2. FEVER
Definition :
Fever is an elevation of body
temperature above the normal
physiological variation as a result of the
change in the thermoregulatory center,
located in the hypothalamus
At oral site fever is defined as temp:-.
• Am >98.9 F
• Pm > 99.9 F
5. Site of measuring Tempreature
• Oral cavity-sub lingual
• Axilla
• Rectum .
• Tympanic Membrane based thermometer.
• Rectal temp is 1 .F higher then then Oral which is 1.F higher then Temp
recorded in Axilla
• Rectal temp mos accurate for core body temp.
6. VARIATION
Hypothermia = rectal temperature <35 °C (<95 °F).
Body temperature °F (oral site)
Normal
Febrile
98.6–99.9
>100
Mild/low grade fever 100.5–102.2
Moderate grade fever 102.2–104.0
High grade fever 104.1–106.0
Hyperpyrexia >106.0
7. VARIOUS RELATIONSHIPS
Every one degree rise of core body temp above 100.F – Pulse >10 , RR by
4
Fever increases o2 demand
• This law when not followed in respect of pulse, for some diseases , called
RELATIVE BRAYCARDIA (Faget sign), reported in typhoid fever, typhus,
leptospirosis, malaria etc.
9. Remittent Fever
• The temperature fluctuation exceeds 0.6°C (1°F), but without touching the
baseline eg:- Brucellosis , Typhoid fever , Infective Endocarditis .
10. Intermittent Fever
• The elevated temperature touches the
baseline in between
diurnal variation is extremely large 3-4 .F
associated with septicemia .
11. Relapsing Fevers
Febrile episodes are separated by normal temperature for more than one
day, various types described
a. Tertian fever---, e.g. Plasmodium vivax, ovale, falciparum.
b. Quartan fever -----, e.g. Plasmodium malariae.
c. Pel-Ebstein -----e.g. Hodgkins and other lymphomas.
d. Saddle back fever/Bi-Phasic fever:----e.g. Dengue fever.
ef)cyclic neutropenia ---- every 21 days
12.
13. Drug induced fever
• It begins 1–3 weeks after the start
• persists 2–3 days after withdrawal
• Rash, arthralgia, Hypotension
• Relative bradycardia
• CBC –Eosinophilia
• Any drug but most notorious are
Sulphonamide Procainamide Penicillins Propylthiouracil Iodides Methyldopa
Anti-TB drugs Anticonvulsants
14. Hyperpyrexia
• core body temperature, above 41°C (106°F)
• Medical emergency,
• Causes
• 1. Severe infection & septicemia
2 CNS haemorrages eg Pontine haemorrhage
• 3. Rheumatic fever
• 4. Meningococcal meningitis
• 5. Cerebral malaria.
• Treatment emergency: physical cooling
• later treat the cause
15. APPROACH TO THE PATIENT
Fever
• Documentation & Same site.
• Chronology with other symp? , Age , Duration, Events before fever ?
Exposure, immune status , underlying Renal or Liver conditions?
• LABORATORY TESTS
• The workup must include
CBC and PS
• Urine Analysis, naked eye and laboratory
• CXR
• C-reactive protein (CRP) level and the ESR
• Further -- case by case basis.
• Fever must be relived by anti-pyretics,as no evidence has been found that
its reduction hampers disease recovery in any way.
16. Nacked Eye Urine Examination
Turbid urine– sign of UTI and infection
Reddish/pink Urine – s/o Gross Hematurea ? renal./urethral
stones,? Cystitis / Ca bladder
Cola coloured Urine(dark/brown urine) –Choluria is a common
symptom of liver diseases, when serum bilirubin is higher than 1.5
mg/dL.
Black coloured – Black water fever , P. Falcifarum inf not
adequately treated ? Black water fever sudden and severe
intravascular haemolysis leading to haemoglobinaemia and
haemoglobinuria and clinically manifested by anaemia, passage of
dark urine and often oliguric renal failure
Black Water Urine
choluria
17. TPR RECORDS FROM WARDS FOR TEMP, PULSE CHARTING
• We keep on sos
19. Pyrexia /Fever of Unknown Origin
• FUO is defined as follows:
•
1. Fever ≥38.3°C (≥101°F) on at least two occasions
•
2. Illness duration of ≥3 weeks
•
3. No known immunocompromised state
•
4. Diagnosis that remains uncertain after a thorough history-taking,
physical examination, and the following obligatory investigations
20. Obligatory Investigations for workup
• HIV serology , CBC with PS, ESR, CRP, electrolytes, creatinine, total
protein, alkaline phosphatase(ALP), alanine aminotransferase(ALT/SGPT),
aspartate aminotransferase(AST/SGOT), lactate dehydrogenase, creatine
kinase,
ferritin, antinuclear antibodies, and rheumatoid factor; protein
electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest
x-ray; abdominal ultrasonography; and tuberculin skin test (TST) or
interferon γ release assay (IGRA
• For Indian scenarios , three blood smears for malarial parasites,
urine microscopy, typhi dot also recommended
•
21. Differential diagnosis of PUO
• DIFFERENTIAL DIAGNOSIS
•
The differential diagnosis for FUO is extensive. It is important
to remember that FUO is far more often caused by an atypical
presentation of a rather common disease than by a very rare disease.
22. DIAGNOSTIC APPROCH AND INITIAL
WORKUP
•
Fever Documentation
• ‘Detailed History and Physical Examination
•
24. • If the patient is not in multi-organ system failure,
previous antibiotics/drugs should be stopped, the patient
observed for at least 72 hours, at which point multiple blood
(and fluid, if indicated) cultures should be taken.
• A second tier of
investigations, depending on the constellation of symptoms like CSF
Examination, bone
marrow aspiration with a biopsy and routine, mycobacterial and
fungal cultures and specific radiological investigations like CT, MRI is
undertaken
• PUO if further categorized as :- 1)Classic 2)Nocosomial and with
Neutropenia
25. Classical PUO
• The three major
categories
include
infections,
neoplasms and
non-infectious
inflammatory
diseases
(collagen
vascular
diseases and
sarcoidosis).
Other
minor category
include drug
fever.
26. • In a large series of classic FUO from
Eastern India, infections were the most dominant cause seen in
53% (half of these were tuberculosis), neoplasms in 17% and
collagen vascular diseases in 11%.
27. Infectious Causes
The most common infectious causes of FUO include the following:
• Tuberculosis (TB)
• Subacute bacterial endocarditis (SBE), Discitis
• Enteric (typhoid) fever, Malaria, Extrapulmonary TB
• Less-common infectious causes of FUO include the following:
• HIV infection
Abdominopelvic abscesses
Epstein-Barr virus (EBV) infection
Cytomegalovirus (CMV) infection
Toxoplasmosis
28. Non-infective causes of pyrexia of unknown origin
• common noninfectious inflammatory causes of FUO include the following:
•
Giant cell (temporal) arteritis
Systemic lupus erythematosus (SLE)
Periarteritis nodosa/microscopic polyangiitis (PAN/MPA)
Rheumatoid arthritis (RA)
•
Antiphospholipid syndrome (APS)
Gout
Pseudogout
Behçet disease
Sarcoidosis
Felty syndrome
Takayasu arteritis
29. • Malignant and Neoplastic Causes of FUO
•
Malignant and neoplastic causes of FUO are as follows:
•
Most common: Lymphoma, renal cell carcinoma
•
Less common: Myeloproliferative disorder, acute myelogenous leukemia
Multiple myeloma, breast/liver/pancreatic/colon cancer, atrial myxoma, metastases to
brain/liver
30. Nosocomial PUO
• In Nosocomial origin fever when uncertain diagnosis despite 1 week of
inpatient evaluation.
• About 50% of nosocomial
fever is due to infections. Non-infectious causes include drug fever,
deep venous thrombosis, cholecystitis, pancreatitis and
pulmonary embolism .
32. HIV associated FUO
• In India, tuberculosis
accounts for about 70% of cases of prolonged fever, followed
by disseminated cryptococcosis (10%), Pneumocystis jiroveci
pneumonia (7%), community acquired pneumonia (2%) and
liver abscess (2%).
• In the initial 6 months after the start of ART,
immune reconstitution inflammatory syndrome (IRIS), drug
fever are common whereas after 6 months, causes
of prolonged fever include various forms of tuberculosis,
neoplasms and non-infectious inflammatory diseases similar
to a classic FUO.
34. Miscellaneous Causes of FUO
•
Most common: Cirrhosis (due to portal endotoxins), drug fever
•
Less common: Thyroiditis, Crohn disease
•
Least common: Pulmonary emboli, hypothalamic syndrome, familial periodic fever
syndromes, cyclic neutropenia,
factitious fever (especially in those experienced with the healthcare field)
35. • World Wide - Increasing early use
of positron emission tomography–
computed tomography (PET-CT)
and the development of new
molecular and serological tests for
infection have improved diagnostic
capability, but up to 50% of patients
still have no cause found despite
adequate investigations.
Reassuringly, the cohort of
undiagnosed patients has a good
prognosis.
36. Neutropenic Fever
• Causes of Neutropenia are divided as
• Decreased production – These conditions are either a) Drug Induced
b)Infections and others .
• At least 50% of
neutropaenic patients who become febrile have an established
or occult infection
37. • Drug fever with the drugs may be presented with neutropenia like, drug
induced fever with Alkylating agents , Antimetabolites eg MTX , Non
Cytotoxic agents like antibiotics Chloroquin , Penicilline , Sulphonamides ,
anticonvulsant like carbamazepine , antipsycotics like clozapine , and
many others .
• some infections like Tuberculosis , Typhoid fever, Brucellosis , Tularemia ,
Measels , Infectious Mononucleosis , Malaria , Viral Hepatitis,
Leishmaniasis and AIDS may present with neutropenic puicture.
• Conditions with Increase peripheral pooling may present with Transient
Neutropenuia e.g. Overwhelming Bacterial Infections
• Conditions with inc destructions like Autoimmune Disorders ,
Rheumatoid arthritis , Lupus erythrematosis , Feltys syndrome may also
present eith febrile illness with neutropenia
40. Fever and Rash
• Fever with rash is a common presentation of many infectious and non
infectious diseases that range from benign to life threatening.
44. CENTRALLY DISTRIBUTED
MACULOPAPULAR
ERUPTIONS
• Diseases with fever and rash may be classified by type of eruption:
centrally distributed maculopapular & peripheral
• Centrally distributed rashes, in which lesions are primarily truncal,
are the most common type of eruption.
45. Measels
• The rash of rubeola (measles)
starts at the hairline 4th days into the
illness and moves down the
body, typically sparing the palms and
soles . MaculoPapular Rash
Causative agent is Measels Virus or
ParaMyxoVirus
• Mgt- Symptomatic & supportive
• Complication– Associated Pneumonia,
encephlitis and Subacute sclerosing
panencephalitis (late n rare)
46. Rubella German Measels
• Causative Agent- Rubella Virus
• Ip- 18 days
• Pink maculopapular , develops on forehead spread
to extremities , fades by third day . Forchheimer
sign small red papule on area of soft palate in 20%
of cases
• Mgt- supportive and symptomatic
47.
48. Epidemic typhus
• Epidemic typhus is due
to Rickettsia prowazekii spread
by body lice,
• no vaccine is commercially
available
• Treatment – Tab Doxy 100 mg Bd
x 14 days
51. Dengue
Fever
• Diffuse flushing
• Maculopapular rash
begins on trunk and
spread to extremities
and face , petechial
on extremities ,
pruritic during
recovery
• t/t- Supportive with
Carefull attention to
fluid management
53. Typhoid
Fever
Rose spots on chest and
abdomen on 1st week ,
small pale red macule
blanchable . Last 2-3
days
54. Bacterial
endocarditis
• Rash – Janeway
lesions – Painless
erythematous macules
usually on palms or
soles
• Osler Nodes –
Tender pink nodules on
finger or toe pads
• Petechial rash on
skin mucosa
• Splinter hemorrhage
on Nails
55. Chikungunya
fever
• Vector – Aedes aegypti ,
Aedes albopictus .
• IP- 2-4 days
• Rash Transient between 1-
4 days , Maculopapular
mostly on face , trunk ,
extremities
56. Erythema
marginatum
(Rheumatic
fever )
• Cause– Gp A
streptococcous , in patient
with Rheumatic fever
• Rash- Erythematous
annular papule and plaque
over trunk and proximal
extremities . Evolving and
resolving within hours.
(evanescent rash )
64. Herpes Zoster
• Herpes zoster is viral infection that occurs
with reactivation of the varicella-
zoster virus. It is usually a painful but self-
limited dermatomal vasicular rash
• Reactivation of varicella-zoster virus (VZV)
that has remained dormant within dorsal
root ganglia
65.
66.
67. Drug Indused
Rash
• Mild , mostly disappear with 2-3 days
and rarely upto 14 days , when
offending drug is withdrawn
• In CBC – Eosinophilia may be present
• Macular eruptions ,a/w itching ,
arthralgia , mild fever
• Some drugs are more notorious :
68.
69.
70.
71. SJS is defined as skin involvement of < 10%, TEN is defined as skin
involvement of > 30%, and SJS/TEN overlap as 10-30% skin
involvement.
72. Ebola
• Hemorragic Viral fever
• Virus appeared in South sudan
Ebola is a nonspecific maculopapular rash that appears
between day four and six of disease. ,
• Dark-red pinpoint papules arise on the face, arms, legs,
buttocks, and around the hair roots with subsequent
spread to the rest of the body.
• Ebola treatment is largely supportive and symptoimatic,
VACCINE is available
73. Waterhouse-Friderichsen syndrome
• meningococcal septicemia but may
complicate sepsis caused by other
organisms
• Waterhouse-Friderichsen
syndrome is characterized by the
abrupt onset of fever, petechiae,
arthralgia, weakness, and
myalgias,
• Acute adrenal insufficiency due to
adrenal gland hemorrhage
74. CLINICAL SCENARIOS
• A RECENTLY DIAGNOSED PLHA BY
ROUTINE INCIDENTAL EXAMINATION
,AFEBRILE ERLIER HAS BEEN
STARTED ART , AFTER `12 DAYS HE
PRESENTEED AGAIN WITH C/O
INTERMITTENT FEVER , ALL
DIAGNOISTIC TEST HAS FOUND TO
BE NEGATIVE . WHAT IS MOST
PROBABLE CAUSE OF FEVER ?
• OPTION ?????
• ??1) IMMUNE RECONSTITUTION
SYNDEOME
• ??2) DRUG FEVER
•
75. • ANS- DRUG FEVER, DUE TO ONE OF ART COMPONENT IS ,MOST
LIKEKY AS IT APPERED BEFORE < 6 WEEK OF STARTING OF ART
AND ALL DIAGNOSTIC TESTS WERE NEGATIVE
76. Clinical scenario 2
• A 60ye old female with a H/o CAD and on regular medications ,
presented with she h/o mild intermittent fever since 15 days Gross
ascites, on ascitic fluid exam cell count 384/Cum, 92% lymphocytes
and 8% PMN were found , further ESR was 42 mm in 1 hr. SAAG
ratio of ascitic fluid was 1 . On P/e JVP was not raised chest was
clear. BP was 100/60 and pulse 80/min . s.Amlyase was normal and
s.create was 0.7, her Mantoux was negative , what is most
probable cause of her recently developed ascitis>?
• Option 1 CHF
• 2 abdominal Koch
• 3 CRF
77. • Ans- Here SAAG Ratio 1 indiacate
infective causes , in that
mononuclear cells being 90 %
with abundant cellularity and 42
esr indicate toward chronic
indolent infection , all most
consistence with Abdominal Koch
• Q2 – For confirmation what further
workup as tier 3 investigation
should be done ?
78. • Ans – USG W/A and CECT Abdomen for evidence of
enlargement of Mesenteric nodes is most likely step
forward .
79. Take home message
• Fever is commonly encountered in OPD and IPD patients ,
• Red flag sign which should alert clinician
• Fever with Hypotension , Visual disturbences, Severe Headache, Neck
rigidity, H/o Significant weight loss, Aneamia , Cr. Jaundice , Anuira/Oligurea,
Toxic look, S/o Multi-Organ Involvement , Unintentional weight loss, seizures,
dark coloured urine , h/o drenching night sweats , new cardiac murmer,
splinter hemorrhage
• Fever with Hemoptysis or ahematoemesis
• These are associated with disease with severe outcomes and should not be
taken casualy
