Fever Pattern

Fever without focus
Dr Abhijeet
Definition
• Fever is defined as a rectal temperature

≥38°C, and a value >40°C is called
hyperpyrexia.
Pathogenesis
• Body temperature is regulated by

thermosensitive neurons located in the
preoptic or anterior hypothalamus that
respond to changes in blood temperature as
well as cold and warm receptors located in
skin and muscles.
• Thermoregulatory responses include
redirecting blood to or from cutaneous
vascular beds, increased or decreased
sweating, regulation of extracellular fluid
volume via arginine vasopressin, and
behavioral responses, such as seeking a
warmer or cooler environmental temperature.
Mechanism of Fever
1.Pyrogens: Endogenous pyrogens include the
cytokines interleukin 1 (IL)-1 and IL-6, tumor
necrosis factor-α (TNF-α), interferon (IFN)-β
, IFN-γ & (PG)E2.
Exogenous pyrogens :Infectious pathogens
and drugs.
2.Heat production exceeding loss, and
3.Defective heat loss.
Causes of Fever
1. Infectious,
2. Inflammatory,
3. Neoplastic,
4. Miscellaneous.
• The pattern of the fever can provide clues to
the underlying etiology.
• Viral infections typically associated with a
slow decline of fever over a week, whereas
Bacterial infections are associated with a
prompt resolution of fever after effective
antimicrobial treatment is employed.
• Although administration of antimicrobial
agents can result in a very rapid elimination of
bacteria, if tissue injury has been
extensive, the inflammatory response and
fever can continue for days after all microbes
have been eradicated.
Types of Fever
• Intermittent fever:
Temperature fluctuation is more than 1 C and
fever present only few hours in a day. Eg:filaria
• Septic or hectic fever:
Extremely wide fluctuations .
• Sustained fever :
Persistent and does not vary by more than
0.5°C/day.
• Remittent fever :
Persistent and varies by more than 0.5°C/day.
• Relapsing fever :
Characterized by febrile periods that are
separated by intervals of normal temperature.
• Tertian fever:
Occurs on the first and third days (malaria
caused by Plasmodium vivax)
• Quartan fever :Occurs on the first and fourth
days (malaria caused by Plasmodium
malariae).
• Biphasic fever: A single illness with 2 distinct
periods (camelback fever pattern);
poliomyelitis is the classic example,also
characteristic of other enteroviral
infections, leptospirosis, dengue fever, yellow
fever, Colorado tick fever, spirillary rat-bite
fever (Spirillum minus), and the African
hemorrhagic fevers (Marburg, Ebola, and
Lassa fevers).
• Factitious fever or self-induced fever: May be
caused by intentional manipulation of the
thermometer or injection of pyrogenic
material.
Fever Without Localizing signs
• Etiology & Evaluation of fever without
localizing signs depends upon age of the child
• Neonates-1 month:
Challenge to evaluate because of difficulty to
clinically distinguish between serious bacterial
& self limiting viral illness.
- Immature immune response in this period
increases the significance of illness.
• Neonates without sick look & with fever have
7% risk of serious bacterial infection.
i.e. occult bacteremia, meningitis (Caused by
E.Coli, Listeria monocytogenes, Herpis
simplex, enterovirus)
, pneumonia, osteomyelitis, septic
arthritis, enteritis & UTI.
Management
• Admit
• CBC, Blood culture, CSF studies, Urine analysis
Stool C/s, Chest X ray etc.
• Combination of antibiotics such as Ampicillin &
Cefotaxime.
• Acyclovir for suspected HSV infection (CSF
pleocytosis), maternal H/O genital HSV during
delivery.
1- 3 Months
• Mostly viral origin
• May be vaccine induced, if recent
immunization done in recent past.
• But can be serious bacterial infections such as:
Gr. B streptococcus, L.
monocytogenes, Salmonella enteritis, E.Coli, S.
Pneumoniae, HIB , Staph aureus
• Otitis
media, pneumonia, omphalitis, mastitis, skin
& soft tissue infections.
• In contrast to bacterial infections, viral
diseases have seasional pattern.
- Winter : RSV, Influenza A
- Summer & Fall: Enterovirus.
Management
• Sick/ Toxic looking febrile infants should be
admitted
• CBC, Blood culture, CSF studies, Urine analysis
Stool C/s, Chest X ray etc.
• Combination of antibiotics such as Ampicillin
(to cover L.monocytogenes & Enterococcus)&
Cefotaxime/ Ceftriaxone.
• This regimen is effective against usual bacteria
causing sepsis, UTI & Enteritis in infants.
• If meningitis is suspected, VANCOMYCIN
should be added to t/t possible Penicillinase
resistant S. Pneumoniae until C/S reports
come.
• A well looking infant with no clinical focus of
infection (TC < 15000, Band form< 20%, CRP
neg, urine WBC <10HPF) can be observed at
home without antibiotics.
LOW RISK CRITERIA IN 1-3 MONTHS
OLD WITH FEVER
Boston Criteria
3-36 Months
• Risk of serious bacterial infections is 5%.
• Detailed Immunization H/O
• Sick contacts in family.
Management
• Sick looking babies – Admit.
• Prompt administration of antibiotics after
collecting Urine, blood, CSf Samples.
• HiB bacteremia is characteristically associated
with higher risk of localized serious infection
than S. Pneumoniae.
• .
• Empirical antibiotic therapy is recommended
for well appearing children < 36 months who
have not received HiB & Conj. pneumococcal
vaccine& who have rectal temp > 39 C with TC
> 15000
Management of Fever without
localizing signs.
THANK YOU
• Nelson 18th ed

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Fever without focus

• Fever is defined as a rectal temperature

• Body temperature is regulated by

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