LEUKEMIA
 DISSEMINATED TB
 INFECTIVE ENDOCARDITIS
 BRUCELLOSIS
 KALA AZAR

43.  ENCEPHALITIS +/-
MENINGITIS
 MENINGISM- TYPHOID
 HIV
 BRUCELLOSIS
 CNS NEOPLASMS
 TOXIC encephalopathy

44.  TONGUE- RELAPSING FEVER
 TRAPEZIUS – SUB DIAPHRAGMATIC ABSCESS
 STERNAL – METASTASIS, PRE –LEUKEMIA
 SPINAL – BRUCELLOSIS,TYPHOID,SBE,OM
 THIGH- POLYMYOSITIS,BRUCELLOSIS
 CALF – POLYMYOSITIS, RMSF

45.  SEPSIS
 Leptospirosis/Dengue
 H1N1/SARS INFECTION
 HANTA VIRUS INFECTION
 CEREBRAL MALARIA (P FALCIPARUM )

46.  TB
 TEMPORAL ARTERITIS
 CARCINOMA
 LYMPHOMAS
 ABSCESS
 MYELOPROLIFERATIVE DISORDER

47.  DENGUE FEVER
 VIRAL FEVERS
 LEUKEMIA
 LYMPHOMA
 MYELOPROLIFERATIVE DISORDER
 DRUG FEVER
 SLE
 HIV INFECTION

48.  Assess the extent and severity of the
inflammatory response to infection
 Determine the site(s) and complications
of organ involvement by the process
 Determine the etiology of the infectious
disease

49.  CBC (diff.)+ESR
 Urine R/E
 RBS
 RFT and L.F.T.
 PBS Routine / Malaria
 Two Blood Cultures,10ml each in 30 min.
Interval from two different sites
 CXR
 U/A (in selected patients)
 TFT (with caution and only when indicated)

50.  PNEUMONIAS
 TB
 CA LUNG/ABSCESS
 LYMPHOMAS- MEDIASTINAL INVOLVEMENT
 SARCOIDOSIS
 AUTOIMMUNE DISEASES

51.  ABSCESS
 HEPATOMA
 HYPERNEPHROMA
 LYMPHOMA
 PELVIC TUMORS

52.  BLOOD CULTURE and Bone marrow aspiration C&S - IE,SEPSIS
 ANA PROFILE – CONNECTIVE TISSUE DISORDERS
 AGGLUTININ TEST -SALMONELLA , BRUCELLOSIS ,RICKETTSIAL
 ELISA IGM AB - LEPTOSPIRA ,DENGUE,LYME’S
 SMEAR TEST – MALARIA, LEUKAEMIAS
 ECHO HEART – ATRIAL MYXOMA,IE,PERICARDITIS
 BONE SCAN- OSTEOMYELITIS,METASTASIS
 VIRAL CULTURE - EBV,CMV INFECTIONS
 DISEASE SPECIFIC INVESTIGATIONS- Mx Test , PCR etc

53.  Biopsies:
Bone marrow
Lymph node
Skin lesion
Liver
Temporal artery

54. 54

55. LEPTOSPIROSIS

56. 56

57.  PATHOGENEGIS
Contamination of the drug with a
pyrogen or microorganism
Pharmacologic action of the drug
itself
Allergic (hypersensitivity) reaction
to the drug

58.  All drugs can produce Drug INDUCED fever except DIGOXIN
 Bradycardia, hypotension, Skin rash, pruritus +,
 Eosinophilia eg) pencillin, sulpha, ATT

59.  Fever out of proportion to
clinical picture
 Associated findings:
Rigor (43%), Myalgia (25%), Rash
(18%), Headache (18%),
 Leukocytosis (22%), Eosinophilia
(22%), Serum sickness,Proteinuria
Abnormal liver function test

60.  Onset and duration:
Onset: 1-3 weeks after the start of
therapy
Duration: remits 2-3 days after
therapy is stoped

61.  Classic FUO
 Nosocomial FUO
 Neutropenic FUO
 HIV-Associated FUO

62.  Definition:
Fever of 38.3 C or higher on
several occasions
Fever of more than 3 weeks
duration
Diagnosis uncertain, despite
appropriate investigations after
at least 3 outpatient visits or at
least 3 days in hospital

63.  Definition:
Fever of 38.3 or higher on
several occasions
Infection was not manifest or
incubating on admission
Failure to reach a diagnosis
despite 3 days of appropriate
investigation in hospitalized
patient

64.  Definition:
Fever of 38.3 or higher on
several occasions
Neutrophil count is <500/mm3
or is expected to fall to that
level in 1 to 2 days
Failure to reach a diagnosis
despite 3 days of appropriate
investigation

65.  Definition:
Fever of 38.3 or higher on
several occasions
Fever of more than 3 weeks for
outpatients or more than 3
days for hospitalized patients
with HIV infection
Failure to reach a diagnosis
despite 3days of appropriate
investigation

66. Infections 22-58%
Neoplasms up to 30%
Noninfectiouse
inflammatory diseases
up to 25%
Miscellaneous causes up to 25%
Undiagnosed up to 30%

67.  Localized pyogenic infections
 Intravascular infections
 Systemic bacterial infections
(Tuberculosis, Brucellosis,…)
 Fungal infections
 Viral infections
 Parasitic infections

68.  Hodgkin’s disease
 Non-hodgkin’s lymphoma
 Leukemia
 Renal cell carcinoma
 Hepatoma
 Colon carcinoma
 Atrial myxoma

69.  Collagen vascular/
hypersensitivity
diseases
Lupus
Still’s disease
Temporal
arteritis (Giant
cell arteritis)
 Granulomatouse
diseases
Crohn’s
disease
Sarcoidosis
Idiopathic
granulomatous
e disease

70.  Drug fever
 Factitious fever
 FMF
 Recurrent pulmonary
emboli
 Subacute thyroiditis

71.  Diagnosis should be considered in any FUO,
especially in:
Young women
Persons with medical training
If the patients clinically well
Disparity between temperature
and pulse
Absence of the normal diurnal
pattern

72. Undiagnosed 19%
Miscellaneous 13%
Factitious 9%
Granulomatous hepatitis 8%
Neoplasm 7%
Infection 6%
No fever 27%

73.  To lower the body temperature
 To completely eradicate the pathogen
73

74.  Most fevers are associated with self-limited
infections, most commonly of viral origin.

75.  For each 1 °C elevation of body
temperature:
Metabolic rate increase 10-15%
Insensible water loss increase
300-500ml/m2/day
O2 consumption increase 13%
Heart rate increase 10-15/min

76.  Reasons to treat fever:
The elderly individual with pulmonary or
cardiovascular disease
The patient at additional risk from the
hypercatabolic state (Poor nutrition,
Dehydration)
The young child with a history of febrile
convulsions
Toxic encephalopathy or delirium
Pregnant women (contraversy)
For the patient comfort
Hyperpyrexia

77.  Reasons not to treat fever:
 The growth and virulance of some organisms
 Host defense-related response
 Fever is an indicator of disease
 Adverse effect of antipyretic drugs
 Iatrogenic stress
 Social benefits

78.  Persons who are clinically unstable or are at
risk for rapid deterioration
 Major alterations of immunity
 Need for IV Antimicrobials or other fluids
 Advanced age

79. Objectives of treating fever
 reduce the elevated hypothalamic set point
 facilitate heat loss
.

80. ANTIPYRETICSANTIPYRETICS
 drugs that reduce fever
 drugs that cause a lowering of the elevated
hypothalamic set point
 The antipyretic potency of various drugs is
directly correlated with the inhibition of
brain cyclooxygenase.

81.  Acetaminophen is generally a first-line antipyretic
due to being well tolerated with minimal side
effects.
 Pediatric dose: 10-15mg/kg q4-6h (2400mg/day);
 Adult dose: 650mg q 4 h(4000mg)
 Can be hepatotoxic in high doses; can upset stomach

82.  a poor cyclooxygenase inhibitor in peripheral
tissue and is without noteworthy anti-
inflammatory activity
 oxidized by the p450 cytochrome system, and
the oxidized form inhibits cyclooxygenase
activity
 the inhibition of another enzyme, COX-3
82

83. Membrane Lipid
Arachidonic Acid
Phospholipase A2
EndoperoxidesHydroperoxides
TXA
PGE, PGEF
PGILeukotrienes
Cyclooxygenas
e
Lipoxygenase
- Corticosteroids
NSAIDs
-
83

84. 84

85.  Use of antimicrobial therapy directed against
the pathogen
85

86.  agents used to destroy or inhibit the growth of
other microorganisms
 used to inactivate microbial cells
 limit toxicity to the host and maximize
chemotherapeutic activity affecting invading
microbes only.
86

87.  Selective toxicity
 Inhibition of cell wall synthesis
 Β-lactams (Penicillin and Cephalosporin)
 Vancomycin
 Inhibition of cell membrane function
 Polymyxins
 Inhibition of protein synthesis
 Macrolides
 Chloramphenicol
 Tetracycline
 Aminoglycosides
 Inhibition of nucleic acid synthesis
 Rifampin
 Metronidazole
87

88.  Widespread sensitization of the population
 Changes in the normal flora of the body
 Masking serious infection without eradicating it
 Direct drug toxicity
 Development of drug resistance
88

89.  ALL WE KNOW IS STILL INFINITELY
LESS THAN ALL THAT REMAINS UNKNOWN….
-WILLIAM HARVEY -