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Description of Acute Febrile Illness

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  • Normal Body Temperature - 36.2 – 37.2 Acute Febrile illness – Fever >38.50C Hyperpyrexia - >41.590 % of patients with Acute Febrile Illness have complete recovery within a week. Only 10% develop complications .These complications like myocarditis, bronchopneumonia and meningoencephalitis can result in sudden unexpected death.Detailed and thorough history is important Alcoholic liver disease,, diabetes, malignancy, and chemotherapy, Splenectomy, IV drug use, HIV infectionRecent URTI, prior trauma; disruption of cutaneous barriers due to lacerations, burns, surgery, or decubitus ulcers; The presence of foreign bodies like nasal packs, barrier contraceptives, AV fistulas, or prosthetic jointsTravel, contact with pets or other animals, or tick exposure, recent dietary intake, medication use, Social or occupational contact with ill individuals, recent sexual contactsMeticulous Clinical Examination is mandatory. Keep all the instruments at hand
  • A simple viral fever is characterized by high grade fever. Chills are unusual except in UTI, Pneumonia, filariasis and malariaHead ache is usually presents but corelates with the increase in body temperature; if out of proportion it needs attentionGeneralized aches and pains are common; but muscle tenderness and joint pains are unusual in common viral feversRunning nose, sneezing and nasal block are characteristic of Influenza. Adeno & Respiratory Syncitial viruses may also occurCough is usually dry irritant cough with minimal amounts of mucoid sputum which is white in color
  • The pulse is carefully examined for at least 30 seconds for any tachycardia or irregularities. Assess the volume of pulse and if found to be low record BPMeasurement of blood pressure is important in early detection of any hypotension or shock as would occur in septicemia or myocarditis.The normal respiratory rate is 14-16/minute. If it is increased to more than thirty per minute decreased oxygenation as in bronchopneumonia or ARDS suspectedThe temperature should be recorded at least once and correlation with pulse determined. For every degree rise in Celsius temperature pulse increase by18The neurologic examination must include a careful assessment of mental status for signs of early encephalopathy. Evidence of nuchal rigidity or focal neurologic findings should be sought.
  • Now to proceed with the systemic examination, the upper respiratory tract should be examined for any enlargement of tonsils or congestion of pharynx.The heart should be briefly auscultated or any tachycardia, gallop rhythms or murmurs, which are either pre-existing or new in onset as in endocarditisThe respiratory system is examined for any evidence of bronchial breathing or crepitations and added sounds like rhonchi and wheezeThe abdomen should be palpated for any hepatic , splenic or renal enlargement and any evidence of free fluid in the abdomenThe neurological examination should be for any alteration in sensorium, neck rigidity , kerning sign or other signs of encephalopathy
  • The fever is irregular at first (that of falciparum malaria may never become regular). Although headache may be severe in malaria, there is no neck stiffness or photophobia resembling that in meningitis. While myalgia may be prominent, it is not usually as severe as in dengue fever, and the muscles are not tender as in leptospirosis or typhusSplenic enlargement is very common among otherwise-healthy individuals in malaria-endemic areas and reflects repeated infections; however, in nonimmune individuals with malaria, the spleen takes several days to become palpableWhen a patient in or from a malarious area presents with fever, thick and thin blood smears should be prepared and examined immediately to confirm the diagnosis and identify the species of infecting parasite.Repeat blood smears should be performed at least every 12 to 24 h for 2 days if the first smears are negative. Alternatively, a rapid antigen detection card or stick test should be performed.chloroquine remains the treatment of choice for the "benign" human malarias (P. vivax, P. ovale, P. malariae). Artesunate has broader stage specificity and more rapid than other drugs; no action on liver stages; kills all but fully mature gametocytes of P. falciparum
  • A single Widal test inan unvaccinated individual showing elevated O and H titers isstrongly suggestive of typhoid fever if the person comes froma non-endemic area or is a child less than 10 yr of age in anendemic area. Because of the high prevalence of antibody amongsthealthy individuals over 10 yr of age in endemic areas, a singleWidal test offers virtually no diagnostic assistance in adolescentsand adults.
  • Acute arthritis is the most frequent early clinical manifestation of MSU gout. Usually, only one joint is affected initially, but polyarticular acute gout is also seen in male hypertensive patients with ethanol abuse as well as in postmenopausal women. Attempts to normalize serum uric acid to <300 µmol/L (5.0 mg/dL) to prevent recurrent gouty attacks and eliminate tophaceous deposits entail a commitment to long-term hypouricemic regimens and medications that generally are required for lifeAllopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It can be given in a single morning dose, 300 mg initially and increasing up to 800 mg if needed.
  • Fever

    1. 1. Acute Febrile Illness<br />Dr. S. Aswini Kumar. MD<br />Professor of Medicine<br />Medical College Hospital<br />Thiruvananthapuram<br />
    2. 2. Acute febrile illness should be approached with consideration and caution:<br />Definition:<br />Temperature &gt;38.5OC<br />For &gt;2 consecutive days<br />Life threatening in 1% as a result of complications <br />Clinical Examination +<br />Routine, Screening<br />And Special tests<br />Complete recovery<br />is the rule in &gt;99% of these patients<br />Detailed history with occupation and contact required<br />2<br />
    3. 3. Viral Fever can be suspected from following history:<br />Generalized aches and pains without real arthralgiaor arthritis<br />High grade continuous or remittent fever without chills<br />Dry cough with<br />Minimal white<br />mucoid sputum<br />Nonspecific headache which corresponds with increase in temperature<br />Running nose, sneezing & nasal block characteristic of influenza<br />3<br />
    4. 4. One must check for the vital signs carefully in every patient:<br />Check the pulse rate for tachycardia or relative bradycardia<br />Respiratory rate for any tachypnoea as in bronchopneumonia <br />Check sensorium to exclude <br />Encephalitis, NMS or<br />Cerebral malaria<br />Record blood pressure for evidence of hypotension or shock suggesting sepsis<br />Record the Temperature and verify in accordance with the pulse rate<br />4<br />
    5. 5. Now to proceed with a systematic examination for:<br />Look for evidence of pharyngitis or tonsillitis throat ulcers or abscesses<br />Auscultate the lung fields for any bronchial breathing/crepitations<br />Look for meningeal signs<br />focal deficits, increased ICT and plantar reflex<br />Palpate the abdomen for hepatosplenomegaly or any renal mass<br />Auscultate the heart for any tachycardia, murmur or gallop<br />5<br />
    6. 6. Routine tests to exclude other causes of fever are:<br />Urine examination under the microscope for any Urinary Deposits<br />Peripheral Smear for any atypical lymphocytes, abnormal cells or parasites<br />Chest X-Ray PA<br />For any Homogenous or <br />Non-homogenous shadows<br />Blood TC DC ESR for any leucocytosis, lymphocytosis,<br />neutropeniaor high ESR<br />Platelet Count for any thrombocytopenia or thrombocytosis<br />6<br />
    7. 7. General measures to be taken in uncomplicated Viral Fever:<br />Plenty of fluids boiled and cooled, tender coconut or kanji water<br />Complete bed rest is advised in every patient till the fever subsides<br />Hospitalization?<br />very sick patient,<br />any complications<br />Antipyretic drugs – acetaminophen, mefenemic acid<br />Easily digestible diet<br />kanji or oats or even plain rice and vegetables<br />7<br />
    8. 8. If the temperature is more than 400C, it should be managed by:<br />Tepidsponging of whole body with luke warm water but not tap/well/ice water<br />Drinking plenty of water is mandatory to ensure good urine output<br />Small breeze of air,<br />cold compresses or<br />Internal cooling<br />Good ventilation to the room should be provided<br />Only if there is chills consider covering with a blanket<br />8<br />
    9. 9. Antibiotic therapy is indicated only in certain circumstances:<br />Secondary Infection of upper respiratory tract like pharyngitis<br />Diabetics and patients on chemotherapy or radiation<br />Old Patient with <br />immobility, incontinence<br />institutionalization<br />Community acquired or hospital acquired bacterial pneumonia<br />HIV other types of immuno-compromized patients <br />9<br />
    10. 10. Life threatening complications may occur in viral fever:<br />Viral Myocarditisif tachycardia or hypotension<br />Viral Meningoencephalitis if alteratedsensorium<br />Thrombocytopenia<br />&lt;40,000 + bleeding<br />&lt;20,000 – bleeding<br />Viral Gastroenteritis if profuse watery diarrhea<br />Viral Bronchopneumonia if tachypnoea or rales<br />10<br />
    11. 11. Weil’s disease is likely to occur in the following circumstances: <br />Exposure to rat’s urine via abraded lower limbs<br />Sewer Work or working in a paddy field<br />Flooded water<br />contaminated with <br />drainage water -<br />Anybody can get it<br />Swimming in ponds or even a swimming pool or rafting<br />Contamination of drinking water with rat’s urine<br />11<br />
    12. 12. Diagnosis of Weil’s Disease can be suspected if there is:<br />Mild to moderate Jaundice which is rapidly progressing<br />Rapid decline in quantity of urine or not passing urine<br />Hepato-renal <br />Involvement -<br />often requiring <br />dialysis<br />SubconjunctivalHemmorrahge is classical<br />Sever muscle pain and Muscle tenderness up on pressure<br />12<br />
    13. 13. Investigations to arrive at a diagnosis of Weil’s disease are:<br />Urine examination shows protinuria and RBC casts<br />Mild to moderate thrombocytopenia is common<br />Weil’s Antibody?<br />IgM or<br />Rapid ELISA<br />PCR in 1st week<br />Blood routine will shows PMN leucocytosis<br />Abnormal renal function – high blood urea and creatinine<br />13<br />
    14. 14. Important complications of Weil’s disease are:<br />Acute onset Hemorrhagic Pneumonia<br />Acute Renal Failure develops rapidly over 1-2 days<br />Bilateral Iridocyclitis<br />- a non-fatal <br />complication, which <br />may lead to blindness<br />Aseptic Meningitis is common but usually non-fatal<br />Weil’s Myocarditis with tachycardia and hypotension<br />14<br />
    15. 15. Fatal outcome of these complications of Weil’s disease are:<br />Acute Respiratory Distress Syndrome with dyspnea<br />Progressive azotemiaresulting from acute renal shut down<br />Internal bleeding -<br />Transfusion of <br />fresh blood or <br />packed cells<br />Cerebral edema is another fatal complication<br />Arrhythmia cardiogenic shock and acute heart failure<br />15<br />
    16. 16. Crystalline penicillin is the drug of choice in Weil’s disease because:<br />Weil’s disease<br />No drug resistance so far to penicillin in Weil’s disease<br />It is a leptospiraldisease due to L. Icterohemorrhagiae<br />Earlier the trt the better<br />Or Erythromycin<br />Or Amoxycillin<br />Doxycyclin<br />Practically no side effects including anapylaxis seen<br />The organism is universally sensitive to penicillin<br />16<br />
    17. 17. Infective hepatitis as differential diagnosis of Weil’s Disease<br />Loss of appetite especially to fried foods<br />Gradually progressive jaundice over one or two weeks<br />Viral markers<br />HAV<br />HBV<br />HCV<br />Aversion to cigarettes in smokers as a surprise<br />High SGPT levels when compared to SGOT levels<br />17<br />
    18. 18. Septicemia is the other possibility in acute febrile illness with jaundice:<br />Source of sepsis can be very subtle like the IV cannula<br />Evidence of Septic shock - hypotension and cold extremities<br />Severe Sepsis -<br />Dysfunction of <br />organs distant from<br />Site of infection<br />Multi-organ dysfunction – kidney heart and lungs<br />Signs of inflammation – redness, swelling and tenderness <br />18<br />
    19. 19. Management of Sepsis has following essential components:<br />Sequence of events<br />SIRS, Sepsis and severe sepsis<br />Antibiotic Cocktail covering gram +ve, -ve and anaerobic<br />Drotrecogin Alfa<br />Activated Protein C<br />24 µg/kg per hour<br />IV infusion<br />Admission to the medical intensive care mandatory<br />In best of centers the Mortality rate is 5-15%<br />19<br />
    20. 20. Dengue fever can be suspected from the following symptoms:<br />High grade fever lasting for more than 2 days in duration<br />Retro-orbital pain - Pain behind the eyes is considered diagnostic<br />Epidemic in the community -<br />seasonal febrile<br />emergency<br />Severe bone and joint pains of upper and lower limbs<br />Mosquito bite especially during morning hours<br />20<br />
    21. 21. Dengue Hemorrhagic fever is identified by the detection of:<br />Classical dengue fever history some times a biphasic illness<br />Bleeding tendencies- purpura, petechiae, echymosis<br />Increased Capillary <br />Permeability <br />resulting in Polyserositis<br />Positive tourniquet test – simple done any where<br />Thrombocytopenia Platelet count &lt;1,00,000<br />21<br />
    22. 22. Steps in Tourniquet test for diagnosing Dengue fever are:<br />Wait for 5 minutes keeping the blood pressure elevated<br />A BP apparatus is used for this purpose which is tied around the upper arm<br />More than20 Petechiae highly suggestive of but how ever not <br />diagnostic of Dengue<br />Mercury column is elevated to between systole diastole<br />Count the number of petechiae one inch square marked<br />22<br />
    23. 23. 2nd infection with another serotype is dangerous because:<br />The dengue Virus has 4 Serotypes, which do not have cross resistance<br />Homologous Antibodies are formed against the dengue I viruses and neutralizes them<br />Dengue 2 virus-HAB complexes enter monocytes and replicate rapidly<br />Hetrologous Antibodies against Dengue I remain and form non-neuralizing complexes<br />Transmission is by AedesEgypti mosquito which feed the virus and injects it <br />23<br />
    24. 24. Diagnosis of Chikungunya Fever can be considered if:<br />Severe and prolonged functional disability lasting for months or even years<br />Severe arthralgia involving the peripheral small and large joints symmetrically <br />IgM levels are elevated; Virus isolation facilities are not available<br />Desquamating rash all over the trunk and limbs but sparing the palms and soles<br />Elevated SGOT and CRP levels are suggestive<br />24<br />
    25. 25. Treatment of Chikungunya Fever consists of the following:<br />Anti-inflammatory agent to combat the arthritis<br />No specific treatment is available for Chikungunya<br />Chloroquine /HCQS/Salazopyrine found to be useful<br />Or if necessary Steroids<br />There is no vaccine currently available for chikungunya<br />Aspirin, ibuprofen, naproxen and other NSAIDs<br />25<br />
    26. 26. The Novel H1N1 Influenza virus infection in 2009:<br />No longer called as Swine flu as swine is not involved<br />Virus were detected in April 2009 in San Diego, US<br />The novel virus has a structure of Hemagglutinin 1 and neuraminidase 1<br />This created a new pandemic as well as a panic<br />26<br />The human and swine strain of Influenza is mixed in the swine<br />
    27. 27. Diagnosis of H1N1 Fever can be considered if patient is having:<br />The government started screening travellers in the airports<br />The symptoms are the same as that of any severe flu<br />The confirmation of diagnosis was done by R- PCR technique in Rajeev Gandhi Institute<br />It rapidly spread in the community as there was no resistance<br />Throat swabs were taken and sent to specified labs<br />27<br />
    28. 28. Treatment of of H1N1 Fever can be very simple in uncomplicated:<br />Artificial ventilator support needed in selected case<br />The patient should rest at home isolated from others<br />New vaccines have been produced but not currently available in India<br />Shall be admitted to an intensive isolation facility if breathless<br />Tamiflu should be started in all category B patients<br />28<br />
    29. 29. Prevention of H1N1 Influenza Fever is considered more important<br />Wearing a mask effectively prevents transmission<br />Washing hands every time after seeing a patient<br />If you develop fever to stay at home till all the fever and symptoms have subsided<br />Or ideally alcohol based hand washes should be used<br />Patients also should be taught the same principles<br />29<br />
    30. 30. Lobar Pneumonia is recognized by the symptom triad and CXR<br />High grade remittent fever, cough productive of sputum<br />Laterally placed catching type of pleuritic pain<br />Clarithromycin<br />Or Azithromycin<br />Or Levofloxacin<br />Rusty Sputum or mild degree of frank hemoptysis<br />Characteristic Air Bronchogram inside homogenous opacity<br />30<br />
    31. 31. Acute Malaria is possible if patient has travelled outside Kerala:<br />Intermittent high grade fever with chills and rigor<br />Peripheral smear –parasites with blue cytoplasm, red nucleus<br />Artesunate<br />50mg 4 TAB ODX3D<br /> +Metakelfen<br />3TAB Day 1<br />Rapid Malaria test – Highly sensitive and specific test<br />Anemia jaundice and Moderate splenomegaly<br />31<br />
    32. 32. Acute Meningitis as a cause for Acute Febrile Illness:<br />Bacterial or Viral origin can not be distinguished clinically<br />Signs of meningitis – neck stiffness, Kerning’s, Brudzinski<br />Meningitic Dose<br />Ceftriaxone<br />2gm IV BID<br />10-14 days <br />Classical triad of symptoms of Meningitis<br />Lumbar Puncture is done under asceptic caution after CT<br />32<br />
    33. 33. Diagnosis of Enteric Fever can be suspected from following:<br />Step ladder fever manifest if the initial fever pattern is not altered by antibiotics<br />Splenomegaly is usually mild to moderate along with mild hepatomegaly<br />Blood/ Clot Culture<br />for Salmonella Typhi if <br /> +ve is Proof of diagnosis<br />Abdominal pain, diarrhoea vomiting and malena are characteristic of enteric<br />Single positive Widal Test is not diagnostic of enteric in endemic areas<br />33<br />
    34. 34. Urinary Tract Infection is managed in the following lines:<br />Urinary Deposits will show pus cells and bacteria along with presence of albumin<br />Ciprofloxacin started and after C & S results changed to Sensitive Antibiotics<br />Urinary Alkalinization<br />Potassium citrate<br />2 tbs twice daily<br />Urine Culture and sensitivity test should be done with mid-stream specimen <br />Patients should be motivated to drink several liters of water every day<br />34<br />
    35. 35. Diagnosis of Brucellosis can be suspected from following:<br />Cervical lymphadenopathy & hepatosplenomegaly is highly suggestive <br />Contact with Animals like in farming or handling animal meat<br />Brucella Antibody <br />Test<br />Streptomycin + Tetracycline<br />In areas endemic for TB<br />Other wise Rifampicin<br />Drinking unpasteurized or raw milk gives a definite risk of developing Brucellosis<br />Brucella Antibody Test is diagnostic otherwise demonstration in FNAC<br />35<br />
    36. 36. Focal infections require appropriate radiological investigations:<br />Trans Thoracic Echo or better still TEE is helpful in detecting BE vegetations<br />CXR is indicated in cases like suspected lung abscess bronchopneumonia<br />MRI and MR Spectroscopy<br />Can detect even small sized Brain Abscess & tuberculoma<br />Ultrasound Scan is very useful in detecting, liver and splenic abscess or PID<br />CT of abdomen is better for demonstrating retroperitoneal abscess<br />36<br />
    37. 37. Neuroleptic Malignant Syndrome occurs with intake of several drugs:<br />Any drug which acts at the level of The Central Dopaminergic System<br />Hyperpyrexia is associated with severe extra-pyramidal lead pipe rigidity<br />Bromocryptine<br />2.5mg orally BD<br />Titrated up to 45mg/D<br />There can be several autonomic symptoms like dry skin and dilated pupils<br />These are mainly the Antipsychotic drugs belonging to neuroleptics<br />37<br />
    38. 38. Miscellaneous conditions presenting as Acute Febrile Illness:<br />Scrub Typhus, a tick borne Acute Ricketsial Infection is suggested by an Eschar<br />Temporal Arteritis and other collagen diseases like SLE can also present acutely<br />Pontine Hemorrhage<br />Malignant Hyperthermia<br />Heat Stroke, Thyroid storm<br />Skin Infections like cellulitis, abscess and Varicella infections can cause AFI<br />Acute Gout, septic arthritis and Acute Rheumatic fever DD of Acute Febrile Illness<br />38<br />
    39. 39. Summary:<br />A patient with acute febrile illness should be always received with consideration and caution<br />90% of these patients will have an uneventful course, with complete resolution of fever<br />The ability of the physician is in identifying those with potentially fatal complications<br />These patients must be admitted to intensive care immediately and well cared for<br />Serial physical examinations and investigations are sometimes more important<br />Unexpected lab results must be cross checked and repeated when necessary<br />Diagnosis should not be postulated too early in the course of the disease<br />Empirical Antibiotic therapy is not to be withheld in life threatening situations<br />39<br />
    40. 40. Thank You <br />For The <br />Patient Listening<br />40<br />