SFI ....is a very good intety for all beginer in pediatriv and infection speciality...... it the 1st lecture i was prepare and my 1st presentation

1. Short febrile illnessShort febrile illness
BYBY::
Dr, WALAA SALAH MANAADr, WALAA SALAH MANAA
SPECIALEST OFSPECIALEST OF feverfever & PEDIATRIC& PEDIATRIC

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

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

5. FF = 9 × c +32.= 9 × c +32.
55
cc = 5 (F -32) .= 5 (F -32) .
99
2°F (1.1°C),2°F (1.1°C),

6.  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)

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

8. DegreeDegree::
Mild….rectal….37.8-38.4
c.
Mod…rectal….38.5-39.5 c.
High…rectal….39.5- 41 c.
Hyperpyrexia…> 41 c.

9. HyperthermiaHyperthermia::
 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.

10. HypothermiaHypothermia
1-septic shock.
2-enviromental exposure.
3-hypothyrodism.
4-DM with autonomic dysfunction.

12. Types: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 .

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

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

15. 1-Chang in ! Environment
2-Misuse of antibiotics.
3-Vaccination.
4-Mutation of infectious agents (RVF).

16. Causes:Causes:
Common causes:Common causes:
1-Infections:1-Infections:
Bacterial, Viral, Fungal , ParasiticBacterial, Viral, Fungal , Parasitic
2-Collagen diseases.2-Collagen diseases.
3-Tissue injury or infarction3-Tissue injury or infarction
4- Immunization reactions4- Immunization reactions..
5- Inflammatory disorders5- Inflammatory disorders
6-6- Drug Fever:(DD nasocomial infection)Drug Fever:(DD nasocomial infection)
Penicillin , cephalosporin's ,Penicillin , cephalosporin's ,
sulphonamides , phenytoin ,antihistamines , aspirin &sulphonamides , phenytoin ,antihistamines , aspirin &
theophylline intoxication andtheophylline intoxication and
anti cholinergics, paracetamolanti cholinergics, paracetamol..

17. Other causes:Other causes:
7- Malignancy.7- Malignancy.
8- Heat illness.8- Heat illness.
9- Allergic reactions.9- Allergic reactions.
10- Thyrotoxicosis.10- Thyrotoxicosis.
11- Hypothalamic injury.11- Hypothalamic injury.
12- Hyperactivity, seizers or vigorous12- Hyperactivity, seizers or vigorous
exerciseexercise
13- Neuroleptic malignant syndrome.13- Neuroleptic malignant syndrome.
14- Malignant hyperthermia.14- Malignant hyperthermia.
15- Factitious fever [Hysterical]15- Factitious fever [Hysterical]

18. Factitious fever:
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.

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

20. Precaution in temp.Precaution in temp.
Measurement to avoidMeasurement to avoid
Factitious feverFactitious fever::

21. 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)

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

23. Harmful effects of feverHarmful 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.

24. Fever is not an enemy…….itFever is not an enemy…….it
maymay be even a friendbe even a friend..?..?

1) it activate leucocytosis and
phagocytosis.
2) Inc. interferon production.
3) It increases the sensitivity of the
organisms to antibiotics.
4) increases the sensitivity of tumor cells
to chemotherapy.
5) proliferation and transport of
lymphocytes.

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

26. Short febrile illnessShort 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.

27. Short febrile illnessShort 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.

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

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

30. (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.:

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

32. Serious infectionSerious infection::
=serious focal inf. should be excluded…:
1)bacterial meningitis:
Dist. consciousnessconvulsion
mening. Irritation inc. ICP.
2)Pneumonia:
Resp. distress crepitation bronch.

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

34. 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.

37. N.BN.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).

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

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

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

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

42. N.BN.B.(SFI.(SFI((
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.

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

44. 4)O.M is very
common in
inf.&child.
-so exclusion of
focal infection is not
complete
without otoscop ear
exam.
5)Skin inf.
gluteal. & Perianal
abscess.

45.  Vomiting in SFI :
is not a localizing sign:
(GE.-appendix-entrica-CNS-
Renal failure) .
 Diarrhea also is not a localizing
sign.
(parentral)
Always remember

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

47. 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

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

49. Non specific feb. illness
=fever with out focus
=simple fever
viremia bacteremia septicemia

50. Clinical diagnosis of viremiaClinical 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 bacteremiaClinical 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.

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

55. ManagementManagement
of septicemiaof septicemia::
urgent hospitalizationurgent hospitalization
++urgent investigationurgent investigation
++immediate combinedimmediate combined
Antibiotic tttAntibiotic ttt..

56. InvestigationInvestigation::
 CBC >15,000 PMNL +toxic granule.
ESR high.
CRP +ve.
Blood culture.

57. Septicemia: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

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

59. 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 +

61. ConclusioConclusio
nn

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

63. Non specific feb. illness
=fever e out focus
=simple fever
viremia bacteremia septicemia

64. Fever presentationFever presentation

65. Fever with headacheFever with headache::
1. Menengitis,encephalitis,
menengism……… (occipital).
2. Influenza, common cold.
3. Typhoid …
(frontal+dullach).
4. RVF.
5. malaria.

66. Fever with chills or rigorFever with chills or rigor::
 Chill : sensation of coldness.
 Rigor: tonic contraction of
muscles
+ shacking of whole body.
+ stucking of the teeth .
*** Chill : may accompany marked
rise of temp. in any fever.

67. RigorsRigors::
1-malaria
2-influenza
3-UTI.
4-pyaemia & septicaemia.
5- pus under tension
(subphrenic abscess,,,,liver abscess,,,,
cholangitis,,,,Puerperal sepsis).
6-after IV fluid containing pyrogens.
7-after taking antipyretics.dt sudden drop of
temp.

68. Fever with painsFever with pains::
1-Eye pain  mostly viral in origin.
2-Backpain  meningitis ,encephalitis , RVF,
brucellosis
3-Chest pain  bronchitis , pneumonia,
pleurisy.
4-abdominal pain  typhoid , peritonitis,
hepatitis.

69. Fever with epistaxisFever with epistaxis
1-Acute typhoid fever.
2-Acute Rh. Fever.
3-Acute leukemia.
4-haemorrahgic fevers.

70. Fever with pallorFever with pallor::
1- Acute Rh. Fever.
2-malaria.
3-Haemolytic
anaemia.
4-Malignancies.

71. Fever with herpes labialisFever with herpes labialis::
1-Common cold & influenza.
2-Malaria.
3-Meningo coccal meningitis.
4-Pneumonia.
exclude typhoid and brucella

72. Fever with jaundiceFever with jaundice::
1-Viral hepatitis.
2-Paratyphoid B fever.
3-I.M.N.
4-Liver abscess.
5-Falciparum malaria.
6-Haemolytic crises.
7-Septic cholangitis.
8-Acute leukemia.
9-Yellow fever.

73. Fever with convulsion:Fever with convulsion:
1-febrile convulsion.
2-C.N.S.infection.
3-fever associated with
other causes of
seizures:
* epilepsy .
* cerebral stroke .
* cerebral tumor.
*cerebral trauma .
* drug or alcohol
withdrawal.

74. Fever with coma:Fever with coma:
1-CNS infection
encephalitis meningoencephalitis
(viral, bact., rechetsial, fungal, parasitic.)
2-cerebro-vascular stroke
(pontine hge. , subarachnoid hge.,
cerebral hge.)
3-infection associated with
CNS trauma ,
brain tumor ,
toxic coma : * external toxins (poison ingestion)
* internal toxins .eg. diabetic coma,
uremia , hepatic coma ,,,,,,,)

75.  Do not diagnose hysterical coma in febrileDo not diagnose hysterical coma in febrile
pt.pt.
 Do not lose the hope or the prognosis inDo not lose the hope or the prognosis in
prolonged coma.prolonged coma.

77. Fever with rash:Fever with rash:
May indicate a serious bacterial
infection in 20% of cases
(e.g.menengococcal
menengitis,HIb,,,,,,,,,)
80% of cases are caused by viral
infection.

78. Fever with rashFever with rash::
1-very  (varecilla) chicken pox & menigitis.
2-Sick  scarlet fever & erysipelas.
3-People small pox.
4-Must  measles.
5-Take  typhus.
6-Entire  enterica.
7-good  glandular fever.
8-Rest  relapsing fever.

80. Dangerous sings inDangerous sings in
fever with rashfever with rash::
1-if associated with1-if associated with
sever constitutionalsever constitutional
S&S.S&S.
2-if hemorrhagic.2-if hemorrhagic.
3-if is extensive.3-if is extensive.
4- if associated with4- if associated with
shock or coma.shock or coma.

81. Infant with necrotizing
fasciitis, a complication
of varicella

83. fever Hosp.fever Hosp.
casescases
(1(1((

86. 18 yr. old female pt. presented by
fever,arthralgia.ESR..40-75……
ASOT400
With history of recurrent tonsillitis
My diagnosis was Rh. Fever& I start
LAP.
…………………………
…………………………(true….false).

87. ))22((

88. 13yr old male presented by fever
,vomiting ,abd.pain since 2 days
Widal test was done 1/160 my
diagnosis was typhoid fever & start
ttt by
ciprofloxacin………………………………
… …………………………(true….false)..

89. Widal testWidal test::
(O)raising.7-10 day.
(H)------carrier..

90. Case definition:Case definition:
Suspected case :
fever , headache , abd. Discomfort,
+at least 3 of the following:
1-toxic look
2-bronchitic chest.
3- typantic abdomen
4-palpable recessive spleen
(disappear after cure)

91. Probable caseProbable case ::
suspected case+
+ve Widal test by
tube
agglutination>160
after 1 week of
fever.

92. Confirmed case:Confirmed case:
any suspected case with + ve blood culture.
Or : significant rise in the tube
agglutination..
N.B. bright spleen is one of the abdominal U/S findings
if the bright spleen is reversible after cure.

93.  Chlormaphenichol is not prescribed
except WBCS>3.000
 Quinolones are contra indicated:
1-child<18 yrs
2-pregnancy & lactation.
3-elderly> 65yr
4-psycho-neurological diseases.
5- joint disease.
Always remember

94. (3)(3)

95. Degree of tetanusDegree of tetanus::
Mild:
trismus ,distance between upper & lower
incisors >2cm.
Moderate:
trismus + mild fits+ D.I <2cm.
Severe :
trismus +frequent fits +(D.I)<1cm

99. ))44((

102. Management ofManagement of
febrile patientfebrile patient

103. 11--antipyreticsantipyretics::
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.

104. Indication of antipyretics in SFI: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

105. 22--External coolingExternal 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).

106. 33--Internal coolingInternal 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.

107. 44--good hydrationgood hydration::
Excess fluid intake.
( in patient receiving I.V. fluids , the
requirement is increased 10% for
each degree rise of body temp.)

108. 55--ttt the causettt the cause

109. Indication of empiricalIndication of empirical
antibioticsantibiotics
1.1. Fever. > 105.6 FFever. > 105.6 F
2.2. Immunosuppression:Immunosuppression:
(Neutropenia,asplenia,cirrhosis,)(Neutropenia,asplenia,cirrhosis,)
3.3. Elderly.Elderly.
4.4. Unstable vital singe.Unstable vital singe.
5.5. Presence of protheticPresence of prothetic
device&foreign body.device&foreign body.
6.6. Recent bite.Recent bite.
7.7. Recent travel.Recent travel.

110. What are the feverish patientWhat are the feverish patient
requirerequire??
1-Plenty of fluids1-Plenty of fluids either oral or parentral toeither oral or parentral to
maintains water and electrolyte balance.maintains water and electrolyte balance.
2-Highly nutritious2-Highly nutritious ,, easily digestible diet to faceeasily digestible diet to face
the increased demands of energythe increased demands of energy
production and cover the needs of immuneproduction and cover the needs of immune system.system.
3-Rest,3-Rest, physical and mentalphysical and mental ..
4-Keeping the temp4-Keeping the temp.. below the lethal level.below the lethal level.
5-Quick diagnosis & proper therapy5-Quick diagnosis & proper therapy..
6-Re-assurance&6-Re-assurance& information about his illness.information about his illness.

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

112. Thank
You