Fever

1. Body heat is generated by basal metabolic activity and muscle movement, and lost
by conduction (which is more effective in water than in air), convection,
evaporationand radiation (most important at lower temperatures when other
mechanisms conserve heat).
2. Body temperature is controlled in the hypothalamus, which is directly sensitive to
 Diseases of Rasavaha Srotas 39

changes in core temperature and indirectly responds to temperature-sensitive

neurons in the skin. The normal 'set-point' of core temperature is tightly regulated
within 37 +0.5'C, necessary to preserve the normal function of many enzymes
and other metabolic processes.
3. The temperature set-point is increased in response to infection
4. In a cold environment, protective mechanisms include cutaneous vasoconstriction
and shivering; however, any muscle activity which involves movement may
promote heat loss by increasing convective loss from the skin, and respiratory heat
loss by stimulating ventilation.
5. Ina hot environment, sweating is the main mechanism for increasing heat loses.
This usually occurs when the ambient temperature rises above 32.5°C or during
exercise.

6. "Fever implies an elevated core body temperature > 38.0°C, i.e. above the normal
daily variation.
7. Fever is a response to cytokines and acute phase proteins and is a common
manifestation of infection because microbial pyrogens or the endogenous
pyrogens released during tissue necrosis simulate specialised cells such as
monocytes/macrophages to release cytokines, although it also occurs in other
conditions.

Thermoregulation
Heat loss occurs through five mechanisms:
Radiation (55-65% of heat loss)
.Conduction (10-15% of heat loss but much greater in cold water)
Convection (increased in the wind)
Respiration
Evaporation (which are affected by the ambient temperature and the relative
humidity).
* The preopticanterior hypothalamus normally orchestrates thermoregulation
* The immediate defense of thermoneutrality is via the autonomic nervous system,
whereas delayed control is mediated by the endocrine system.
of norepinephrine,
* Autonomic nervous system responses include the release increase in
increased muscle tone, and shivering, leading to thermogenesis and an
the basal metabolic rate.
reflex vasoconstriction to conserve
* Cutaneous cold thermoreception causes direct
heat.
thyroid axis, leading to an
* Prolonged exposure to cold also stimulates the
increased metabolic rate.
 Vijñãna
40 Text Book of Vikrti Vijñãna & Roga

Causes of Fever
parasitic etc.
1. Infections: Bacterial, viral, rickettsial, fungal,
Neoplasms: Fever may be present with any neoplasm but commonly with
2. pancreas, lung
hypernephroma, lynmphoproliferative malignancies, carcinoma of
and bone and hepatoma.
Vascular: Acute myocardial infarction, pulmonary embolism, pontine
3.
haemorrhage etc.
4. Traumatic: Crush injury.
5. Immunological:
a. Collagen disease, SLE, Rheumatoid arthritis.
b. Drug fever
c. Serum sickness
6. Endocrine: Thyrotoxicosis, Addison's disease.
7. Metaboic : Gout, Porphyria, Acidosis, Dehydration
8. Hematological : Acute Haemolytic crisis
9. Physical agents: Heat stroke, Radiation, Sickness.
10. Miscellaneous :Factitious fever, Habitual hyperpyrexia, Cyclic neutropenia.
Special types offever
1. Fever with rigors: observed in
a. Malaria b. Kala azar
c. Filariasis d. Urinary tract infection, pyelonephritis
e. Cholangitis f. Septicaemia
g. Infective endocarditis h. Abscesses, any site
i. Lobar pneumonia
2. Fever with herpes labialis: Elevated body temperature may activate the herpes
simplex virus and cause small vesicles around the angle of the mouth (herpes
labialis). It occurs with:
a. Pneumonia b. Malaria
c. Meningitis d. Severe streptococcal infection
3. Fever with rash: observed in
a. Chicken pox b. Small pox
c. Measles d. Rubella
e. Typhus g. Allergy
4. Fever with membrane in the throat: Occurs in:
a. Diphtheria b. Infectious mononucleosis
c. Agranulocytosis d. Moniliasis
 Diseases of Rasavaha Srotas 41

e. Vincent's angina.
5. Fever with delirium: observed in
.Encephalitis
b. Typhoid state
c.Meningitis
d. Pneumonia (especially) in alcoholics and elderlypeople with dementia)
e. Hepatic encephalopathy
6. PUO (Pyrexia of Unknown Origin)
a. Temperature> 1010F (38.30C) on several occasions.
b. Duration 3weeks
c. Duration>1 week in hospital with failure to reach diagnosis.
Classification
a. Classical PUO lymphoma, collagen vascular disease, abscess, TB, viral
infection, endocarditis)
b. Nosocomial PUO : hospitalized, no fever on admission (thrombophlebitis,
catheter infections, deep vein thrombosis, drug fever, transfusion reaction)
C Neutropenic PUO :Absolute neutrophil count < 500 (fungal infection, perianal
infection)
d. PUO in HIV infection (TB. Pneumoncystis jiroveci, toxoplasma, cryptococcus,
CMV, Non Hodgkins Lymphoma.
Investigations
If the cause is not obvious, e.g. in a patient with purulent sputum or symptoms
rinary tract infection, then initial screening investigations should inclu
"A fullblood count with differential, including eosinophil count (Nutrophilia and
raised ESR and CRP in bacterial infections are observed in the initial phase of
fever).
" Urea and electrolytes, liver function tests, blood glucose and muscle enzymes
Inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive
protein (CRP)
" Auto-antibodies, including antinuclear antibodies (ANA)
" Chest X-ray and electrocardiogram (ECG)
"Urinalysis and urine culture
. Blood Culture (a minimum of 20 mL blood in three sets of blood culture bottles)
" Throat swab for culture
42
Text Book of Vikrti Vijñãna & Roga Vijñna
"Other specimens, as indicated by history and examination, e.g. wound swab;
OPutumn culture; stool culture. microscopy for ova and parasites and Clostridiunt
dtficile toxin assay; if relevant. malaria films on 3 consecutive days or a malaria
rapid diagnostic test (antigen detection by lateral flow immunochromatograph.
Subsequent investigations in patients with HIVrelated, immune-deficient,
nosocomial or travel related pyrexia and in patients with associated symptomsor
signs of involvement of the respiratory, gastrointestinal or neurological systems.
Management
Fever and its associated systemic symptoms can be treated with paracetamol, and
by tepid sponging to cool the skin. Replacement of salt and water is important in
patients with drenching sweats. Further management is focused mainly on cause.