Description of Acute Febrile Illness

1. Acute Febrile Illness Dr. S. Aswini Kumar. MD Professor of Medicine Medical College Hospital Thiruvananthapuram

2. Acute febrile illness should be approached with consideration and caution: Definition: Temperature >38.5OC For >2 consecutive days Life threatening in 1% as a result of complications Clinical Examination + Routine, Screening And Special tests Complete recovery is the rule in >99% of these patients Detailed history with occupation and contact required 2

3. Viral Fever can be suspected from following history: Generalized aches and pains without real arthralgiaor arthritis High grade continuous or remittent fever without chills Dry cough with Minimal white mucoid sputum Nonspecific headache which corresponds with increase in temperature Running nose, sneezing & nasal block characteristic of influenza 3

4. One must check for the vital signs carefully in every patient: Check the pulse rate for tachycardia or relative bradycardia Respiratory rate for any tachypnoea as in bronchopneumonia Check sensorium to exclude Encephalitis, NMS or Cerebral malaria Record blood pressure for evidence of hypotension or shock suggesting sepsis Record the Temperature and verify in accordance with the pulse rate 4

5. Now to proceed with a systematic examination for: Look for evidence of pharyngitis or tonsillitis throat ulcers or abscesses Auscultate the lung fields for any bronchial breathing/crepitations Look for meningeal signs focal deficits, increased ICT and plantar reflex Palpate the abdomen for hepatosplenomegaly or any renal mass Auscultate the heart for any tachycardia, murmur or gallop 5

6. Routine tests to exclude other causes of fever are: Urine examination under the microscope for any Urinary Deposits Peripheral Smear for any atypical lymphocytes, abnormal cells or parasites Chest X-Ray PA For any Homogenous or Non-homogenous shadows Blood TC DC ESR for any leucocytosis, lymphocytosis, neutropeniaor high ESR Platelet Count for any thrombocytopenia or thrombocytosis 6

7. General measures to be taken in uncomplicated Viral Fever: Plenty of fluids boiled and cooled, tender coconut or kanji water Complete bed rest is advised in every patient till the fever subsides Hospitalization? very sick patient, any complications Antipyretic drugs – acetaminophen, mefenemic acid Easily digestible diet kanji or oats or even plain rice and vegetables 7

8. If the temperature is more than 400C, it should be managed by: Tepidsponging of whole body with luke warm water but not tap/well/ice water Drinking plenty of water is mandatory to ensure good urine output Small breeze of air, cold compresses or Internal cooling Good ventilation to the room should be provided Only if there is chills consider covering with a blanket 8

9. Antibiotic therapy is indicated only in certain circumstances: Secondary Infection of upper respiratory tract like pharyngitis Diabetics and patients on chemotherapy or radiation Old Patient with immobility, incontinence institutionalization Community acquired or hospital acquired bacterial pneumonia HIV other types of immuno-compromized patients 9

10. Life threatening complications may occur in viral fever: Viral Myocarditisif tachycardia or hypotension Viral Meningoencephalitis if alteratedsensorium Thrombocytopenia <40,000 + bleeding <20,000 – bleeding Viral Gastroenteritis if profuse watery diarrhea Viral Bronchopneumonia if tachypnoea or rales 10

11. Weil’s disease is likely to occur in the following circumstances: Exposure to rat’s urine via abraded lower limbs Sewer Work or working in a paddy field Flooded water contaminated with drainage water - Anybody can get it Swimming in ponds or even a swimming pool or rafting Contamination of drinking water with rat’s urine 11

12. Diagnosis of Weil’s Disease can be suspected if there is: Mild to moderate Jaundice which is rapidly progressing Rapid decline in quantity of urine or not passing urine Hepato-renal Involvement - often requiring dialysis SubconjunctivalHemmorrahge is classical Sever muscle pain and Muscle tenderness up on pressure 12

13. Investigations to arrive at a diagnosis of Weil’s disease are: Urine examination shows protinuria and RBC casts Mild to moderate thrombocytopenia is common Weil’s Antibody? IgM or Rapid ELISA PCR in 1st week Blood routine will shows PMN leucocytosis Abnormal renal function – high blood urea and creatinine 13

14. Important complications of Weil’s disease are: Acute onset Hemorrhagic Pneumonia Acute Renal Failure develops rapidly over 1-2 days Bilateral Iridocyclitis - a non-fatal complication, which may lead to blindness Aseptic Meningitis is common but usually non-fatal Weil’s Myocarditis with tachycardia and hypotension 14

15. Fatal outcome of these complications of Weil’s disease are: Acute Respiratory Distress Syndrome with dyspnea Progressive azotemiaresulting from acute renal shut down Internal bleeding - Transfusion of fresh blood or packed cells Cerebral edema is another fatal complication Arrhythmia cardiogenic shock and acute heart failure 15

16. Crystalline penicillin is the drug of choice in Weil’s disease because: Weil’s disease No drug resistance so far to penicillin in Weil’s disease It is a leptospiraldisease due to L. Icterohemorrhagiae Earlier the trt the better Or Erythromycin Or Amoxycillin Doxycyclin Practically no side effects including anapylaxis seen The organism is universally sensitive to penicillin 16

17. Infective hepatitis as differential diagnosis of Weil’s Disease Loss of appetite especially to fried foods Gradually progressive jaundice over one or two weeks Viral markers HAV HBV HCV Aversion to cigarettes in smokers as a surprise High SGPT levels when compared to SGOT levels 17

18. Septicemia is the other possibility in acute febrile illness with jaundice: Source of sepsis can be very subtle like the IV cannula Evidence of Septic shock - hypotension and cold extremities Severe Sepsis - Dysfunction of organs distant from Site of infection Multi-organ dysfunction – kidney heart and lungs Signs of inflammation – redness, swelling and tenderness 18

19. Management of Sepsis has following essential components: Sequence of events SIRS, Sepsis and severe sepsis Antibiotic Cocktail covering gram +ve, -ve and anaerobic Drotrecogin Alfa Activated Protein C 24 µg/kg per hour IV infusion Admission to the medical intensive care mandatory In best of centers the Mortality rate is 5-15% 19

20. Dengue fever can be suspected from the following symptoms: High grade fever lasting for more than 2 days in duration Retro-orbital pain - Pain behind the eyes is considered diagnostic Epidemic in the community - seasonal febrile emergency Severe bone and joint pains of upper and lower limbs Mosquito bite especially during morning hours 20

21. Dengue Hemorrhagic fever is identified by the detection of: Classical dengue fever history some times a biphasic illness Bleeding tendencies- purpura, petechiae, echymosis Increased Capillary Permeability resulting in Polyserositis Positive tourniquet test – simple done any where Thrombocytopenia Platelet count <1,00,000 21

22. Steps in Tourniquet test for diagnosing Dengue fever are: Wait for 5 minutes keeping the blood pressure elevated A BP apparatus is used for this purpose which is tied around the upper arm More than20 Petechiae highly suggestive of but how ever not diagnostic of Dengue Mercury column is elevated to between systole diastole Count the number of petechiae one inch square marked 22

23. 2nd infection with another serotype is dangerous because: The dengue Virus has 4 Serotypes, which do not have cross resistance Homologous Antibodies are formed against the dengue I viruses and neutralizes them Dengue 2 virus-HAB complexes enter monocytes and replicate rapidly Hetrologous Antibodies against Dengue I remain and form non-neuralizing complexes Transmission is by AedesEgypti mosquito which feed the virus and injects it 23

24. Diagnosis of Chikungunya Fever can be considered if: Severe and prolonged functional disability lasting for months or even years Severe arthralgia involving the peripheral small and large joints symmetrically IgM levels are elevated; Virus isolation facilities are not available Desquamating rash all over the trunk and limbs but sparing the palms and soles Elevated SGOT and CRP levels are suggestive 24

25. Treatment of Chikungunya Fever consists of the following: Anti-inflammatory agent to combat the arthritis No specific treatment is available for Chikungunya Chloroquine /HCQS/Salazopyrine found to be useful Or if necessary Steroids There is no vaccine currently available for chikungunya Aspirin, ibuprofen, naproxen and other NSAIDs 25

26. The Novel H1N1 Influenza virus infection in 2009: No longer called as Swine flu as swine is not involved Virus were detected in April 2009 in San Diego, US The novel virus has a structure of Hemagglutinin 1 and neuraminidase 1 This created a new pandemic as well as a panic 26 The human and swine strain of Influenza is mixed in the swine

27. Diagnosis of H1N1 Fever can be considered if patient is having: The government started screening travellers in the airports The symptoms are the same as that of any severe flu The confirmation of diagnosis was done by R- PCR technique in Rajeev Gandhi Institute It rapidly spread in the community as there was no resistance Throat swabs were taken and sent to specified labs 27

28. Treatment of of H1N1 Fever can be very simple in uncomplicated: Artificial ventilator support needed in selected case The patient should rest at home isolated from others New vaccines have been produced but not currently available in India Shall be admitted to an intensive isolation facility if breathless Tamiflu should be started in all category B patients 28

29. Prevention of H1N1 Influenza Fever is considered more important Wearing a mask effectively prevents transmission Washing hands every time after seeing a patient If you develop fever to stay at home till all the fever and symptoms have subsided Or ideally alcohol based hand washes should be used Patients also should be taught the same principles 29

30. Lobar Pneumonia is recognized by the symptom triad and CXR High grade remittent fever, cough productive of sputum Laterally placed catching type of pleuritic pain Clarithromycin Or Azithromycin Or Levofloxacin Rusty Sputum or mild degree of frank hemoptysis Characteristic Air Bronchogram inside homogenous opacity 30

31. Acute Malaria is possible if patient has travelled outside Kerala: Intermittent high grade fever with chills and rigor Peripheral smear –parasites with blue cytoplasm, red nucleus Artesunate 50mg 4 TAB ODX3D +Metakelfen 3TAB Day 1 Rapid Malaria test – Highly sensitive and specific test Anemia jaundice and Moderate splenomegaly 31

32. Acute Meningitis as a cause for Acute Febrile Illness: Bacterial or Viral origin can not be distinguished clinically Signs of meningitis – neck stiffness, Kerning’s, Brudzinski Meningitic Dose Ceftriaxone 2gm IV BID 10-14 days Classical triad of symptoms of Meningitis Lumbar Puncture is done under asceptic caution after CT 32

33. Diagnosis of Enteric Fever can be suspected from following: Step ladder fever manifest if the initial fever pattern is not altered by antibiotics Splenomegaly is usually mild to moderate along with mild hepatomegaly Blood/ Clot Culture for Salmonella Typhi if +ve is Proof of diagnosis Abdominal pain, diarrhoea vomiting and malena are characteristic of enteric Single positive Widal Test is not diagnostic of enteric in endemic areas 33

34. Urinary Tract Infection is managed in the following lines: Urinary Deposits will show pus cells and bacteria along with presence of albumin Ciprofloxacin started and after C & S results changed to Sensitive Antibiotics Urinary Alkalinization Potassium citrate 2 tbs twice daily Urine Culture and sensitivity test should be done with mid-stream specimen Patients should be motivated to drink several liters of water every day 34

35. Diagnosis of Brucellosis can be suspected from following: Cervical lymphadenopathy & hepatosplenomegaly is highly suggestive Contact with Animals like in farming or handling animal meat Brucella Antibody Test Streptomycin + Tetracycline In areas endemic for TB Other wise Rifampicin Drinking unpasteurized or raw milk gives a definite risk of developing Brucellosis Brucella Antibody Test is diagnostic otherwise demonstration in FNAC 35

36. Focal infections require appropriate radiological investigations: Trans Thoracic Echo or better still TEE is helpful in detecting BE vegetations CXR is indicated in cases like suspected lung abscess bronchopneumonia MRI and MR Spectroscopy Can detect even small sized Brain Abscess & tuberculoma Ultrasound Scan is very useful in detecting, liver and splenic abscess or PID CT of abdomen is better for demonstrating retroperitoneal abscess 36

37. Neuroleptic Malignant Syndrome occurs with intake of several drugs: Any drug which acts at the level of The Central Dopaminergic System Hyperpyrexia is associated with severe extra-pyramidal lead pipe rigidity Bromocryptine 2.5mg orally BD Titrated up to 45mg/D There can be several autonomic symptoms like dry skin and dilated pupils These are mainly the Antipsychotic drugs belonging to neuroleptics 37

38. Miscellaneous conditions presenting as Acute Febrile Illness: Scrub Typhus, a tick borne Acute Ricketsial Infection is suggested by an Eschar Temporal Arteritis and other collagen diseases like SLE can also present acutely Pontine Hemorrhage Malignant Hyperthermia Heat Stroke, Thyroid storm Skin Infections like cellulitis, abscess and Varicella infections can cause AFI Acute Gout, septic arthritis and Acute Rheumatic fever DD of Acute Febrile Illness 38

39. Summary: A patient with acute febrile illness should be always received with consideration and caution 90% of these patients will have an uneventful course, with complete resolution of fever The ability of the physician is in identifying those with potentially fatal complications These patients must be admitted to intensive care immediately and well cared for Serial physical examinations and investigations are sometimes more important Unexpected lab results must be cross checked and repeated when necessary Diagnosis should not be postulated too early in the course of the disease Empirical Antibiotic therapy is not to be withheld in life threatening situations 39

40. Thank You For The Patient Listening 40