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FEVER MANAGMENT , OVERVIEW , AND CAUSES.
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- 2. PATHOPHYSIOLOGY • Inflammation and/orinfection release of endogenous pyrogens → (cytokines) induced by exogenous pyrogens (e.g, proteins, lipopolysaccharides) cytokine-induced upward → displacement of the set point of the hypothalamic thermoregulatory center elevation in → body temperature immune system activity → ↑ and pathogen growth ↓
- 3. EMERGENCY EVALUATION Basic approach Identifyand treat sepsis, if present. Identify and treat the underlying cause. Provide supportive therapy (antipyretics, IV fluids, tepid sponging).
- 4. EMERGENC Y EVALUATIO N • Red flags •General • Fever lasting > 3 weeks • Temperature > 40°C (104°F) • Rash (especially petechial) • Anemia • Neutropenia • Jaundice • Lymphadenopathy (if generalized or persisting > 2 weeks)
- 5. EMERGENCY EVALUATION • Localized •CNS: neck stiffness, seizures, headache, altered level of consciousness, altered mental status • ENT: purulent ear discharge, mastoid pain • Chest: hemoptysis, hypoxemia • Abdomen: guarding, organomegaly, ascites, melena, hematochezia, persistent vomiting, voluminous diarrhea • Musculoskeletal: joint swelling, reduced range of motion
- 6. FOCUSED HISTORY History of presentillness Onset Duration Characteristics (e.g., continuous vs. intermittent or nocturnal, high grade vs. low grade)
- 7. FOCUSED HISTORY Recent exposures Travel Sick contacts Newmedication or substance Animals, including farm and wild animals Associated symptoms General Chills, rigors Night sweats Unintentional weight loss
- 8. FOCUSED DIAGNOSIS • Laboratory studies •Routine • CBC with differential • Blood glucose • BMP • LFTs • Coagulation studies (e.g., INR, PTT) • Urinalysis with microscopy
- 9. FOCUSED DIAGNOSI S • In patientswith suspected SIRS or sepsis • Blood gas analysis • Serum lactate • Procalcitonin assay • ESR/CRP • Blood cultures (at least 2 sets) • Additional cultures from other sites as indicated • Chest x-ray
- 10. Further diagnostic testingto consider based on suspected localization of symptoms
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- 15. TREATMENT • Antipyretics: indicatedin case of intolerable fever; do not prevent febrile seizures • Acetaminophen • NSAIDs • Ibuprofen • Aspirin • Antibiotics in case of suspected bacterial infection (e.g., pneumonia) • Acetaminophen is the preferred antipyretic during pregnancy but should be avoided in patients with severe hepatic dysfunction. • NSAIDs are contraindicated in pregnancy and hemorrhagic fevers. They should be used with caution in breastfeeding patients and those with CAD.
- 16. INHERITED FEVER SYNDROMES •Familial Mediterranean fever (FMF) • Description: A hereditary autoinflammatory disorder characterized by recurrent, self-limiting fever attacks, serositis, and often other inflamed tissue. Patients do not experience any symptoms between attacks. • Epidemiology: mostly limited to individuals of eastern Mediterranean descent ; most common inherited fever syndrome • Genetics: an autosomal-recessive mutation in the MEFV gene on chromosome 16 • Clinical presentation: can vary greatly • All patients experience fever attacks lasting 1–3 days that recur over weeks to months. • Most patients (95%) experience abdominal pain and arthralgia (75%). • Other manifestations • Chest pain (40%): due to pleuritis and sometimes pericarditis • Scrotal pain: due to inflammation of the tunica vaginalis • Myalgia • Erysipeloid • The disorder often goes undiagnosed in patients with mild to moderate symptoms. • Patients often have an appendectomy scar from a past episode of FMF that was mistaken for acute appendicitis.
- 17. INHERITED FEVER SYNDROMES • Complication: AAamyloidosis • Therapy: Prevention of acute episodes and progression to AA amyloidosis through inhibition of granulocyte function by colchicine. • Other hereditary fever syndromes • Hyper-IgD syndrome • TNFα reception-associated periodic syndrome
- 18. ACUTE MANAGEME NT CHECKLIST • Treat sepsis(if present). • Identify and treat the underlying cause. • Antipyretic therapy • Evaluate for hypovolemia and consider hydration (see intravenous fluid therapy). • Tepid sponging • Consider isolation precautions.
- 19. PATIENT PRESENTATIO N • A 22-year-oldmale presents to the Emergency Department (ED) with a complaint of continuous fever for one week. He reports associated symptoms including intermittent chills, night sweats, fatigue, and a mild headache. He denies any cough, shortness of breath, abdominal pain, urinary symptoms, or recent travel.
- 20. IMMEDIATE ACTIONS #) Triage andInitial Assessment 1.Vital Signs: • Temperature: Confirm presence of fever. • Heart Rate: Assess for tachycardia. • Respiratory Rate: Check for tachypnea. • Blood Pressure: Monitor for hypotension. • Oxygen Saturation: Ensure adequate oxygenation. 2.Patient Stability: Address Airway, Breathing, Circulation (ABCs). #) Initial Management: 3. IV Access: Establish intravenous access for fluids and medications. 4.IV Fluids: Administer IV fluids if there are signs of dehydration or hypotension. 5.Antipyretics: Administer acetaminophen or ibuprofen to reduce fever and alleviate discomfort.
- 21. DETAILED HISTORY • History ofPresent Illness: • Onset, duration, and pattern of fever. • Associated symptoms (chills, sweats, headache, fatigue). • Exacerbating and relieving factors. • Past Medical History: • Previous similar episodes. • Chronic illnesses (e.g., diabetes, hypertension). • Medications: • Current medications, including over-the-counter and herbal remedies. • Allergies: • Known drug allergies. • Social History: • Recent travel, exposure to sick contacts, substance use (alcohol, drugs). • Family History: • Hereditary conditions, recent family illnesses.
- 22. Physical Examination Assess forsigns of distress, lethargy, or dehydration. General Appearance: Inspect for pharyngitis, sinus tenderness, ear infection, and lymphadenopathy. HEENT: Auscultate for wheezes, crackles, or diminished breath sounds. Respiratory: Listen for murmurs, extra heart sounds, or signs of endocarditis. Cardiovascular: Palpate for tenderness, hepatosplenomegaly, or masses. Abdominal: Examine for rashes, petechiae, or other signs of systemic infection. Skin: Assess for altered mental status, neck stiffness (meningitis signs). Neurological:
- 23. Diagnostic Workup • Laboratory Tests: •CBC with Differential: Evaluate for leukocytosis or leukopenia, indicative of infection or inflammation. • Basic Metabolic Panel (BMP): Assess electrolytes, renal function. • Liver Function Tests (LFTs): Check for hepatic involvement. • Coagulation Studies (INR, PTT): Evaluate coagulation status. • Blood Cultures: Obtain at least 2 sets to identify bacteremia. • Urinalysis with Microscopy: Detect urinary tract infection. • Procalcitonin Assay: Marker for bacterial infection. • ESR/CRP: Inflammatory markers. • HIV Test: To rule out immunosuppression and potential opportunistic infections. • Imaging Studies: • Chest X-ray: Evaluate for pneumonia, lung abscess, or other thoracic abnormalities. • Abdominal Ultrasound/CT: If abdominal pain or hepatosplenomegaly is present. • Head CT/MRI: If neurological symptoms suggest central nervous system involvement. • Echocardiogram: If endocarditis is suspected.
- 24. Differential Diagnosis and Approach InfectiousCauses: • Bacterial Infection: Positive blood cultures, leukocytosis, elevated procalcitonin. • Viral Infection: Normal/slightly elevated WBC, specific viral serology or PCR. • Tuberculosis: Consider in presence of night sweats, weight loss, and contact with TB patients. • Malaria: Consider if travel history to endemic areas. Non-Infectious Causes: • Autoimmune/Inflammatory Diseases: Elevated ESR/CRP, specific autoantibodies (e.g., ANA for lupus). • Malignancy (e.g., Lymphoma, Leukemia): Unexplained weight loss, night sweats, persistent lymphadenopathy, abnormal CBC.
- 25. • Based onthe patient’s symptoms (fever, chills, night sweats, fatigue, mild headache), physical examination findings, and initial laboratory results, we suspect a viral infection such as infectious mononucleosis (considering the patient's age and typical presentation). #) Elimination of Other Diagnoses • Negative Blood Cultures: Rule out bacterial sepsis. • Normal Chest X-ray: Rule out pneumonia. • Normal Abdominal Ultrasound: Rule out intra-abdominal infections. • Negative Malaria Test: Rule out malaria if no travel history to endemic areas. • Normal Echocardiogram: Rule out endocarditis if not suspecting cardiac involvement. • Negative HIV Test: Rule out HIV-related infections.
- 26. MANAGEMENT AND STABILIZATION Symptomatic Treatment: Antipyretics: Continue acetaminophenor ibuprofen for fever management. Hydration: Encourage oral fluids or continue IV fluids if necessary. Antiviral Therapy: Not typically required for suspected viral infection like infectious mononucleosis. Patient Education: Advise rest, adequate hydration, and symptomatic care. Educate on the self- limiting nature of viral infections and when to seek further medical attention.
- 27. ADMISSION VS DISCHARGE #) Admission: • Patientis hemodynamically unstable. • Signs of sepsis or severe infection. • Significant abnormalities on initial investigations. #) Discharge with Follow-up: • Stable Vital Signs: Patient remains hemodynamically stable. • No Significant Abnormalities: Initial lab tests and imaging do not reveal serious pathology. • Outpatient Follow-up: Schedule a follow-up appointment with primary care or infectious disease specialist if symptoms persist or worsen.
Editor's Notes
- #8 Leukocytosis with neutrophilia suggests bacterial infection. Lymphocytic leukocytosis is more strongly associated with viral infections and certain bacterial infections, e.g., TB. A low white blood cell count or thrombocytopenia may be due to an infectious cause in patients with a history of recent travel. An increase in eosinophil count suggests drug-induced fever or parasitic infection………. Hyperglycemia or hypoglycemia in a nondiabetic patient should raise concern for sepsis or septic shock………… To evaluate renal function and electrolytes; also required to document baseline levels before initiating potentially nephrotoxic antibiotics, e.g., aminoglycosides………. To evaluate liver function and to document baseline levels to monitor possible drug toxicity…………… New-onset coagulopathy should raise concern for sepsis, DIC, and/or viral hemorrhagic fevers………. Pyuria with bacteriuria suggests a UTI……….
- #9 Blood gas analysis is indicated in severely ill patients or those with recurrent vomiting, acute abdominal/chest pain, or dyspnea to evaluate for acid-base and electrolyte abnormalities…………. Elevated lactate indicates organ hypoperfusion, which, in the setting of fever, may be due to sepsis or septic shock…………. Procalcitonin is a biomarker that can be helpful in identifying bacterial causes of LRTI and sepsis………… Nonspecific inflammatory markers that, if elevated, suggest an infectious or inflammatory process