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  1. 1. Differential Diagnosis &Management of common Febrile illness Dr.Praful Chhasatia,md
  2. 2. Fever• Since antiquity, Fever has been recognized as cardinal manifestation of disease.• Given importance over other symptoms and demands high therapeutic expectation.• Persistent and relapsing fevers are amongst the most difficult diagnostic challenges in medicine
  3. 3. Definition of Fever• A state of elevated core temperature, which is often, but not necessarily, part of defensive response of body to invasion of live or pathogenic matter.• Pyrogen endogenous,or exogenous,iduced.
  4. 4. Definition of Hyperthermia• Unregulated rise in body temp.• Uncontrolled heat production, inadequate heat dissipation, defective thermoregulation• Not pyrogen related.• No response to antipyratics.
  5. 5. Normal Temperature• 37°C(98.6°F) is defined as normal• There are various differences among workers• Diurnal variation exist .• Morning Temp.< Evening Temp.• Female have higher Temp. ,and rises further during menstruation• Hyperpyrexia > 105°F
  6. 6. Measurments• Shell: axillary, oral• Core: rectal , Tympanic membrane• Instruments: Mercury in glass, Electronics,
  7. 7. Antipyresis• Physical: Tepid water sponging, Alcohol sponging, ice packs, cooling blankets, exposure to circulating fan• Drugs: 1.Corticosteroids. 2.Aspirin & NSAID 3.Acetoaminophen (paracetamol)• Benefits Vs Risk of lowering Temp.
  8. 8. Patterns of Fever• Hi grade spike intermittent with /without rigor• Low grade• Continuous Hi grade• Recurrent-intermittent• Temperature-pulse dissociation: typhoid fever, leptospirosis, brucellosis, and drug- induced fever.• Cyclical: hodgkin’s
  9. 9. Patterns of Fever• Tertian, quartan: Malaria• Travel related: H1N1 Swine Flu, Bird Flu• Drug Fever• Factitious Fever• Fever in Immunocompromized• PUO
  10. 10. Differential diagnosis of fever and hyperthermia• Fever—common causes• Infections: bacterial, viral, rickettsial, fungal, parasitic• Autoimmune diseases• Malignant disease, especially renal cell carcinoma, primary or metastatic• liver cancer, leukemia, and lymphoma• Fever—less common causes• Cardiovascular diseases, including myocardial infarction, thrombophlebitis,• and pulmonary embolism• Gastrointestinal diseases, including inflammatory bowel disease,• alcoholic hepatitis, and granulomatous hepatitis• Miscellaneous diseases, including drug fever, sarcoidosis, familial• Mediterranean fever, tissue injury, hematoma, and factitious fever• Hyperthermia• Peripheral thermoregulatory disorders, including heat stroke, malignant hyperthermia of anesthesia, and malignant neuroleptic
  11. 11. Common Febrile illnessFever without Rash Fever with RashURTI,Sinusitis,Tonsillitis,Otitis,PharyngitisViral :Infections:Dengue,Flu,Hunta virus,Viral Chickenpox,Measles,Dengue,Herpes,MumpsHepatitis, Measles,MumpsBacterial:Brucelosis,plague,Leptospirosis Typhus,Enteric Fever,Sec.Syphilis,N.meningitis,gonorrhoea,L eptospirosis,Staphylococcua aures,Strepto(Scarlet Fever)Respiratory:Pneumonia,Tuberculosis,Diptheria,Measles ,plagueGI: Enteric Fever,BacillaryDesentry,Peritonitis,pancreatitis,LiverAbscess,Hepatitis,Abscess,appendicitis,cholecystitisCNS:Meningitis,Brain AbscessUrinary:Gonococci,UTI,Prostatitis
  12. 12. Protozoa: Malaria,Babesosis P.F.malariaParasites:Filariasis
  13. 13. Clinical Evaluation• History• Physical Examination• Investigations• Management
  14. 14. History Fever• O,D,P• Nature of Fever:High grade,Low grade,• Continuous /intermittent• Diurnal variation• Rigors: Present/Absent• Past history of fever
  15. 15. Associated Symptoms• Headache• Vomiting• Diarrhea• Cough• Jaundice• Body ache/arthralgia/myalgia• Abdominal pain• Chest pain• Localized pain• Retro orbital pain• Prostration/toxic
  16. 16. Associated Symptoms• Altered sensorium• Convulsions• coma• Red Eyes• Dark red/black urine
  17. 17. Associated Symptoms• Urinary symptoms• Breathlessness• Joint pain• Backache• Eruptions• Mouth ulcers/stomatitis• Throat pain• Swelling /Ulcers anywhere• Recent travel• Urticaria
  18. 18. Examination generalTempraturePulse Tachycardia, relative bradicardia,irregular,low volumeRespiration Tachypnoea,shallow,Sp o2 OptionalBP Hypotension, tourniquet testSclera,conjuctiva Jaundice,pallor,suffusion,haemorrhageTongue Coating,glossitis,candida,ulcers,cynosisThroat,mouth Tonsills.pharyngs,diptheria,rash,dental abscess,trysmusNeck Lymph nodes-type,rigidiry,Skin Rash,ulcers,abscess,nodules,perspirationAxilla,groin Lymph nodes,abscess
  19. 19. Examination generalNails Pallor,clubbing,cynosis,infarcts,fungusHigher function altered
  20. 20. Examination SystemicRS RR,Movments of chest,dull/tympanic node, Air entry, plural rub, rales, rhnchi, bronchial breathingAS Brathing,Distension,peristalsis,Tenderness- quadrant,organomegaly,rigidity,gaurding,lump,dull-tympanic node,CVS Tachycardia,murmur,pericardial rubCNS Higher function,Neck rigidity,Kernig’s sign,pupils,Bones & joint Spine abnormality, tenderness,joint infammation
  21. 21. Investigations basic• Blood: CBC with ESR & Platelet count,PS. SGPT, RBS, S.CREATININE,RDT(pf)• Urine• X-ray chest• USG: Abdomen,chest
  22. 22. Investigations specific & advanced• Serology:Widal,NS1antigen,IgM,IgG for Lepto,Hunta,TB,Virus,HIV• Sputum:AFB,Gram st.,C&S,Cytology• Culturs:Blood,urine,pus,aspirates,stool• CT Scan: Abdoman,Brain,Chest+HRCT,Sinus• MRI:Spine.Joints,Brain• Acute phase reactant: CRP,ProCalcitonin
  23. 23. CBC• Hb: down,up,• RBC:down,Sickle,MP,Fragments• WBC:N,H,D• Platelet:N,H,D,ask for manual count,look for other cause• ESR:non specific• PS: MP,Parasites,Leucamia,TTP,ITP,RBC morphology,Platelet,Thin and Thick(3) smear• Auto Cell counter
  24. 24. Urine• Proteins:Infection,renal,pregnancy• Acetone:DM,dehydration,poor nutrition• Sugar:DM,IV fluid,renal• Pus cells:infection,renal• Organism:bacteria,fungus
  25. 25. X-Ray• Chest:PA,Portable• Spine:• Sinus:• Abdoman:Supine,Standing
  26. 26. USG• Look for areas studied.Discuss with sonologist• Always ask for Whole abdoman+Chest• In doubt confirm with CT
  27. 27. Investigations increase plateletCondition Adults, >500,000/μL >1,000,000/μLInfection 22% 31%Rebound thrombocytosis 19% 3%Tissue damage (surgery) 18% 14%Chronic inflammation 13% 9%Malignancy 6% 14%Renal disorders 5% <1%Hemolytic anemia 4% <1%Post-splenectomy status 2% 19%Blood loss NS 6%Primary thrombocythemia 3% 14%
  28. 28. Investigation Decrease plateletImmune destruction Autoantibodies: ITP, disease-associated IT (collagen disease, lymphoproliferative disorders) Alloantibodies: post-transfusion purpura, neonatal purpura Drug-induced IT: quinidine, quinine, sulfonamides, gold, etc. Acute ITPInfection HIV, hepatitis, cytomegalovirus, Epstein-Barr virusNonimmune destruction Infection (bacterial, viral, malarial)or platelet removal Thrombotic thrombocytopenic purpura/hemolytic- uremic syndrome D.I.C. ,Hemangiomas,Platelet loss (massive bleeding) Platelet redistribution (enlarged spleen) Congestive splenomegaly Other (non-Hodgkins lymphoma, Gauchers disease, etc.)
  29. 29. Investigation Decrease plateletDECREASED PLATELET PRODUCTION Myeloproliferative disorders (acute or chronic leukemias, multiple myeloma, myelofibrosis Lymphoproliferative disorders (non-Hodgkins lymphoma, CLL) Aplasia or hypoplasia (idiopathic, drug induced, radiation) Ineffective hematopoiesis (myelodysplasia, vitamin B12 or folate deficiency) Myelophthisis (prostate, lung, breast, gastrointestinal cancers) Drugs (chemotherapy, thiazides, alcohol, etc.) Congenital/hereditary disorders
  30. 30. Important corelation Malaria Viral Typhoid PyogenicSGPT ↑ ↑ N NLDH ↑ N N NCRP N N ↑ ↑
  31. 31. Plt. & atypical Lymphocytes• Platelet :↓ + Atypical Lymphocytes Day 1-2 – Malaria• Platelet : N Day 1-2 + Atypical Lymphocytes ↓ Day 2-3-4+ Atypical Lymphocytes - Dengue
  32. 32. Indirect evidence of Malaria• Platelet:↓ Day 1-2• Hb:↓ Day 1-2• Atypical Lymphocytes day 1-2• SGPT:↑• Bilirubin:↑• Band cells & Monocytes:↑• Polychromasia• Cholesterol:↓
  33. 33. Rash• Morbilliform• Macular• Papular• Nodular• Vesicular or bullous• Pustular• Plaques• Purpura, petechiae, ecchymosis• Erythematous
  34. 34. Measles
  35. 35. Mumps
  36. 36. Dengue
  37. 37. Dengue
  38. 38. Secondary Syphilis
  39. 39. Chickenpox-vesicles
  40. 40. Chickenpox -pustules
  41. 41. Herpes zoster ophthalmicus
  42. 42. Petechial and purpuric illnesses• Purpura fulminans• Viral hemorrhagic fevers• Thrombocytopenia• Vasculitis
  43. 43. ecchymosesSeverely ill patient withecchymoses and gangrene.Meningococcus, othersSpenectomized host
  44. 44. MeningococcemiaSeverely ill patient with papular purpuric rash, with or without meningitis
  45. 45. Eschar of scrub typhus
  46. 46. Erythema multiforme Drug Rash
  47. 47. Treatment• General • Specific• Antipyresis • Antibiotics• Hydration • Antimalarial• Nutrition • Vaccines• Antiemetics • Antibodies serun• Antacids • Steroids?• Reassurance• Prevent panic in epidemics• Family care
  48. 48. Dengue• Self limited• Symptomatic in majority cases• Close observation• IV fluids
  49. 49. DHF Grade 1-2 iv fluid
  50. 50. DHF Grade 3-4 iv fluid
  51. 51. Dengue-What not to do• Do not give Aspirin or Brufen for treatment of fever.• Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding.• Avoid giving blood transfusion unless indicated, reduction in haematocrit or severe bleeding.• Avoid giving steroids. They do not show any benefit.• Do not use antibiotics• Do not change the speed of fluid rapidly, i.e. avoid rapidly increasing or rapidly slowing the speed of fluids.• Insertion of nasogastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) is not recommended since it is hazardous
  52. 52. P.vivex-Chloroquin250mg
  53. 53. P.F.Malaria• Uncomplicated:treat• Complicated:Reference• Tratment:ACT(Artemisinin derivative combined with long acting antimalarial)(Amodiaquinine,Lumefantrine, Mafloquine,Sulfadixine-pyrimethamine)• Artemisinin alone? No• Pregnancy:ACT in 2nd & 3rd trimester,Quinine in 1st• Mixed Infection: treat like pf• Clinical Malaria: RDT,PS negative but strong clinical presentation• Vaccine
  54. 54. Complicated PF• If not detected early and treated ,in severe pF malaria,sevre meifestations can develop in 12-24 hr,and lead to death• Platelet factor responsible for immunity storm• P.Knowelsi : Thailand , in Monkey
  55. 55. Complicated PF Severe manifestations• Impaired conciousness/coma• Convulsions• Renal failure• Jaundice• Anaemia:rapid lowerin of Hb <5 g/dl• ARDS• Hypoglycemia• Metabolic Acidosis(clinical?)• Shock• DIC /bleeding• Haemoglobinuria• Hypothermia• Heavy parasitemia• Pregnancy
  56. 56. Enteric Fever
  57. 57. Pneumonia• Antibiotics:covering Gram positive and or negative/anaerobs/atypical oraganism• Analgesics• Cough suppresants• Mucolytics• Close observation
  58. 58. UTI• Antibiotics:• Quinolons• Aminoglycosides• Septran• Cephalosporins• C&S• USG
  59. 59. Tonsillitis,Pharyngitis,URTI• Antibiotics: gram positive
  60. 60. Brucelossis• Doxycycline,quinolons,SM,• 6 weeks
  61. 61. Flu• Symptomatic• Observe closely• Severe, refer
  62. 62. PRACTICAL PROBLEMS• DIFFERENTIAL DIAGNOSIS :any fever in endemic area demands for quick identification• QUICK DETECTION & TRETMENT : Late diagnosis &treatment & inadequate treatment in PF,LEPTO,Dengue,PNEUMONIA ,Enteric,Meningitis. Proves expensive and lethal• Variable presentation
  63. 63. Gram positive-negative• What is it• What and when to choose• Same group, differs, individually
  64. 64. Antibiotics case1• Oral quinolon,IV• 3rd cephalosporin• Cefaparozone+sulbactum+new quinolon• Anti viral• Carbapenum + quinolon• Aminoglycoside+carba+new quinolon• 8 in 48 hr
  65. 65. Antibiotics case 2• 80/male• Circumsion• Aminoglycoside single dose• ARF• Bleeding p/r• Hemicolectomy• Ventilated/VAP/recovered• Rebleed• ARDS• 3 weeks
  66. 66. DHF case 3• 45/m• Platelet :2000• Ascites,Pl.effusion• Iv Fluid• Platelet count low <15000 for 6 days
  67. 67. Thank You