Fever

Introduction
Types
Causes
History & Associated Symptoms
Physical Examination

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Introduction
Definition
Some important facts
Pathophysiology

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Definition

Fever is an elevation of body

temperature above the normal
circadian variation.

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Every person's temperature varies slightly,
but the average "normal" temperature for
humans is 37°C (98.6°F). Various things
influence body temperature, for example
activity, metabolic rate, environmental
temperature, and infection.

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 Pathophysiology of Fever
Infectious agents / / Monocytes Pyrogenic cytokines
Toxins / IL - 1
Mediators of
stimulate / Macrophages release

/ Endothelial cells TNF ,IL - 6, IFNs

inflammation
(Pyrogens) Other cell types

stimulate
Anterior hypothalamus
Mediated by PGE2((
)(Antipyretics/ NSAIDs act here

results in
FEVER

Increased Heat conservation

(Vasoconstriction/ behaviour changes) Elevated
result in leads to
Increased Heat production thermoregulatory
((involuntary muscular contractions set point
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Types

How to classify fever?

Types according to classification “I”
Types according to classification “II”

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How to Classify Fever?

Fever can be classified in two

ways:

1- Continued, Intermittent,
Remittent, Relapsing.

2- Acute, Chronic.

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Types according to classification “I”
type character examples
Continued Does not remit Typhoid fever, typhus, drug fever,
malignant hyperthermia.

Intermittent Temperature falls to Pyogenic infection, lymphoma,

normal everyday military T.B.
Remittent Daily fluctuation >2c Not characteristic for any
.temperature dos not particular disease.
return to normal
Relapsing Temperature returns to Malaria:
normal for days before tertian-3days pattern, fever peaks
rising again every other day (plas. Vivax,
plas.ovale), quatrain-4day
pattern . fever peaks every
third day (p.malaria)
lymphoma:
HODJKIN lymphoma
Pyogenic infection
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Types according to classification “II”

Acute Fever(fever
takes 2-3weeks) Pertussis
Bartonellosis
Plague
Chikungunya
Dengue Fever Pneumonia
Diphtheria Q fever
Encephalitis Relapsing fevers
Familial Mediterranean Typhoid and
fever
paratyphoid fever
Hemorrhagic fevers
(HFs): Typhus
Malaria Yellow fever
Melioidosis Viral diseases
Meningitis
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Types according to classification “II”

MORE THAN 3 WEEKS

Fever:
Actinomycosis
Brucellosis or undulant
fever
Familial Mediterranean
fever
Filariasis
Histoplasmosis
HIV/AIDS
Relapsing fevers
Tuberculosis
Typhoid and
paratyphoid fever
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Causes
Fever of unknown origin
Big 3 & Little 6
Causes of the PUO

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Causes of Fever

Fever of unknown origin:

Fever more than 38 c persisting for
more than 3 weeks with no clear
diagnosis intelligent and intensive
investigation.

patient with HIV or

immunosuppression conditions are
normally excluded from the definition
of (PUO) .

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Causes of Fever
BIG 3
Infection
Neoplasm
Autoimmune diseases
Little 6
Drug fever
Granulomatous diseases
Regional enteritis
Familial Mediterranean fever
Pulmonary emboli
Factitious fever
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Causes of Fever

CAUSES OF THE PUO:

1-INFECTION:(20-40%)
-pyogenic abscess
-T.B.
-infective endocarditis
-EBV
-CMV
-brucellosis
-fungal infection
(histoplasmosis,blastomycosis)
-parasitic infection (malaria,toxoplasmosis
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Causes of Fever

CAUSES OF THE PUO:

2-MALIGNANT DISEASE:(10-30%)
-lymphoma
-leukaemia
-renal cell carcinoma
-hepatocellular carcinoma

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Causes of Fever

CAUSES OF THE PUO:

3-COLLAGEN VASCULAR DISEASE:(15-
20%)
-SLE
-RHEUMATOID ARTHRIRTIS
-giant cell arteritis
-wegener's granulomatosis

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Causes of Fever

CAUSES OF THE PUO:

4-MISCELLANOUS:(10-20%)
-drug fever(beta-lactam antibiotic)
-thyrotoxicosis
-inflammatory Bowel diseases
-sarcoidosis
-granulomatous hepatitis
-factitious fever(self induced)

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Causes of Fever

CAUSES OF THE PUO:

5-UNDIAGNOSED(5-25%)

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History
& Associated Symptoms

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History
QUESTION RELATED TO FEVER ITSELF:
-1-onset

-2-duration:*how long have you had it?

*how long does it take?
*at what time of the day?
*how often do you get it (daily
,weekly or monthly)

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History
-3-measured temp. : (value and site)

-4-relieving factors

-5-aggrevating factors

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History
ALSO, ask about the associated symptoms:
most common associated symptoms with fever are :
-sorethroat
-headache
-blurred vision
-neck stifness
-arthritis
-chest pain with cough
-abd. Pain or change in bowel habits
-swelling in the neck or other parts of the body
-skin rash ,blister or pruritis.

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History

Constitutional symptoms:
(sweat , loss of appetite , loss of
weight and fever)
the constitutional symptoms can
give
differential diagnosis for a lot of
cases
as,in cancer ,infections …..etc

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History

-ask the patient if he had contact with

febrile or T.B patient.

-ask about any previous exposure to

infection

-ask about any contacts with animals

(toxoplasmosis)

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History

-ask if the patient ingest raw milk before

,raw fish or poorly cooked brucellosis.

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History

Prior or current medications

Agents that may mask fever
Agents that may preclude positive bacterial
cultures
Agents that may select out resistant
microorganisms
Agents that may mask signs and symptoms of
infection

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History
Past history:
What is the patient’s immune status?
Has there been a surgical intervention?
Recent manipulations or surgery?
Ask if he had any blood transfusion?
*Underlying diseases
Valvular lesions: endocarditis
Splenectomized patients
Biliary or GI disease
Immunocompromised state

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History
Social history:
*ask about sexual contact for sexual
transmitted disease.
*ask about the job if he has contact
with
animals .
*ask about travel histrory
*alcohol and smoking.

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Drug Fever: Causative Agents
Antimicrobial agents Cardiovascular drugs
Carbapenems Hydralazine HCl
Cephalosporins Procainamide HCl
Minocycline HCl Quinidine
Nitrofurantoin Histamine2 (H2) blockers
Penicillins Cimetidine
Rifampin Ranitidine HCl
Sulfonamides Nonsteroidal anti-
Iodides inflammatory drugs
Herbal remedies Ibuprofen
Phenothiazines Sulindac
Antihistamines Anticonvulsants
Salicylates Barbiturates
Carbamazepine
Phenytoin WWW.SMSO.NET
History
SYSTEMIC REVIEW:
1-C.V.S
2-RESPIRATORY SYSTEM
3-HEMATOLOGY SYSTEM
4-GIT
5-GENITOURINARY
6-MUSCULOSKELETAL
7-OTHER SYSTEMS….

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Physical
Examination
Sites for temperature measurement
The commonest Sites for temperature
measurement
Body normal temperature
Oral temperature
Systemic physical examination of fever
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Common Sites for Temperature Measurement
Site Pros Cons Uses
Affected by eating,
drinking, etc.
Easy access Temperature varies Most common site in
Oral cavity Familiar
Minimally invasive
within oral cavity.
Hard to keep
adults and children
over 5.
thermometer in place,
esp. if edentulous.
Site records highest temp
Often requested by MDs as
in body. Lags behind
the 'most accurate'
Rectum Preferred by MDs. other core sites when
temp is changing
site for core
temperature.
rapidly.

Reflects skin temperature.

Easy access
Not always a good
Familiar Most common site in
indicator of core
Minimally invasive. children under 5.
Axilla Preferred by American
temperature.
Must be held in place.
Sometimes used
Academy of Pediatrics during surgery.
Takes long time to
for use in infants.
reach equilibrium.

Easy access
Familiar
Requires thorough training
Minimally invasive. Commonly used in
Ear Two sites available.
and attention to
technique.
hospitals and clinics.
Reflective of brain
temperature.

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Body Normal Temperature

Mouth 36.8 c

Axilla 36.4 c

Rectum 37.7 c

Ear 36.8 c

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 Oral Temperature

The maximum oral temperature at 6.00 A.M is37.2 c

The maximum oral temperature at 4.00 P.M is37.7 c

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HANDS :
LOOK FOR FEATURES OF :
-CLuBBING
-SPLINTER HEMORRHAGE
-PALLOOR……..ETC.

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ARMS:
-BRUISES
-DRUG INJECTION SITES
-EPITROCHLEAR AND
AXILLARY
LYMPH NODES

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Systemic physical examination of fever

Skin
Furuncles/track marks
Intravenous sites
Peripheral stigmata of bacterial endocarditis

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Systemic physical examination of fever

Skin findings
Ecthyma gangrenosum
– Pseudomonas

Petechial rash
Rocky Mountain Spotted
Fever

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Systemic physical examination of fever

HEENT:
-Feel the temporal arteritis

-Eyes: -pallor
-jaundice(balck water fever ,
ascending cholangitis)
-iritis and conjuctivitis
-fundi:-choroidal tubrecle in
miliary T.B.
-roth’s spots in infective
endocarditis

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-face : as,
fly rash in SLE

-mouth:
-ulcers
-gum diseases or hemorrhage
-dental abscess
-tonsillar infection

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-ears:
-otitis media

-neck :
-cervical lymph nodes
-thyroid enlargment and
tenderness.
-meningism

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CHEST EXAMINATION:
-palpate for bony tenderness
-full examination of respiratory
system and look for :
pneumonia,T.B.,empyema and
carcinoma.
-heart: murmur :(infective endocard.
it is, atrial myxoma)
-rubs : pericarditis.

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Systemic physical examination of fever

Abdomen and pelvis:

Look for splenectomy scar
Findings may be subtle in the elderly or
those on steroids
Liver and spleen span.
Inguinal lymph nodes.
Suprapubic tenderness
Renal tenderness
ascitis

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 evidence of:
* hepatomegaly and ascitis:
-bacterial peritonitis
-hepatic carcinoma
-pancreatitis
*spleenomegaly:
-infective endocarditis
-malaria
-haemopoitic malignancy

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*renal enlargment:
-renal cell carcinoma

Rectal
Important in neutropenic
patients or those with IBD
(perirectal abscess)

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CNS: -level of consiousness:
score Eye Opening Best Verbal Response Best Motor Response

1 non non non

2 To pain Incomprehensible Sounds Extensor posturing

3 To voice Inappropriate Words Flexor posturing

4 spontanous Conversant; Disoriented Withdraws to pain

5 Conversant; Oriented Localizes to pain

6 Obeys Command

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- Obtundation
-Focal neurologic defects
-Signs of meningeal inflammation
-Cranial nerves examination.

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Repeated Examinations
Are Very Important!

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Medications: Drug Fever

The occurrence of fever is predictable for

some drugs, such as biologic response
modifiers, amphotericin B, and bleomycin.
For many other drugs, drug fever is a
diagnosis of exclusion.

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Medications: Drug Fever

Contamination of drug with pyrogen or

micro-organism
Related to the pharmacologic action of the
drug itself (ie Amphotericin B)
Allergic (hypersensitivity) reaction

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Medications: Drug Fever

Pattern of fever variable.

Rigors, myalgias, rashes, headache,
leukocytosis, eosinophilia may also occur.
Typical onset within 10 days.
Duration is variable but usually
resolves within 24 hrs depending
on 1/2 life of drug.

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 Medications: Neuroleptic Malignant Syndrome

(NMS) is a rare but potentially fatal

syndrome that may develop during
treatment with neuroleptic drugs for
conditions such as psychotic disorders,
delirium, nausea, and vomiting. It is marked
by fever, rigidity, confusion, and autonomic
instability, as well as by elevations in white
blood cell count, creatinine phosphokinase,
and urine myoglobin.

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 Medications: Neuroleptic Malignant Syndrome

NMS should be considered in the differential

diagnosis of the delirious patient receiving
neuroleptic agents who develops rigidity and
whose condition does not improve on
neuroleptics

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Medications: Neuroleptic Malignant Syndrome

Hyperthermia (T 41° C or more)

Hypertonicity
Fluctuating consciousness
Autonomic nervous system lability

Causative agents: butyrophenones,

loxapine, phenothiazines, thioxanthenes,
antidepressants, antiemetics

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Thank You

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