Dr D Ogoina

Dept of Medicine
Niger Delta University
 Define fever and describe pathogenesis of fever
 Discuss classification and types of fevers
 Outline management principles of fevers
 Fever (aka Pyrexia) is the most common reason
for presentation in most out-patient
departments.
 Most common symptom amongst children on
admission and a common cause of morbidity in
adult in-patients.
 Most typical symptom indicative of an
infection.
 May also occur in non-infectious diseases.
 In healthy individuals body temperature is kept at
normal ranges by thermoregulatory mechanisms
mediated by the hypothalamus.
 Normal temperature 36.8˚C +-0.4 ˚C (oral), 36.5-
37.5 ˚C (axillary temp), 37-38 ˚C (rectal) is
maintained by heat loss and conservation under
varying conditions.
 Temp shows a diurnal variation ; lowest in the
morning around 4am and highest in the evening
around 6pm.
 Also affected by physical activity, ingestion of
meals, menstrual cycle(ovulation) and hot
environment-all of which increase body temp.
 Fever is an elevation of body temperature that exceeds
the normal daily variation and occurs in conjunction
with an increase in the hypothalamic set point .
 Fever occurs in response to infection, inflammation
and trauma
 Should be differentiated from hyperthermia
 Hyperthermia is characterized by an
unchanged(normothermic) setting of the
thermoregulatory centers in conjunction with an
uncontrolled increase in body temp. that exceeds the
body's ability to lose heat.
 Body temp. is recorded using a thermometer at
several sites. Intraoesophageal infrared
thermometry is closest to core temp. others are Ear,
Rectal, Oral and Axillary thermometry in ↓ing
order of sensitivity.
 Fever is present if
 Rectal temp> 38˚C (100.4˚F)
 Oral temp> 37.7˚C (100˚F) (>37.2 ˚C in the morning)
 Axillary temp.> 37.5˚C (99.5˚F).
 Acute <7days, subacute <2weeks,
chronic>2weeks
 Hypothermia< 35˚C
 Normal temp- 37-38 ◦C
 Low grade fever- 38-39 ˚C
 Moderate grade fever- 39.1-40 ˚C
 High grade fever- 40.1-41-1 ˚C
 Hyperpyrexia ->41.1 ˚C
 Lethal temp -> 42.6 ˚C , < 25.6 ˚C
 Hyperpyrexia in severe malaria is defined as
axillary temp> 39.5 ◦C or rectal temperature
above 40 ◦C
 Infections- bacteria, fungal, viral , parasites
 Immunological disorders- SLE, RA
 Destruction of tissues- trauma, myocardial
infarction, pulmonary infarction, rhabdomyolysis.
 Neoplastic – haemopoietic, lymphoproliferative,
solid tumors, metastatic.
 Metabolic disorders- gout, porphyria
 Drugs –β lactams antibiotics, penicillin, atropine,
nitrofurantion, barbiturates etc
 Brain disorders- hemorrhage, tumors, infarction
( hypothalamic fever)
 Factitious fever.
 Hypothalamus(anterior and posterior)
 Autonomic nervous system(sympathetic and
parasympathetic nervous system)
 Skin, blood vessels
 Liver, muscle, adipose tissue, heart
 A pyrogen is any substance that induces fever.
 Exogenous pyrogens- micro-organisms or their products. egs
 Lipopolysaccharide LPS- endotoxin- from gram negative organisms
 Superantigens-Enterotoxins of gram positive organism-staph. aureus,
grp A and B streptoccocus.
 Muramyl dipeptidase MDP- peptidoglycan layer of gram positive
organism.
 Endogenous pyrogens-produced by monocytes, neutrophils,
lymphocytes, astrocytes on exposure to micro-org. or their
products.
 Include- IL-1, IL-6, TNFα, INFα, ciliary neurotropic factor(CNTF)
    
ENDO
TO X I N
 Chills
 Rigors
 Hotness or warmth
 Sweating
 Night sweats- particularly in TB, cancers.etc
 Weight loss- induced by TNF
 In presence of active infection fever may be
absent in seriously ill new born, elderly
patients, uremic patients, malnourished
children, patients on steroids or NSAID.
 Myalgias and althralgias- due to increase
peripheral release of PGE2.
 Loss of appetite- TNF , IL-1 directly inhibit
appetite.
 Altered mental state- TNF, IL-1 cause release of
β endorphins in brain.
 Herpes labialis- ↑body temp. may activate
latent herpes simplex.
 CVS- ↑in heart rate by 10-15beats per 1˚C↑, ↑ BP, ↑
PR.
 Temperature pulse dissociation- faget’s sign-
failure of HR ↑ with ↑ temp. seen in
 typhoid fever
 Brucellosis,
 Leptospirosis
 Mycoplasma pneumonia
 Meningitis with raised intracranial pressure
 Factitious fever
 Drug induced fever.
 Fever is a compensatory defensive mechanism
 Infection without fever is a bad prognostic sign.
 Fever cytokines have potent anti-infective
properties.
 With fever there is improved immune reactions.
 ↑ chemotaxis, ↑phagocytosis,↑bactericidal activity
of neutrophils, ↑antibody production,
↓proliferation of micro-organism, ↓plasma Fe,
zinc ,Cu- unfavourable growth of micro-organism.
 From RCT, however, no evidence that fever
facilitates recovery from an infection.
 Very high temp. = detrimental effects on
predisposed individuals e.g. children, elderly
 Febrile convulsions-common in children
 Precipitate cardiac arrthymias- in patients with
heart disease.
 Worsen cardiac or pulmonary dss in view of
↑O₂ demand and ↑Pul VR.
 Recording axillary temp> 37.5˚C.
 detailed history, physical examination,
investigations
 Type/Pattern of fever very important in
determining aetiology.
 Pattern of resolution-lysis(gradual drop) or
crisis(sudden drop) also useful in diagnosis.
 there are 3 classic types of fever. Continuous ,
intermittent and remittent.
 Classic types may not be seen because of use of
antibiotics and analgesics.
 Continuous fever- fever does not fluctuate
more 1˚C (1.5˚F) during 24hrs and at no time
touches normal.
 Examples- lobar pneumonia, typhoid
fever(slow step wise ↑), UTI, gram negative
septicemia, acute bacterial meningitis
DROP BY LYSIS
 Fever is present only for several hours during
the day.
 Seen in – malaria, pyogenic infections, TB,
schistosomiasis, lymphomas, Leptospira,
Borrelia.
 QUOTIDIAN TERTIAN QUARTAN
mixed p.falciparum, p.malariae
infections vivax

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days
1 2 1 2 3 1 2 3 4
39 TREATMEN
T
DROP BY CRISIS
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 Daily fever fluctuations exceed 2˚C but at no
time touches normal.
 Not typical of any disease.
 May be seen in infective endocarditis,
brucellosis (undulant fever.)
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40 101
temperature

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1 2 3 4 5 6 days
 Relapsing fever- days of fever (2-5days) followed
by afebrile days lasting 1week or less -typical of
louse and tick borne Borrelia infection
 Pel -Ebstein fever- low grade intermittent fever last
3-10days with afebrile periods of 3-10days. A rare
manifestation of Hodgkins lymphoma.
 Saddle back fever- fever for 1-2days, remission 2-3
days, then relapse of fever. Typical of dengue fever.
 Cyclic neutropenic fever- characteristically occurs
every 21days and accompany neutropenia.
 Febricula –mild fever of short duration of
indefinite origin and without any distinctive
pathology.
 Charcot's fever- fever with chills, right upper
quadrant pain and jaundice. Due to bile stones
 Fever inversa- change in diurnal variation- fever is
high in the morning than in the evening. Seen in
miliary TB.
 Monoleptic fever- single paroxysm of fever-may
follow drug reaction
 Polyleptic fever- fever with multiple paroxysms
e.g. malaria
 As a general rule symptomatic treatment should
not be offered for an undiagnosed fever in an adult
patient.
 Symptomatic treatment masks the fever, alters the
course of the disease and obscures the response to
treatment.
 Response of fever to antibiotics is an important
tool in monitoring progress of in-patients with
infectious diseases.
 When there is no dire need to reduce temp. fever
in hospital admitted patients should not be treated
symptomatically.
 High fevers in children and elderly.
 Patients with mod-severe cardiac,
cerebrovascular or pulmonary insufficiency.
 Hyperpyrexia – rectal temp>41.2˚C
 Hypothalamic fevers- e.g. intracranial
hemorrhage etc
 Diagnosed fever-treatment benefits patients, no
need/other means of monitoring response,--at
physicians discretion.
 Principle-reduce elevated hypothalamic set
point, facilitate heat loss.
 Facilitate heat loss- non specific measures-tepid
sponging, cooling blankets
 Reduce elevated hypothalamic set point by
↓PGE2 synthesis using drugs- aspirin,
acetaminophen, NSAID.
 Treat underlying cause- especially in cases of
PUO
 Fever is the most common symptom indicative of
an infection.
 Though inappropriate medications alter classical
fevers patterns a knowledge of the varying types
of fever in different diseases is essential in
evaluating and management of patients.
 Undiagnosed fever should preferably not be
treated symptomatically
 When diagnosis is established treatment should be
at the discretion of the attending physician.
 Questions and
comments