Approach To

The Febrile Patient

 FEVER
Is an elevation of body temperature above
the normal circadian range as the result of a
change in the thermoregulatory center
located in the anterior hypothalamus and
pre-optic area

thermoregulation
Body heat is
Generated by
a) basal metabolic activity and
b) muscle movement
and lost by
1) Conduction
2) Convection (which is increased by wind or
fanning)
3) Evaporation which is increased by sweating

 Body temperature is controlled in the hypothalamus,

which is directly sensitive to changes in core temperature

The normal 'set-point' of core temperature is tightly

regulated within 37 0.5C, as required to preserve
normal function of many enzymes and other metabolic
processes.

 In a hot environment,
sweating is the main mechanism for increasing heat loss.
This usually occurs when the ambient temperature rises
above 32.5C or during exercise

FEBRILE RESPONSE
The initiation of fever begins
when exogenous or endogenous stimuli are
presented to specialized host cells, principally
monocytes and macrophages ,they will stimulates
the synthesis and release of various pyrogenic
cytokines including :
1)interleukin-1, interleukin-6
2)TNF-, and
3)IFN-.

 1) Exogenous : stimuli from out side the host

Like : microorganism, their products, or toxins and it is
called Endotoxin
Endotoxin : lipopolysaccharide ( LPS)
LPS: is found in the outer membrane of all gram negative
organism
Action :
1) through stimulation of monocytes and macrophages
2) direct on endothelial cell of the brain to produce fever

 2) Endogenous pyrogens:
polypeptides that are produced by the body
( by monocytes and macrophages ) in
response to stimuli that is usually triggered
by infection or inflammation stimuli

 Pyrogens:
Substances that cause fever are called pyrogens
What are these pyrogens:

Cytokines :
Definition :
Cytokines are regulatory polypeptides that are produced by
1) monocytes / macrophages
2) lymphocytes
3) endothelial and epithelial cell and hepatocytes

 The most important ones are :

Interleukin 1 and 1 - :The most pyrogenic
Tumor necrosis factor
Interferon
Interleukin 6 The least pyrogenic
cytokines>fever develop within 1h of
injection

Mechanism of action
Cytokine-receptor interactions in the pre-optic
region of the anterior hypothalamus
activate phospholipase A.
This enzyme liberates plasma membrane arachidonic
acid as substrate for the cyclo-oxygenase pathway.
The resulting mediator, prostaglandin E2, then
modifies the responsiveness of thermosensitive
neurons in the thermoregulatory centre.

 Diurnal variation
6 am : 37.24pm : 37.7
Rectal temperature>0.6o C oral temperature
Fever: Morning : AM >37.2o C
Evening : PM >37.7o C

PRESENTATION OF FEVER
Feeling hot
A feeling of heat does not necessarily imply fever
Rigors.
profound chills accompanied by chattering of the teeth and severe
shivering and implies a rapid rise in body temperature. Can be produced
by :
1) brucellosis and malaria
2) sepsis with abscess
3) lymphoma
Excessive sweating.
Night sweats are characteristic of tuberculosis, but sweating from any
cause is usually worse at night.

Definition of fever
Headache.
Fever from any cause may provoke headache.
Severe headache and photophobia, may suggests
meningitis
Delirium.
Mental confusion during fever is well described and
relatively more common in young children and in old age.
Muscle pain. Myalgia is characteristic of
Viral infections such as influenza
Malaria and brucellosis

 Hyperthermia
Is an elevation of core temperature without
elevation of the hypothalamic set point.
Cause : inadequate heat loss
Examples:
1) Heat stroke
2) Drug induced such as tricyclic antidepressant
3) Malignant hyperthermia. associated with
psychiatric drugs

Why fever
Elevation of body temperature increases chance for survival
Temperatures appear to increase
1) The phagocytic and Bactericidal activity of
neurtrophils
and
3) The cytotoxic effects of lymphocytes ..so
The growth and virulence of several bacterial species are
impaired at high temperature .

Fever Patterns
Intermittent fever
Remittent fever
Hectic fever
Sustained fever
Relapsing

 Intermittent fever : exaggeration of the normal circadian rhythm

and
when the variation is large it is called hectic
cause :a) Deep seated infection
b) Malignancy
c) Drug fever
Quotidian fever : hectic fever that occur daily .
Remittent fever :Temperature falls daily but not to normal .
Causes : a) tuberculosis
B) viral infection
C) many bacterial infections

 Relapsing fever :febrile episodes are separated by

intervals of normal temperature
a) Malaria fever every 3days (tertian).plasm. falciparam
or every 4 days (quartan) ..plasm .vivax
b) Borrelia ..Days of fever followed by days of no fever .

Fever pattern

Pel-Ebstein fever : fever for 3 to 10 days followed by no

fever for 3 to 10 days
Causes : a) Hodgkin lymphoma

b) Tuberculosis

Fever Pattern
Fever pattern cannot be considered
diagnostic for a particular infection or
disease and the typical pattern is not usually
seen because of use of :
1) Antipyretics
2) Steroids
3) Antibiotics

 Temperature pulse dissociation ( Relative bradicardia )

is seen in
A) Typhoid fever
B) Brucellosis
C) leptospirosis
D) factitious fever
E) acute rheumatic fever with cardiac conduction abnormality
F) Viral myocarditis
G) Endocarditis with valve ring abscess affecting conduction .

Fever Patterns..Degree

Fever with extreme degree:

gram-negative bacteremia,
Legionnaires disease, and
bacteremic pyelonephritis
Noninfectious cause of extreme pyrexia:
heat stroke, intracerebral hemorrhage

Physical examination

Fever may sometimes be absent:

seriously ill newborns
elderly patients,
uremic patient,
significantly malnourished individuals,
receiving corticosteroids or
contineous treatment with anti-inflammatory or
antipyretic agents

Approach to the febrile patient

The most important step is

Meticulous detailed history

Approach to fever
Rule out common infection
Careful history:
1) chronology

of symptoms
Detailed complain of the patient with the
symotoms arranged chronologically

2) Use of drugs
Drug fever is uncommon and therefore easily missed.
The culprits include :
penicillin and
cephalosporin
sulphonamide
anti tuberculous agents
anticonvulsants particularly phenytoin

3)Surgical or dental procedure

Patient known to have rheumatic heart disease is
endocarditis if not given prophylaxis

at risk to develop infective

4)Nature of any prosthetic material or implanted devices

prosthesis implant for : the knee joint
prosthatic valve replacment

5). occupational history including

Exposure to animals : brocellosis
infected person at home ..tuberculosis or
infleunza

6) Geographic area of living..

4) Travel history
Always ask about foreign travel.
a) Where have you been? Endemic area or not ?
b) What have you done?
C) How long where you there?
d) Did you have insect bites or contact with animals?
e) Did you take precautions/prophylaxis against malaria

If the patient has been in an endemic area

The most common final diagnoses:
Malaria,
Typhoid fever,
Viral hepatitis and
Dengue fever
Malaria must be excluded whatever the presenting
symptoms

5) Household pits
6) Ingestion of unpasteurized milk or cheeses
7) Sexual practice
8) Iv drug abuse
9) Alcohol intake
10) Prior transfusion or immunization
11) Drug allergy

HISTORY-TAKING IN FEBRILE
PATIENTS
Symptoms of common respiratory infections.
1) Sore throat, nasal discharge, sneezing URTI (VIRAL )
2) Sinus pain and headache. .suggesting A sinusitis
3) Elicit symptoms of lower respiratory tract infection
cough, sputum, wheeze or breathlessness

 Genitourinary symptoms.
Ask specifically about :
frequency of micturition, dysuria, loin pain, and
vaginal or urethral discharge .suggesting
a) Urinary tract infection,
b) Pelvic inflammatory disease and
c) Sexually transmitted infection (STI)

 Abdominal symptoms.
Ask about diarrhea, with or without blood, weight
loss and abdominal pain ..suggesting :
a) Gastroenteritis,
b) Intra-abdominal sepsis,
c) Inflammatory bowel disease,
d) Malignancy

 Joint symptoms.
joint pain, swelling or limitation of movement . If
present ask about
A) distribution : mono , oligo or poly arthritis
B) appearance : fleeting or additive
It suggest 1) infective arthritisoligo
2) collagen vascular disease..fleeting
3) reactive arthritis

 Travel history
Always ask about foreign travel.
If the patient has been in an endemic area
The most common final diagnoses:
Malaria,
Typhoid fever,
Viral hepatitis and
Dengue fever

Malaria must be excluded whatever the presenting symptoms

 Drug history.
Drug fever is uncommon and therefore easily missed.
The culprits include :
penicillin and
cephalosporin
sulphonamide
anti tuberculous agents
anticonvulsants particularly phenytoin

 Alcohol consumption.
Alcoholic hepatitis,
hepatocellular carcinoma
are all recognized causes of fever.


a)
b)
c)
d)

Family history OF
Tuberculosis
Arthritis
Other infectious diseases
Any one with symptomatology of
Polyserositis or bone pain

 Ethnic origin of the patient

is important. .Example:
Turks , Arabs , Armenians likely to have
Familial Mediterranean fever

2. Physical examination
Repeated meticulous examination on a regular
basis until diagnosis is made .
Temperature should be taken
1) Orally ..or
2) Rectally .
Axillary temperature is notoriously unreliable .

 Cautions while taking oral temperature

1) Recent consumption of hot or cold drinks
2) Smoking
3) Hyperventilation

EXAMINATION
1) Document the presence of fever and
Do not miss
FACTITIOUS FEVER

FACTITIOUS FEVER
This is defined as fever engineered by the patient
By manipulating the thermometer and/or
temperature chart apparently to obtain medical
care.
uncommon and typically presents in young women
who work in paramedical professions.

 Examples include
The dipping of thermometers into hot drinks to
fake a fever,
The factitious disorder is usually medical
but may relate to a psychiatric illness with reports
of depressive illness.

FACTITIOUS FEVER

CLUES TO THE DIAGNOSIS OF FACTITIOUS FEVER

A patient who looks well

Absence of temperature-related changes in pulse rate
Temperature > 41C
Absence of sweating during defervescence
Normal ESR and CRP despite high fever
Useful methods for the detection of factitious fever include
1) Supervised (observed) temperature measurement
2) Measuring the temperature of freshly voided urine

 A careful examination is vital and must be repeated

regularly
Particular attention should be paid to :
The skin .for skin rash
Throat.for pharyngitis
Eyesfor jaundice , scleritis.
Nail bed .for clubbing, splinter hemorrhage.
lymph nodes.. for enlargmant
abdomen for ascitis or sign of peritonitis
heart ...for murmurs indicating endocarditis.

 2) Look for RASH

a) Erythmatous rash ( rash that blanch on pressure )
Causes :
1) Meseals : often accompanied by
upper respiratory tract symptoms
and conjunctivitis
2) other viral infection like : rubella , scarlet fever

 B) a purpuric or petechial rash : (donot

blanch on pressure )
May suggest meningococcal septecemia

 Vesicular rash : may be caused by

chickenpox or shingles

 Mouth and oropharynx

Vesicular lesions ,tonsillar exudate :suggest
Infectious aetiology:
1) streptococcal pharyngitis
2) coxsakie infection
Hairy leukoplakia.OR oropharyngeal candidiasis suggest :
HIV /AIDS
oropharyngeal candidiasis..suggest
Immunodefficiency syndrom

Eyes
Conjunctival petechiae.
may suggest ..meningococcal meningitis
Jaundice may suggest acute hepatitis A
Cervical lymphnodes enlargment :
Tonsillar LN enlargmant .suggest :
Acute pharyngitis or tonsillitis
Posterior lymphadenopathysuggest :
1) Infectious mononucleosis
2) HIV infection

 Axillary lymph node enlargment :..may suggests:

1) Sepsis
2)leukemia
3) lymphoma
Joints ( any joing but commonly the knee and ankle )
Look for swelling , redness,hest and effusion
suggest active arthritis ..?infective

Factitious fever

Neck ..look for stiffness..may suggest meningitis

Abdomen :
Look for : Tenderness especially in the RIF
acute appendicitis
Chest and heart
1) Sign of consolidation
2) Pleural effeusion
3) Pericardial rub
4) Cardiac murmurEndocarditis or acute rheumatic
fever

FACTITIOUS FEVER
Recatal examination :look for
1) perianal abscess 2) acute prostatitis

Drug-IV user

20 years male who is heroin drug abuser for long

time came to ER c/o:
of left thigh pain and fever .
Look at the picture and guess what is his problem

 The answer :
Hip flexor spasm due to psoas abscess
Secondary to staphylococcus septicemia with
seeding into the muscle

Laboratory tests
Laboratory investigation is indicated if
presentation suggests more than
Simple viral infection or
acute phartngitis in children,
Lab test can be focused if the history is suggesting certain
diagnosis

 1) invetigations:
1) complete blood count with deifferential ,
** band forms and toxic granulation ..suggest bacterial
infection
** Neutropenia : may be seen with :
Infection : Typhoid,brucellosis ,viral infection
vasculitis : systemic lupus erythromatosis

** lymphocytosis : may be seen in :

a) Tuberculosis , brucellosis , Viral disease.
** Monocytosis : is seen with
a) Tuberculosis , typhoid and brucellosis
b) lymphoma
**Eosinophilia is seen in :
a) Hypersensitivity drug syndrom
b) Hodgkin disease
c) Adrenal insufficiency

 blood films to exclude Malaria

Urinalnalysis
Sample any fluid and examine : pleural, peritoneal
or joint
Bone marrow biopsy for histopathology study if :
an infiltrative disease is suspected
Stool inspection for occult blood

 2) chemistry : electrolytes ,glucose, urea , and liver function

3) microbiology
Samples from : sputum , urethra and other sites like joint,
pleural fluid , ascetic fluid ..and send for

smears and culture

Sputum evaluation :a) gram staining
b) Z-N staining for asid fast bacilli
Culture for :blood, abnormal fluid collection and urine
CSF: if meningitis is suspected ..gram stain and culture

 SPECIAL BLOOD TEST :

HIV screening for patient who has risk factor :
1)Recent travel with sexual exposure
2) injection drug user
3) sex workers
4) blood transfusion recipient
Radilology
chest x ray is indicated for any patient with significant
febrile illness.

Outcome of diagnostic efforts

1) patient recover spontaneously
suggesting : viral illness or some of the spontaneously
recovering bacterial infection : mainly intracellular
organism like typhoid or brucellosis
2) diagnosis is reached
3)If fever persist for more than 2-3 weeks with no diagnosis
is reached by : a) repeated physical examination
b) laboratory test .then
It is pyrexia of unknown origin

Treatment of fever
Is it fever or hyperthermia
Hyperthermia
1.Heat stroke
Classic heat stroke
2.Drug-induced hyperthermia
3.Malignant hyperthermia

 Heat stroke
Thermoregulatory failure in association with
a worm environment
1) Exertional : young person exercising at
ambient temperature and or humidities that
are higher than normal .
2)non Exertional :typically occur in elderly.

 Hyperpyrexia : more than 40 should be

treated by : anti pyretics and physical cooling
While resetting the hypothalamic set point
with antipyretic will speed the process.
Antipyretics also help for :
Headache , myalgia , chills .

 Low grade or moderate fever is not harmful ;

So no antipyretics use except for
1)pregnant women
2) child with febrile seizures .

Why no antipyretics for mild fever

Obscure the natural history of the patient
disease or syndrome.
Gives false feeling of well being ..may miss
meningitis
Imminently life- threatening

Antibiotics use In ER
Pathogens
Infection focus
host factors (Immune factors)
Common infection in ER
1. UTI
2. Respiratory tract infection
3. CNS infection
4. Cellulitis

Antibiotics use in-UTI

Upper urinary tract infection
Symptomes : Fever , flank pain, dysuria
lab test
: Pyuria , bacturia
Treatment : cotrimoxasole , Cephalosporin or
aminoglycoside .duration: 7-10 days

Antibiotics use In-Respiratory

tract infection
Pneumonia
1. Cough, fever, sputum or not
clinical manifestations: consolidation
CXR : .opacity with air bronchogram
interstitial infiltrate
sputum : grams stain
Treatment :3rd generation cephalsporine and

macrolides

Antibiotic use in-respiratory

tract infection

Nosocomial fever
Fever aquired after 48 hours of admittion to the hospital
1) pneumonia
2) catheter related infection
3) UTI

Consider hospital pathogen while selecting antibiotics

Antibiotics use in-CNS

infection
Bacterial meningitis
1. Aggressive antibiotics-due to
prognosis and sequence
2. cephalosporin
Vancomycin
Viral meningitis
1. Observation, s/s Tx
2. Herpes meningitis- acyclovir
continuing

Antibiotic use in- CNS

infection
TB meningitis
1. Anti-TB agents
2. Prognosis: variation
Fungal meningitis: antifungal agents

Antibiotics use In-cellulitis

Pathogens: common streptococcus, or
staphylococcus
Cellulitis
Antibiotics: PCN G or oxacillin

Pitfalls
Depend on laboratory data
Incomplete Hx.&EX
Atypical presentation
1. Immunocompromised patient
2. Newborn
3. Early sign
4. Dehydration