Fever

Department of Nephrology
Poznań University of Medical Sciences
EQUIPMENT

Mercury Thermometer

Forehead Thermometer

Electronic Thermomter

Ear Thermometer

Infra-Red Camera
NORMAL BODY TEMPERATURE

Commonly accepted value:

37.0 C (98.6 F) orally

37.7 C (99.6 F) rectally

The morning rectal temperature varies

from 36.1 to over 37.2 C for men

from 36.1 to over 37.7 C for women

There is no single normal value for everyone!

It is very helpful if the usual normal range for any
individual is known so comparisons can be made when
illness occurs
NORMAL BODY TEMPERATURE

The normal morning value for any one individual

would be followed by a diurnal variation with a rise
higher than the morning value.
NORMAL BODY TEMPERATURE

Research on temperature of parts of the body, other

than oral and rectal:

the skin of the forehead

the nasopharynx

the esophagus

the tympanic membrane

the skin of infants

the umbilicus of infants

The tympanic membrane and the esophagus provide
temperature levels more indicative of the influence on
the hypothalamic centers than temperatures recorded
in more peripheral portions of the body.
VARIATIONS OF TEMPERATURE
IN DIFFERENT PARTS OF BODY

Oral Temperature:

commonly used in practice

if correctly taken, may be more indicative of
fluctuations of body temperature than rectal readings

easily falsely lowered by mouth breathing, drinking or
eating cold substances

falsely elevated by hot food or drink, chewing (activity
of muscles of mastication), smoking and increased
salivary gland activity

Rectal Temperature:

1-2 C higher than oral temperature (this relationship is
not constant)

used especially in children, in adults with suspected
shock, or where oral reading is not valid for reasons
given above
VARIATIONS OF TEMPERATURE
IN DIFFERENT PARTS OF BODY

Axillary or Groin Temperature:

in well nourished persons this approximates oral
temperature

in thin and emaciated subjects, lower than oral
temperature and not reliable

Urine Temperature:

in a fresh urine specimen, collected in vessels
previously warmed to body temperature

very reliable indicator of body temperature

averages 0.5-1.0 C below rectal temperature

foolproof method for checking on spurious or
malingered body temperature elevations if the
collections are properly made
VARIATIONS OF TEMPERATURE
IN DIFFERENT PARTS OF BODY

Tympanic Membrane:

tympanic thermometry is being utilized increasingly

the readings are more consistent than oral or rectal
recordings.

consistent and only 0.2 C lower than esophageal
readings which are valuable but impractical to utilize for
routine clinical activities

more accurately reflect the central temperature in man
at the thermoregulating centers in the brain than oral,
skin or rectal temperatures

especially helpful for continuous recording of body
temperature during surgical operations while the patient
is under anesthesia
MEDICAL THERMOGRAPHY

Thermography is a technique by which infrared
radiation from the skin of the human body can be
recorded via a special camera and device which
converts infrared radiation to visible light which can
be photographically recorded as a "thermograph".

Warmer areas and colder areas can be recognized
by a different color

Thermography records areas of increased or
decreased skin temperature.

Heat production from the skin:

increased in areas of increased vascularity or
metabolism (i.e inflammation, malignancy, etc.)

diminished over areas of benign processes
(i.e. scar tissue, vascular obstructions, etc.)
MEDICAL THERMOGRAPHY

A surprising number of conditions can be detected
or suspected.

Much interest has centered on its use to detect:

breast cancer and other breast diseases

other types of cancer

placental localization

certain orthopedic conditions

peripheral vascular disease

aid in skin grafts

carotid artery disease

In recent years, thermography use is increasingly

being more refined.
PHYSIOLOGICAL VARIATIONS
IN NORMAL BODY TEMPERATURE

Digestion of food - rise 1.0 to 2.0 C

Vigorous Exercise - rise to 38.8-40.0 C (return to
normal within thirty minutes with rest or shower)

Diurnal Variation - low point early a.m.; peak in late
afternoon, early evening; variation varies - usually 0.5
to 1.0 C

Menstrual Cycle - rise of 0.2-0.3 C rectally at time of
ovulation with drop back at menstruation; absent with
amenorrhea

Pregnancy - continuation of above rise for about the
first four months of pregnancy

Warm Environment - slight increase (1.0 C)

Cold Environment - very slight drop in healthy adults;
marked drop in infants and very old adults

Emotion - slight temporary rise with emotion
INFLUENCE OF AGE

Infants

much more susceptible to environmental changes than
older children or adults

easy to lose heat and get hypothermia

with fever rise may have convulsions rather than a chill

diurnal variations may not be established until 2nd year

rise with infection not as striking as in older children

Children

temperature response to many ordinary ills
(especially infections or toxic agents)

more bizarre and marked than in adults

exercise elevation of mild degree common
INFLUENCE OF AGE

Old People

normal temperature may be subnormal by standards
of young adults

circulation is feeble

temperature often does not respond to infections or
toxic agents as for younger people
 easier to miss an infection

easier to get hypothermia on exposure to cold
environment temperatures

occasionally diurnal variation may be reversed
 CONTROL OF NORMAL
BODY TEMPERATURE
Normal body temperature range is maintained by
balance between factors which increase heat production
and increase heat loss.

HEAT PRODUCTION
HEAT LOSS

Amount of clothing
Radiation (60%) transfer

Metabolism of food to cooler objects by EM

Diminished skin circulation
waves.

Convection (12-15%) to

Tensioning of muscles
air about body and that

Normal muscular activity moving in and out of the

Warm respiratory tract.
environment
Vaporization (20-27%)
from skin and respiratory
tract even without gross
sweating.
HEAT LOSS

Greatly increased by:

vigorous exercise

shivering (chills)

disease (by producing shaking chill)

sweating

panting

Aided and increased by:

cooler environment

less clothing

increased skin circulation

Loss of balance between heat production and heat
loss can either raise or lower body temperature.
BODY TEMPERATURES UNDER
DIFFERENT CONDITIONS
DEFINITION OF FEVER

Often defined as

increase in body temperature over the normal range
which is caused by disease
More exactly

any rise above normal body temperature due to
disease and not from environmental exposure,
pregnancy, emotion, exercise, eating or other such
physiological factors

The clinical thermometer is an instrument

of precision within limits!
MECHANISM OF FEVER

Mechanism of fever from disease is complex

brief definition: fever is produced by action of certain
substances (endogenous or exogenous pyrogens)
acting on thermoregulatory centers in the hypothalamus

the anterior center is concerned with heat

dissipation by vasodilation and sweating related

to parasympathetic activity

the posterior center is concerned with conserving

heat by vasoconstriction and shivering and related

to sympathetic activity

The normal balance between the anterior center and
the posterior center is upset to produce a positive
heat balance and raise the body temperature.
MECHANISMS OF FEVER
FEVER – KEY CONCEPTS
FOUR STAGES OF FEVER

Fist Stage: Prodrome

Mild headache

Fatigue

General malaise

Fleeting aches and pain

Second Stage: Chill

Temperature is rising

Unconfortable sensation of being chilled

Vasoconstriction and piloerection

Onset of generalized shaking

Pale skin covered with goose flesh

Feeling of being cold
FOUR STAGES OF FEVER

Third Stage: Flush

Shivering ceases

Sensation of warmth develops

Cutaneous vasodilation occurs

Skin becomes warm and flushed

Bad taste in mouth

Fourth Stage: Defervescence

Initiation of sweating

Skin is warm and moist

Temperature is rapidly lowered
DEFINITION OF TYPES OF FEVER
AND FEVER CURVES

In clinical practice, especially for patients admitting to
a hospital, the "body temperature" is recorded 2 or
more times a day and plotted on a temperature chart.

This permits a visual recording of the low and high
values for the 24 hours.

The type of fever curve produced is another helpful
indicator of diagnosis and prognosis, along with the
history, physical examination and laboratory data, or
specialized studies.

The following definitions of types of fever or fever
curves will be helpful as background knowledge.
DEFINITION OF TYPES OF FEVER
AND FEVER CURVES

Pyrexia - synonymous with fever.

Habitual Pyrexia - average temperature elevated
minimally and constantly over normal range in a
person otherwise healthy.

Diurnal Variation - daily rhythmic change in body
temperature, varying 1.0-1.5 C with lowest point in
early a.m. and peak in afternoon or evening.

Chill - uncontrollable muscular shivering (and other
physiological phenomena) which produces a sharp
rise in body temperature.

Ague - synonymous with repeated chills.

Rigor - synonymous with chill.

Hyperpyrexia or Hyperthermia - means body
temperature higher than 41.0 C
DEFINITION OF TYPES OF FEVER
AND FEVER CURVES

Hectic (or Septic) Fever - an intermittent fever with
large daily swings in body temperature, usually
accompanied by chills and sweats.

Remittent Fever - significant variations in temperature
level (more than the diurnal variation) each day, but
no drop to a normal level of temperature (i.e.: acute-
rheumatic fever, pulmonary tuberculosis, etc.)

Continuous (or Sustained) Fever - fever sustained at
a high level in which daily diurnal variations are no
wider than usual for the individual (i.e.: pneumococcal
lobar pneumonia before treatment, rickettsial
diseases, certain types of drug fever, etc.)

Spurious (or False) Fever - elevation in the
thermometer reading produced by trickery on part of
the patient; also called factitious fever or fever of
malingering.
DEFINITION OF TYPES OF FEVER
AND FEVER CURVES

Psychogenic (or Emotional) Fever - elevation in
temperature produced by emotional stimulus
(i.e.: slight elevation of temperature on the day of
admission to hospital with normal temperature
thereafter, or rise in temperature while students ☺
are taking complicated or important examinations)

Catheter Fever - passage of catheter, cystoscope,
etc. through infected urethra is followed by fever in
short time due to transitory bacteremia; more severe
forms accompanied by a chill

Charcot's (Hepatic) Intermittent Fever - is due to
cholangitis with intermittent biliary obstruction due to
a ball valve stone often lying in the Ampulla of Vater;
fever occurs periodically; bile duct narrowed by
stricture or tumor, or by a polyp may also be a cause
DEFINITION OF TYPES OF FEVER
AND FEVER CURVES

Pel-Ebstein Type of Fever - rare type seen in Hodgkins
disease, somewhat comparable type may be seen in
Brucellosis (Undulant Fever); a form of relapsing fever
but with longer febrile and afebrile periods and slower
rises and falls in the fever curve

Thirst Fever - a type of fever curve seen in dehydrated
infants in very warm climates characterized by marked
elevation in the morning with return to normal by the
evening

Quartan (Tertian) Fever - in the quartan (tertian)
type of malaria, the chill and fever occur every third
(second) day; a form of relapsing fever curve;
the regularity of this fever pattern may suggest
the diagnosis
Tertian malaria – Plasmodium vivax – 48-hour interval
Quartan malaria – Plasmodium malariae – 72-hour interval
 DOUBLE QUOTIDIAN
FEVER CURVE

Patient gets two spikes of fever every day, generally
once in the morning and once in the evening

Kala-Azar

Juvenile Rheumatoid Arthritis

Adult Onset Juvenile
Rheumatoid Arthritis

Gonococcal Endocarditis

Meningococcal Endocarditis

Miliary Tuberculosis

Rarely in other infections

Common Peripheral Manifestations of Infective Endocarditis. Splinter hemorrhages (Panel A) are normally seen under
the fingernails. They are usually linear and red for the first two to three days and brownish thereafter.
Conjunctival petechiae (Panel B). Osler's nodes (Panel C) are tender, subcutaneous nodules, often in the pulp of the digits.
Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles.
RELAPSING TYPE FEVER CURVE

Short febrile periods of variable duration (usually with
sharp rise and fall in temperature) are interspersed by
periods of one or more days of normal temperature.

Malaria

Chronic Meningococcal Septicemia

Rat-bite Fever

Charcot's (Hepatic) Intermittent Fever

Relapsing Fever - tick borne due to Borrelia duttoni

It should not be confused with the following:

Saddle-Back Fever (biphasic temperatue curve)

Undulant Type Fever (Hodgkins disease, Brucellosis)

Septic Fever (daily fever swings with sweats)
"SADDLE BACK" (BIPHASIC)
TYPE OF FEVER CURVE

A form of relapsing fever curve limited to two febrile
episodes of one or more days each separated by a
period free of fever for a short period.

Recurrence or progression of clinical features occur
with the second febrile episode.

It has been noted in:

dengue fever

yellow fever

Colorado tick fever

lymphocytic-choriomeningitis

poliomyelitis

certain other virus diseases
HECTIC FEVER WITH REVERSED
DIURNAL GRADIENT "TYPHUS INVERSUS"

Reversal of the normal diurnal pattern  the highest
temperature peak occurs in the early a.m. hours and
the lowest in the evening hours.

This type of fever curve suggests tuberculosis
(especially of the miliary type), salmonella bacteremia
and rarely other causes.
METAL FUME FEVER
SYNDROME OF MONDAY NIGHT CHILL AND FEVER

Due to inhalation of zinc oxide fumes (zinc has a low

melting point and volatilizes at 500 C).

On exposure for the first time, one gets a mild
headache, malaise and muscle aches, anorexia and
mild cough.

Later in the day, frequently after work, there may be a
chill, fever and sweats.

Continued exposure produces immunity which is lost
when individual does not work over a weekend or
holiday.

Episodes recur on first day back to work.

A bizarre clinical picture of chills and fever each
Monday night after leaving work.

Fumes of certain other metals may do this.
COMPLICATIONS OF FEVER

Fever, aside from the disease producing it,
may produce certain complications which are
reversible when temperature returns towards normal.

The most important of these are:

delirium (the threshold at which it occurs varies greatly,
more readily produced in infants, the aged, alcoholics)

convulsions (most-common in infants under age 2)

headache (related to dilatation of certain cerebral
arteries as a result of the fever, also certain specific
types of infections are likely to cause this symptom)

herpes (especially when temperature
rises sharply)

febrile albuminuria
COMPLICATIONS OF FEVER

Chill or rigor (with sharp rise in body temperature, and
sweats with rapid drop in body temperature) may also
be considered as a complication of fever.

They may be dangerous in debilitated persons.

Fever may contribute to:

causing anemia

influence certain liver function tests

increase of the body metabolic rate

significant effects on cardiac and pulmonary function

To most physicians, fever is considered a valuable clue of

some abnormal state of body function or disease process.
FEVER OF UNKNOWN ETIOLOGY
F.U.O.

A not uncommon clinical problem in hospital practice
is evaluation of a patient who has had a persistent
and unexplained fever for two or more weeks.

Before undertaking a detailed diagnostic workup,
the following two possibilities should be checked:

Factitious fever

Drug fever i.e.:

Fever From Sulfonamides

Atropine Pyrexia

Syndrome of Erythema and

Fever of the Ninth Day (arsphenamine )

Fever Due to Sympathectomy or
Use of Autonomic Drugs

Unexplained Fever with Early Penicillin Treatment of
Gonorrhea As a Sign Suggesting Co-existent Syphilis
FACTITIOUS FEVER

Failure to consider this possibility as an explanation of
an obscure fever has proved embarrassing to many
physicians.

It can easily be ruled out first without directly
mentioning it by the simple procedure of personally
taking the temperature with your own thermometer.

Simulation of a fever by thermometer trickery is not
too unusual and should be suspected, when:

the pulse reading fails to rise
with temperature peaks

lack of a characteristic
daily diurnal curve

lack of chills & sweats with sharp
rises and falls in temperature

exceptionally high readings
DRUG FEVER

If a patient with persistent unexplained fever has been
on medication therapy, one must consider that the
rise in body temperature may be due to an adverse
effect of the medication.

It is well to withdraw all medication for 24 to 48 hours
and note whether fever diminishes.

Some medications produce fever only after a latent
interval, some after persistent use, and some from
very small doses in susceptible persons.

Mechanisms:

pharmacologic action of the drug itself

immunological reaction to the medication

tissue reaction as a result of a local reaction

pyrogens or bacterial organisms may be
introduced at the time of injection
SUDDEN FEVER IN BED PATIENT
UNDER OBSERVATION WHO WAS PREVIOUSLY AFEBRILE

A common clinical situation is a rise in temperature of

a bed patient whose temperature curve had
previously, under observation, been normal.

When this situation occurs think first of:

changes in thermometer technique:

new nurse

new thermometer

failure to "shake" it down

changes from oral to rectal temperature etc.

urinary tract infection

common respiratory infection

bronchopneumonia

pulmonary infarction

disease of leg veins
CAUSES OF FEVER OF
NON-INFECTIOUS ORIGIN
It is well to emphasize size,
by the list which follows, how
frequently fever may be of
non-infectious origin:

Lesions of CNS
(experimental punctures,
hemorrhage, tumor)

Drugs

Dehydration

Deficiency diseases

Therapeutic fever produced
by physical apparatus

Coronary occlusion with
myocardial infarct

Injections (foreign protein)

Hyperthyroidism

Dissecting aneurysm

Malignant tumors

Cardiac decompensation

Pernicious anemia

Skin diseases

Blood dyscrasias
(leukemia, Hodgkins
disease, etc.)

Free hemorrhage in any
body cavity (pleura,
peritoneum, etc.)
CAUSES OF FEVER OF
NON-INFECTIOUS ORIGIN

Gout

Diabetic acidosis

Serum sickness

Variations during
menstrual cycle

Habitual pyrexia

Exercise

Hot climate

Wyatt Syndrome

Gastrointestinal bleeding

Infarction of any organ

Periodic disease

Riley-Day Syndrome

Sympathectomy

Angiitis

etc. etc. etc.
The preceding list is by no
means complete, but collected
merely to show how broad the
diagnostic possibilities are for
explaining fever on a basis
other than an infectious disease.
PSYCHOGENIC FEVER

Fever may be produced by

an emotional and possibly
an hysterical mechanism.

The slight elevation of
temperature commonly seen
during the first day of a hospital
admission is an example.

Apparently many types of
psychic stimuli can do it.

Fever has been reported in
some cases of neurocirculatory
asthenia.
HYPERTHERMIA
= HYPERPYREXIA

Hyperthermic fever - temperature above 41 C
(prompt treatment indicated!)

Irreversible damage occurs when temperature
reaches 46 C

Temperature of 41 C or over are so unusual that they
are strongly diagnostic and suggest:

thermometer trickery

heat stroke

intravenous pyrogen reaction

rarely severe infections (<5%)

occasional occurrence with fever therapy

malignant hyperthermia during anesthesia

occasionally in miscellaneous conditions, especially
those which damage the cerebral centers controlling
temperature regulation, or with disorders of metabolism
HEATSTROKE

Heat pyrexia, sunstroke, heatstroke, thermal fever,

etc. are all terms meaning the same condition.

Cessation of sweating in a warm environment,
especially in those with old age, alcoholism or chronic
illness is the precipitating factor.

The clinical picture includes:

marked elevation of body temperature (41-43 C)

hot, dry and flushed skin

strong pulse

coma

possibly convulsions

petechiae may be noted

terminally: shock-like state and pulmonary edema

Prompt therapy to lower the body temperature !!!
MALIGNANT HYPERTHERMIA
DURING ANESTHESIA

Malignant Hyperthermia (MH) is a lifethreatening,
acute pharmacogenetic disorder, developping during
or after a general anaesthesia.

Both a genetic predisposition, and one or more
triggering agents are necessary to evoke MH.

Triggering agents include all volatile anaesthetics
(Chloroform, Ether, Halothane, Isoflurane) and
depolarizing muscle relaxants (Suxamethonium).

The classical MH crisis shows a hypermetabolic state,
caused primarly by the muscles of the sceletal
system. Values over 43 C have been reported.

MH is a dangerous disease, and anyone who is
involved with anaesthesia should have up to date
knowledge about MH.
FEVER
INSPIRATION FOR THE ARTISTS

THE END