1st lecture to learn in pediatric and adult fever

1. Short febrile illness
BY:
Dr, WALAA SALAH MANAA
Consultant of pediatric infectious disease
‫الشـيخ‬ ‫كـفر‬ ‫حمـيات‬ ‫مـستشفى‬

2. ‫وسلم‬‫عليه‬‫هللا‬‫صلى‬‫قال‬
:
(
‫بالماء‬‫بردوها‬‫فا‬‫جهنم‬ ‫فيح‬‫من‬‫الحمى‬‫إن‬
)
‫ي‬‫البخار‬ ‫اه‬‫و‬‫ر‬
‫رجل‬‫فسبها‬‫الحمى‬‫ذكرت‬‫عندما‬‫وقوله‬
:
(
‫الحدي‬‫خبث‬‫النار‬ ‫تنقى‬‫كما‬ ‫الذنوب‬‫تنقى‬‫فإنها‬‫تسبها‬‫ال‬
‫د‬
)
‫مسلم‬‫اه‬‫و‬‫ر‬

3. Controlled Inc. of body temp. above normal
Fever

4. Normal temperature
( N….rectal : 36.5-37.8).
( N……..oral : less 0.5).
( AM …..... : > 37.2).
( PM …………. : > 37.7).

5.  IF fever is transient esp.
in children & temp.
decrease to normal with in
1 hr. without antipyretics
or cold fomentations.
=this case is consider
( afebrile)

6. Measuring ! temp. is
mandatory
,,,,,,,,,,why?
1-some pt. may c/p of
joint pain, headache
without saying fever.
2-fever may not be felt
by tactile palpation.

7. Degree
 Mild….rectal….37.8-38.4c.
 Mod…rectal….38.5-39.5 c.
 High…rectal….39.5- 41 c.
 Hyperpyrexia…> 41 c.

8. Hyperthermia
 It is an elevation of body temp. dt ext.
heating :
1)heat stroke (S.S).
2)high incubator temp.
SO Hyperthermia is not a true fever.
because the elevation of body
temp. is against its desire.
 Fever pt. feels cold ± cold extremities.
 Hyperthermia pt. feels hot + hot
extremities.

9. Hypothermia
1-septic shock.
2-enviromental exposure.
3-hypothyrodism.
4-DM with autonomic dysfunction.

10. Types
1) Continuous: temp. does not reach the normal base
line, at any time in 24 hrs. & variation between upper
pole & lower pole < 1 c.
2) Remittent: temp. does not reach the normal base
line, at any time in 24 hrs. & variation between upper
pole & lower pole >1 c.
3) Intermittent or hectic: at any time in 24 hrs.
temp. reach the base line.
4) Relapsing: there are several days of cont. fever
followed by several days of normal temp .

11. Continuous:
Sepsis-drug.
Remittent:
typhoid &brucellosis`
Intermittent or hectic
Abscess.

12. What are the factors which
produce dynamic pattern of
fever & diseases ?
i.e.
=atypical presentation
=change in specific temp. pattern
=clinical overlap.

13. 1-Chang in the environment
2-Misuse of antibiotics.
3-Vaccination.
4-Mutation of infectious agents (RVF).

14. Causes
Common causes:
1-Infections:
Bacterial, Viral, Fungal , Parasitic
2-Collagen diseases.
3-Tissue injury or infarction
4- Immunization reactions
5- Inflammatory disorders
6- Drug Fever:(DD nasocomial infection)
Penicillin , cephalosporin's , sulphonamides , phenytoin
,antihistamines , aspirin & theophylline intoxication and
anti cholinergics, paracetamol.

15. Other causes
7- Malignancy.
8- Heat illness.
9- Allergic reactions.
10- Thyrotoxicosis.
11- Hypothalamic injury.
12- Hyperactivity, seizers or vigorous exercise
13- Neuroleptic malignant syndrome.
14- Malignant hyperthermia.
15- Factitious fever [Hysterical]

16. 10% of FUO
adults with health care experience.
psychiatric problems.
history of multiple hospitalizations.
fever may be caused by injection of non sterile
material (eg, feces, milk).
* Rapid changes of body temperature without
associated shivering or sweating,
* large differences between rectal and oral
temperature,
* discrepancies between fever, pulse rate, or
general appearance.
Factitious fever

17. Precaution in temp.
Measurement to avoid
Factitious fever

18. 1- rectal temp. is more accurate.
2- oral…………is acceptable.
3- tactile………is not acceptable.
Why?
(Skin may be cold in:
obese- collapsed pt.---Shock---
gram –ve infection--- exposure to cold)
4- axillary & skin temp. is not
accurate,
(especially in shocked pt. & in hot or
cold whether)

19.  Neither the height of
the temp. nor fever
curve correlates with
the etiology or
severity of the
disease.
 Fever >39.5 is of
greater concern &
often point to
infection.

20.  Non infectious fever.
 infectious fever.
 Non fever infections:
1-elderly & neonats.
2-severe debilitating diseases.
3-immune deficiency pt. HIV.

21. Harmful effects of fever
There are 3 circumstances in which
high fever can be harmful ,specially
in young children :
1) cardiac pt.,
hypoxia (increased oxygen consumption
and cardiac output)
2) >42 c CNS damage.
3) febrile convulsion.

22. Fever is not an enemy,
it may be even a friend ?
1) it activate leucocytosis and phagocytosis.
2) Increase  interferon production.
3) It increases the sensitivity of the
organisms to antibiotics.
4) increases the sensitivity of tumor cells to
chemotherapy.
5) proliferation and transportation of of
lymphocytes.

23. Classification according to duration:
1) Short febrile illness: < 8day.
2) Prolonged fever :
> 8days-- < 21days.
Or >21days with out doing the traditional
investigation.
3) FUO : > 21 days without diagnosis after
doing complete clinical history & all traditional
investigation.

24. Short febrile illness:
*Fever less than 1 w.
= 25% of urgent presentation.
Our role is to diff. if it is:
a) simple benign infection.
B) serious infection 
which is life threatening
need urgent ttt.

25. Short febrile illness:
This category include:
1-most viral infection (e.g. URTI which often
cured within 1 week).
2-bacterial self-limited disease like URTI.
3-specific fever like typhoid & brucellosis and
other ,in its beginning time.

26. Short febrile illness
Focal infection Fever with out focus
simple serious

27. Focal infection
=organ related
(1)CNS:
Meningitis-encephalitis-br.abscess.
(2)Respiratory:
Upper: nasoph.-O.M.-sinusitis-
tonsillitis-laryngitis.
Lower: bronchitis-brochiolitis-
Pneumonia-lung abscess-empyma.

28. (3)G.I.T.:
stomatitis, G.E., hepatitis,
peritonitis, appendicitis,
pancreatitis.
(4)U.T.I.:
pyelonephritis,cystitis.
(5)Orthop.inf.:
osteomylitis, arthritis.
(6)Skin inf.:
cellulitis, abscess

29. Short febrile illness
Focal infection Fever with out focus
simple serious

30. Serious infection:
=serious focal inf. should be excluded:
1)bacterial meningitis:
Dist. Consciousness-convulsion-
mening. Irritation - inc. ICP.
2)Pneumonia:
Resp. distress - crepitation –bronchial Breathing.

31. 3)Pyelonephritis:
Chills-dysurea (hot st. urine) -freq.-loin tenderness.
4)Peritonitis:
Abd. tenderness distention.
5)Osteomyelitis &Arthritis:
Focal tenderness swelling limitation of
movement.

32. Short febrile illness
Focal infection Fever with out focus
simple serious

33. C/O of inc. Intra-cranial tension
Headache :
esp. in older children &adult.
Vomiting:
repetitive-frequent-projectile.
Bulging ant. Fontanelle 20%
in infant < 1 yr.
High pitched cry.
Photophobia.

36. N.B
 In neonates (=sepsis syndrome)
fever ,lethargy ,fits ,bulging ant. Fontanelle ,g.i.t.
dysfunction ,vomiting .
 Children & adult
(fever-neck rigidity-headache-neck pain-irritability
–change in GCS-vomiting-fits).

37. Signs of meningeal irritation
 Late singes
 Neck stiffness.
 Back stiffness.
 +ve kernig’s sing.
 +veBrudziniski’ neck
sign.
 +veBrudziniski’ leg
sign.
 Early singes
 chin-chest test.
 Chin-knee kissing
test.
 Tripod singe

38. Rapid flexion of the head is accompanied by brisk
flexion of both knee

39. Inability to extend the knee,when the thigh is
flexed at the hip

40. Significant left lower lobe
pneumonia and empyema in
a 14-year-old with fever
Osteomyelitis

41. (SFI) tricks
1)Most children can tolerate
mild to moderate Fever with
no problem.
2)With high fever below 2 yr
,possibilities of serious bact.
infection is high.

42. 3)Strept. Pharyngitis
below 2nd yr.is not
common, so its
diagnosis is not simply
made.
(DD: purulent
tonsillitis)
(SFI) tricks

43. 4)O.M is very
common in
inf.&child.
-so exclusion of focal
infection is not complete
without otoscop ear exam.
(SFI) tricks

44. (SFI) tricks

45. 6) Vomiting in SFI :
is not a localizing
sign:
(GE.-appendix-entrica-
CNS-Renal failure) .
7) Diarrhea also is not a
localizing sign.
(parentral)
(SFI) tricks

46. 8)Grunting:
……. may occur at high
temp.
(DD) : Pneumonia,,
empyema),
so it may be dt causes
other than pneumonia.
(SFI) tricks

47. Short febrile illness
Focal infection Fever with out focus
simple serious

48. 9)In early focal infection:
(24-48 hr) the focus is
not be evident at initial
exam.


Re exam.after24-48hr
reveal the focus in 40% of
cases
(SFI) tricks

50. Clinical diagnosis of viremia:
 Temp.: not high
 G.condition: fair
 ttt: antipyretic &re exam. After
24-48hr
(40%may reveal a focus after re exam.).
 Investigation:no need

51. Clinical diagnosis of bacteremia
 Temp.: high
 G.codition: not fair ,sick
 Investigation
CBC(>15000),,CRP+ve,,
ESR
 .ttt :if investigation is not
available ttt with broad
specterum antibiotic &
re exam. After 1-2days.

52. Clinical diagnosis of septicemia
 Temp.: very high or
even hyperpyrexia
,or….
 G.condition:
seriously ill ±
vomiting, pallor, rash,
toxic look ,unconscious,
cold extremities.

54. Management
of septicemia:
urgent hospitalization
+urgent investigation
+immediate combined
Antibiotic ttt.

55. Investigation:
 CBC >15,000 PMNL +toxic granule.
 ESR high.
 CRP +ve.
 Blood culture.
 Urine culture.
 CSF  cytology& microbiology.

56. Septicemia:
Is a serious condition with a high morbidity &
mortality
so our attention should be directed to its
manifestations & complication .
 Because early detection
early ttt
good prognosis

57. Manifestations &
complication .
1)Serious focal infection:
meningitis, pneumonia ,osteomyelitis,
Arthritis ,peritonitis.
2)Acute hemolytic anemia: dt dirct RBCs
destruction.
3)consumptive thrombocytopenia: dt
direct platelets destruction

58. 4)DIC: dt
endotoxemias, shock ,acidosis
5)Septic shock :dt hypovolemic&
Cardiogenic.
6)Acute renal failure :dt
toxemia & shock
7)Toxic encephalopathy:
dist. Consciousness + inc.ICP + fits.

60. Management of
febrile patient

61. 1-antipyretics:
1-paracetamol,,,,,10-15mg/kg/dose/4-6 hr.
2-acetylsalicylic acid.
,,,,,,,,,,,,,,,,,,,, Ryes syndrome.
3-Ibuprofen,,,,,,,,,,,,,,,,,,10-15mg/kg/dose.
4-diclophenac Na.,,,,,,,,, 0.5 mg/kg/dose.

62. Indication of antipyretics in SFI:
1-Very high fever to comfort the pt..
2-To avoid 2nd ry harmful effect of
hyper metabolic state ( elderly ,
cardiac , chest disease).
3-To avoid febrile convulsions in child
with +ve history of febrile convulsions

63. 2-External cooling:
1-By tepid sponges with tap water….YES.
2-Cold or iced water sponges ……….NO.
(as it induces shivering &
inc. heat production)
3-Alcohol sponges……………………….NO,
(as it causes peripheral V.C. &
dec. heat loss)
4- Running tap water over limbs……..V.good
( inc. heat loss by conduction).

64. 3-Internal cooling
 Used in pt. with hyper pyrexia
not responding to antipyretics
& tepid sponges .
 E.g:
1-cold I.V.. fluids.
2-iced saline gastric
irrigation.
3-iced saline enema.
4-iced saline bladder
irrigation.

65. 4-good hydration:
 Excess fluid intake.
( in patient receiving I.V.
fluids , the requirement
is increased 10% for
each degree rise of
body temp.)

66. 5-ttt the cause

67. Indication of empirical
antibiotics
1-Fever. > 105.6 f =40.9 c
2-Immunosuppression:
(Neutropenia,asplenia,cirrhosis,)
3-Elderly.
4-Unstable vital singe.
5-Presence of prothetic device&foreign body.
6-Recent bite.
7-Recent travel.

68. What are the feverish patient
require ?
1-Plenty of fluids either oral or parentral to
maintains water and electrolyte balance.
2-Highly nutritious , easily digestible diet to face
the increased demands of energy
production and cover the needs of immune system.
3-Rest, physical and mental .
4-Keeping the temp. below the lethal level.
5-Quick diagnosis & proper therapy.
6-Re-assurance& information about his illness.

69. Admission to hospital is
mandatory for:
1-Cases of suspected epidemiological importance e.g. cholera ,
diphtheria , SARS , (Avian,swine) Flu ,covid, RVF,,,
2-SFI with toxemia or serious focal lesion.
3-All cases of prolonged fever >8days.
esp. if the home care is defective.
4-All cases of FUO.
5-All cases of fever in immuno-compromised pt.
6-Any fever with careless family esp., in infants & children.

71. Short febrile illness
Focal infection Fever with out focus
simple serious