aApproach to a patient with fever

PRESENTED BY
DR. MD. MAZHARUL ISLAM
Medical Officer
Chattogram International
Medical College
Hospital,Chattogram
Case-1

Mr. Kolimullah,27 years old,normotensive ,non diabetic,hailing from

Dhaka presented with the complain of fever for 3 days, bodyache
for same duration and vomiting for 1 day.According to the patient’s
statement fever was high grade,intermittent in nature.Highest
recorded temperature was 103 °F,subsided by taking antipyretic.He
also complained of bodyache ,nausea and occational vomiting which
contains undigested food particles.
Case-2

Mrs Nilu Akter,45 years old,normotensive,diabetic presented

with the complain of fever for 5 days,lower abdominal pain for
3 days and burning sensation during micturition for 7days.
According to patient’s statement fever was high grade HRT102
°F, intermittent associated with chills and rigor, subsided by
taking anti pyretic. She also complained of lower abdominal
pain .
 What is
fever
Fever implies an elevated core body temperature of
more than 38 degree centigrade.Fever is a response
to cytokines and acute phase protein and occurs in
both infectious and non infectious condition.
 BODY TEMPERATURE RANGE

TEMPERATURE DEGREE CENTIGRADE DEGREE FAHRENHEIT

Normal 36.6-37.2 98-99

Subnormal <36.6 <98

Febrile >37.2 >99

Hyperpyrexia >41.6 >106.7

Hypothermia <35 <95

Sites for recording temperature in
different age groups

AGE SITES

0-3 MONTHS Rectal

3 months to 3 years Rectal,Ear or Armpit

4 to 5 years Oral,Rectal,Ear or Armpit

5 years to adult Oral,Ear or Armpit

DIFFERENT METHODS OF TAKING
TEMPRETURE

 Digital thermometer
 Mercury thermometer
 Tympanic membrane
thermometer
 Forehead thermometer
 Rectal thermometer
Duration of temperature
measurement
Anus 3 minute

Mouth 2 minute

Axilla 1 minute
 CAUSES OF FEVER

1. Infection: Bacterial,Viral,Protozoal,Fungal

2. Inflammation: Cellulitis ,Vasculitis ,Endocarditis

3.Immunological Disorders: Connective tissue

disorder 4.Granulomatous disorders:

Sarcoidosis, Tuberculosis

5.Neoplasia:Carcinoma, Hepatoma,Lymphoma

6.Metabolic cause:Gout, Pheochromocytoma,

Hyperthyroidism.
PATHOGENESIS OF FEVER
Fever chart
 Pattern of fever
• Continuous/sustained
fever
• Remittent fever

• Intermittent fever

• Quotidian

• Tertian

• Quartan
 Continue..
•Continuous fever: Temperature remain above the baseline
throughout the day and fluctuates < 1°C in 24 hours e.g. lobar
pneumonia, typhoid fever, UTI, typhus, brucellosis
•Remittent fever: Temperature remains above the base line and
fluctuates >1°C in 24 hours e.g. infective endocarditis.
•Intermittent fever: Fever persist for few hours in 24 hours and
remain in the baseline for rest of the time of the day. E.g. malaria,
pyaemia, septicaemia. The periodicity may occurs in 24 hours
(quotidian), 48 hours (tertian) and 72 hours (quartan)
Continue…
 Continue…

Intermittent fever
 Decline of fever
Fall by Lysis: Gradual decline of fever .This indicates that
body is able to maintain normal homeostasis.This is the
desired decline of fever.

Fall by Crisis: Sudden decline of fever.This indicates

impairment of the function of hypothalamus.
Continuous step ladder pattern of classical of typhoid fever & fall
by lysis following effective therapy.

.
In Malaria, fever present only for several hours during the day.
Effective anti-malarial therapy leads to a rapid fever defervescence-
by crisis.
 Hyper-pyrexia
Hyper-pyrexia: Extreme elevation core temperature greater

than or equal to 41.5 °C (106.7 °F)

• It is a medical emergency

•May indicate a serious underlying condition or lead to

problems including permanent brain damage or death.
 Hyper-pyrexia
Cause of hyper-pyrexia:
• Sepsis/infections: viral,
bacterial
• Intracranial haemorrhage

• Neuroleptic malignant
syndrome
• Drug overdose

• Serotonin syndrome

• Thyroid storm.
 Hyper-thermia

An
uncontrolled rise in body temperature that exceeds
the body's ability to lose heat is called Hyperthermia.
 Hyperthermia is not due to fever
 No pyrogenic effects in hyperthermia
 Hypothalamic thermoregulatory set point remain
unchanged
Exogenous
heat exposure and endogenous heat
production are two mechanisms of hyperthermia
 Causes of Hyperthermia
Heat Stroke
• Exertional: Exercise in higher-than-normal heat and/or humidity
• Nonexertional: Anticholinergics, antihistamines; antiparkinsonian drugs,
diuretics, phenothiazines

Drug-Induced Hyperthermia
• Amphetamines, cocaine, salicylates, lithium, anticholinergics,
sympathomimetics

Neuroleptic Malignant Syndrome

• Phenothiazines, benzodiazepines, metoclopramide, domperidone
 Continue…
Serotonin Syndrome
•Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase
inhibitors (MAOIs), tricyclic antidepressants

Malignant Hyperthermia
• Inhalational anesthetics, succinylcholine

Endocrinopathy
• Thyrotoxicosis, pheochromocytoma

Central Nervous System Damage

• Cerebral hemorrhage, status epilepticus, hypothalamic injury
Difference between hyperpyrexia
and hyperthermia
Hyperpyrexia Hyperthermia
● A fever of ● Uncontrolled
>41.5°C increase in body
(>106.7°F) temperature that exceeds
the body's ability to lose
heat.
● The set point is above ● The set point of the
the normal hypothalamic
thermoregulatory center is
unchanged.
● Fever is due to some pyrogens ● Does not involve
pyrogenic molecules.
 Continue…

Hyperpyrexia Hyperthermia
Due to endogenous heat Both exogenous heat exposure
production only and endogenous heat
production occur
No influence of exogenous factors Exogenous heat exposure
and endogenous heat
production
Diagnosis: history Diagnosis: history suggestive

Treatment: responds to Treatment: does not respond

antipyretics. to antipyretics.
 Clinical types of fever
• Fever without localizing sign

• Fever with localizing sign

• Acute/fever of short duration

• Prolonged fever

• PUO

• Fever in injection drug users

• Fever in immunocompromised
host
• Neutropenic fever

• Post transplantation fever

FEVER WITH LOCALIZING
CLINICAL SYMPTOMS AND SIGN
1.Headache,Vomiting,Neck 7.Lymphadenopathy
rigidity,

8.Hepatomegaly
2.Unconsciousness

3.Myalgia 9.Splenomegaly

4.Photophobia 10.Jaundice

5.Conjunctivitis 11.Anemia

6.Skin Rash
FIVE MAJOR GROUPS CAUSING FEVER WITHOUT
LOCALIZING SIGN
● MALARIA-Including all malaria
P.falciparum,P.ovale,P.vivax,P.malariae
● Arboviral infections,Dengue,Chikungunia,Japanese
Encephalitis,Zika,Yellow fever virus
● Enteric fever due to Salmonella typhi,paratyphi A B C
● Spirochaete infections-such as leptospirosis,and tick borne or
louse borne relapsing fever
● Rickettsial infections-including scrub typhus murine typhus
spotted fever
Fever with Abdominal pain, vomiting,
diarrhea and malaise:
Enteric fever ,viral or bacterial gastroenteritis, Hepatitis,
Pyelonephritis, Schistosomiasis, Amoebiasis

Fever and Jaundice with recent tropical Travel:

Dengue fever, Viral haemorrhagic fever, leptospirosis, yellow
fever,plague Hepatitis, enteric fever, typhus, hemolytic uraemic
syndrome
FEVER WITH HEADACHE

Meningitis, Encephalitis, Sinusitis, Influenzae, Typhus, Enteroviral

infection, Tuberculosis,Pneumonia, Occult bacteremia, Common
viral infections
FEVER WITH LYMPHADENOPATHY
HIV, Plague, Rickettsial infection,Brucellosis, Leishmeniasis, Dengue,
Infectious mono neucleosis, Tuberculosis , Anthrax, Cat scratch
disease, West African trypanosomiasis, Lymphatic filariasis
FEVER WITH HEPATOMEGALY
Malaria,Leishmaniasis, Schistosomiasis, Amoebic or pyogenic liver
abscess, Typhoid, Hepatitis, Leptospirosis, Tuberculosis
FEVER WITH SPLENOMEGALY
Malaria, Leishmaniasis, Typhoid, Brucellosis, Dengue,
Scistosomiasis,, Tuberculosis, Toxoplasmosis
FEVER WITH JAUNDICE

Hepatitis, Malaria, Leptospirosis, Cholelithiasis,

Pancreatitis

FEVER WITH RASH

Measles,Dengue ,chikungunia ,Rubella ,Scarlet fever, Chicken pox,
Meningococcal infections.
Fever with rash according to day of
appearance
1st day-Varicella

2nd day-Scarlet

fever 3rd day-

Chicken pox

4th day-

Measles ,Rubella 5th

day-Typhus,Rickettsia

6th day-Dengue fever

 FEVER WITH BLEEDING

Severe malaria

Dengue Haemorrhagic

fever Viral haemorrhagic

fever Acute leukaemia

DIC/

Septicaemia

Kala azar

Leptospirosis
 Fever of short duration
• Duration of fever < 2
weeks
• Common causes
– Infections

– Thromboembolic
disease
– Gout

– Drug allergy
 Continue…
• Characteristic of short fever
– Abrupt onset
– High rise of temperature
– Respiratory symptoms
–Prominent systemic symptoms: Severe malaise, muscle or joint pain
photophobia, pain on movement of eyes, headache
– Nausea, vomiting or diarrhoea
– Acute tender enlargement of lymph nodes or spleen
– Meningeal signs with or without spinal fluid pleocytosis
– Dysuria, urinary frequency, and flank pain
 Prolonged fever
• Duration of fever >2 weeks

• Diagnosis remains obscure for weeks or months

•Needs skilful approach - careful history, repeated physical

examination, carefully considered and staged use of laboratory
examination and imaging techniques
• Common causes: Typhoid malaria, tuberculosis,Kala- azar
 Pyrexia of unknown origin
(PUO)
Defined as:
• Temperature >38.0°C on multiple occasions for
>3 weeks
•No diagnosis, despite initial investigation in

hospital for 1 week, (has been relaxed to

investigation over 3 days of inpatient care) or

• Three outpatient visits or one week of intensive
ambulatory investigation
Aetiology of PUO

 Infections(30%):TB,HIV-1,Viral,Fungal.
 Malignancy(20%):Lymphoma,Leukaemia,Myeloma
 Connective tissue disorder(15%)
 Micellaneous(20%):Atrial
myxoma,Aortitis,Sarcoidosis,Thyrotoxicosis etc.
 Idopathic(15%)
 Approach to fever Patient

• History
• Physical
examination
• Investigation
• Management
 History
 Epidemiology  Animal bites
 Duration of fever  Family history
 Mode of onset  Immunisation
 Fever character H/O
blood transfusion,

drugs, surgery
Occupational
history  Treatment history
 Personal history  Complication of fever
 Travel history
 Symptoms accompanied by fever
• Systemic symptoms: Raised body temperature, Headache, pleuritic chest
pain, body ache, arthralgia, weakness, shivering
•Chills: a symptoms complexes of feeling of cold, piloerection, teeth
chattering and bed shaking.
• Rigor: violent muscle contractions to raise the core temperature

• Sweating: Fall of temperature, night sweat,

• Altered mental status, irritability

• Convulsions: CNS infection, cerebral malaria, meningitis, Herpes labialis:

Malaria,
 Fever with
localizing features
 Physical examination
• General examination
• Systemic examination
• Local or regional
examination
• Relevant examination
 Continue…
Observation
• Temperature
• Sweating
Localising sign
• wt. loss
• Rash
• Dyspnoea • Boil, abscess
• Pallor • Lymph-nodes
• Jaundice •Urethr
al
discharg
Examination sites e
• Skin • Signs
• Hands & nail of MI
• Oropharynx • Joint
• Head & neck
• Eyes swellin
• Heart & lung g
• Abdomen • Celluliti
• Neurological s
• Musculoskeletal • Enlarg
• Rectum & ed
genitalia
RED FLAG SIGN IN A PATIENT WITH FEVER
● Prostration-unable to stand, sit or walk without support
● Temperature-Hyper pyrexia (temp>41.5 C) or Hypothermia (temp< 36 C)
or rigors
● Respiration-Shortness of breath (RR->22 breaths/min) , cyanosis, SPO2-
<92 % in room air
● Circulation-BP <100 mmHg in SBP , Cold clammy extremities, Capillary
refill >3
second
● Neurological-Altered mental status, GCS-<13/15, Convulsion, Positive
meningeal sign
● Abdominal pain, severe or persistent vomiting
● Severe conjunctival or palmar pallor
● Jaundice on examination of sclera
● Petechial or purpuric rash
● Bleeding from nose, gums, or venepuncture site, haematemesis,
malena
 Investigation
•Pathology: CBC, blood parasites, urinalysis, abnormal fluid
examination, Bone marrow, stool examination
• Biochemistry: Electrolytes, glucose, BUN, creatinine, LFT, RFT, CPK,
enzymes
• Radiology & imaging: Chest x-ray, CT, MRI, USG, echo
•Microbiological: Smears, culture & sensitivity of samples from throat,
urethra, anus, cervix, vagina, urine, blood, abnormal fluid, CSF
• Immunological: Antigen, antibody, hypersensitivity reaction
• Molecular: PCR, RT-PCR, Gene x-pert
• Cytology/histopathology: FNAC, Smear, swab, histopathology
 Management of fever
General management: Nutrition, fluid and electrolytes
• Symptomatic managementof Fever

• Pharmacological treatment: Antipyretic

• Acetaminophen: preferred to all antipyretic.If the patient cannot take oral

antipyretic,parenteral or rectal suppositories of different antipyretics can
be used.

•Aspirin: effectively reduce fever but can affect platelets and GIT, In
Children, aspirin increases the risk of Reye's syndrome

• NSAIDs: Rapidly acting and potent, less preferred for adverse effects

• Steroid: Most potent, mask or aggravate the diseases

 Continue…

Non pharmacological measure

 Tepid sponging, fanning, warping with wet blanket, shower
etc
 Continue…
•Other symptomatic management: paracetamol for Myalgia, headache,
arthralgia and for vomiting antiemetic.
•Specific treatment: treatment of the cause e.g. antimalarial for
malaria, antibiotic for sepsis
•Management of complication: for convulsion anticonvulsant,
antiviral for secondary viral infection
•Hyper-pyrexia: Tepid sponging, antipyretics, fanning, cooling blankets,
bathing, treatment of cause
 CONCLUSION

Feverpresentation is variable from undifferentiated to localizing

symptoms and many of them have common symptoms.
Meticulous history and thorough examination is very
important to reach a diagnosis.
Syndromic approaches may helpful for initial management of
disease before confirmed the diagnosis
New molecular diagnostic methods will very helpful for early
diagnosis and prompt treatment .
Referances…

 DAVIDSON’S PRINCIPLES AND PRACTICE OF MEDICINE(24 TH

edition)
 HARRISON’S PRINCIPLES OF INTERNAL MEDICINE(21 ST edition)
Thank You