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Dr.Jithesh.K, MD (Gen. Medicine)
Consultant Physician
Baby Memorial Hospital
1
2
 Mean oral temperature
 36.8 ± 0.4 °C or 98.2 ± 0.7 °F
 low levels at 6 A.M. and higher levels at 4 to 6 P.M.
 Maximum...
 Oral temperature
 Accurate and convenient
 usually quoted at 37°C (98.6°F)
 Place thermometer under tongue, then clos...
 Axillary temperature
 Reads 1°C lower than oral temperature
 Takes 5-10 minutes to register
 Lower accuracy
 Place t...
 Rectal temperature
higher than oral temperatures by 0.4 to 0.5°C
patient lies on one side with the hip flexed
Select ...
 Tympanic Membrane temperature
measures core body temperature
higher than the normal oral temperature by 0.8°C
measure...
Range °C
Hypothermia <36
Normal 37
Low Grade or Mild 38.2-39
Moderate or Average 39 – 40
High-Grade 40 – 41.5
Severe > 41....
 Fever
is an elevation of body temperature
that exceeds the normal daily
variation and occurs in conjunction
with an inc...
 FEVER is a Diagnostic Clue
 It is an essential host defense mechanism
 Associated with or without localizing signs
 I...
 Fever may not be present despite infection,
inflammation and neoplasm in:
Newborn
Elderly
Uremia
Significant malnour...
INCREASE IN HYPOTHALAMIC
SETPOINT
 Feeling of cold despite an
increase in body temperature
 Vasoconstriction in hands an...
WHEN HYPOTHALAMIC SET
POINT IS AGAIN RESET
DOWNWARD
 Intense sweating
 Hot skin (vasodilatation)
Harrison’s Principles of Internal Medicine, 16th
Edition
Infection, microbial toxins,
mediators of inflammation,
immune re...
Reference: Fever: From Symptom to Treatment (1978) 15
 Sustained (Continuous)
Fever:UTI,Pneumonia,Typhus,brucellosis
 Intermittent Fever (Hectic
Fever);Malaria,Kalaazar,septi...
 Infection,Inflammation and Neoplasm
 Exogenous pyrogens: derived from outside an
individual and may include LPS and tox...
 Below 97 degree F – Hypothermia
 98.4 degree F - Normal
 98 to 102 degree F – INFECTIONS
 102 degree to 105 degree F ...
 Heat production exceeds
heat loss, and the
temperature exceeds the
individuals set point
 Heat stroke: Exercise, Anticholinergic
 Drug induced: Cocaine,
Amphetamine,MAO inh.
 Neuroleptic malignant
syndrome:Ph...
 History
 Antipyretics are not effective
 Skin is hot but dry
“THERE IS NO SUBSTITUTE
FOR OBSERVING THE PATIENT,
TALKING TO HIM AND
THINKING ABOUT HIM.”
26
27
 RESPIRATORY SYMPTOMS – URTI ,LRTI,PTB etc
 URINARY SYMPTOMS – UTI,APN,CYSTITIS
 ABDOMINAL SYMPTOMS – DYSENTRY,ABSCESS,...
 MALARIA
 DENGUE FEVER
 VIRAL FEVERS
 TYPHOID
 TUBERCULOSIS
 SCHISTOSOMIASIS - eg Egypt
ENDEMIC AREAS
 BIRDS – SARS, PSITTACOSIS
 ANIMALS CONTACT- TOXOPLASMOSIS (CAT),
BRUCELLOSIS (CATTLE),LEPTOSPIROSIS (RAT)
 UNCOOKED ME...
Fever
 Physical Examination:
Vital Signs
Skin Lesions,Mucous Membrane
Lymphadenopathy
Eyes
Lungs and Heart
Abdominal Regi...
33
 VIRAL FEVERS – LEUCO & THROMBO CYTOPENIA
 INFLUENZA – URTI SYMPTOMS
 POLYMYOSITIS – PROXIMAL M WEAKNESS, MUSCLE
PAIN &...
 TUBERCULOSIS
 LYMPHOMA
 ABSCESS
 BRUCELLOSIS
 INFECTIVE ENDOCARDITIS
 ALCOHOL WITHDRAWAL SYNDROME
 RELATIVE
BRADYCARDIA
 TYPHOID FEVER
 MALARIA
 MENINGITIS
 LEPTOSPIROSIS
 VIRAL
 DRUG FEVER
 RELATIVE
TACHYCARDIA
...
 EYE PAIN – TEMPORAL ARTERITIS
 WATERY EYES- PAN,CONJUNCTIVITIS
 DRY EYES – SLE,RA
 SC HGE –Leukaemias,SBE
 CONJUNCTI...
 DENGUE
 RICKETTSIAL INFC.
 LYME’S DISEASE
 JRA
 MEASLES/RUBELLA
 CHICKEN POX/HZ
38
 LEPTOSPIROSIS
 HEPATITIS- DRUGS (ATT) ,VIRAL
 ALCOHOLIC HEPATITIS
 CIRRHOSIS OF LIVER
 HEPATOMA
 VIRAL FEVERS
 MAL...
 LEUKEMIA – ALL , CLL
 LYMPHOMA – MEDIASTINAL INVOLVEMENT
 HIV INFECTION – ORAL CANDIDIASIS,THIN
BUILT,
 TOXOPLASMOSIS...
 MILIARY TB
 LYMPHOMA
 HIV INFECTION
 SYPHILIS
 Local infections
 MALARIA
 TYPHOID
 LYMPHOMA
 LEUKEMIA
 DISSEMINATED TB
 INFECTIVE ENDOCARDITIS
 BRUCELLOSIS
 KALA AZAR
 ENCEPHALITIS +/-
MENINGITIS
 MENINGISM- TYPHOID
 HIV
 BRUCELLOSIS
 CNS NEOPLASMS
 TOXIC encephalopathy
 TONGUE- RELAPSING FEVER
 TRAPEZIUS – SUB DIAPHRAGMATIC ABSCESS
 STERNAL – METASTASIS, PRE –LEUKEMIA
 SPINAL – BRUCELL...
 SEPSIS
 Leptospirosis/Dengue
 H1N1/SARS INFECTION
 HANTA VIRUS INFECTION
 CEREBRAL MALARIA (P FALCIPARUM )
 TB
 TEMPORAL ARTERITIS
 CARCINOMA
 LYMPHOMAS
 ABSCESS
 MYELOPROLIFERATIVE DISORDER
 DENGUE FEVER
 VIRAL FEVERS
 LEUKEMIA
 LYMPHOMA
 MYELOPROLIFERATIVE DISORDER
 DRUG FEVER
 SLE
 HIV INFECTION
 Assess the extent and severity of the
inflammatory response to infection
 Determine the site(s) and complications
of or...
 CBC (diff.)+ESR
 Urine R/E
 RBS
 RFT and L.F.T.
 PBS Routine / Malaria
 Two Blood Cultures,10ml each in 30 min.
Int...
 PNEUMONIAS
 TB
 CA LUNG/ABSCESS
 LYMPHOMAS- MEDIASTINAL INVOLVEMENT
 SARCOIDOSIS
 AUTOIMMUNE DISEASES
 ABSCESS
 HEPATOMA
 HYPERNEPHROMA
 LYMPHOMA
 PELVIC TUMORS
 BLOOD CULTURE and Bone marrow aspiration C&S - IE,SEPSIS
 ANA PROFILE – CONNECTIVE TISSUE DISORDERS
 AGGLUTININ TEST -...
 Biopsies:
Bone marrow
Lymph node
Skin lesion
Liver
Temporal artery
54
LEPTOSPIROSIS
56
 PATHOGENEGIS
Contamination of the drug with a
pyrogen or microorganism
Pharmacologic action of the drug
itself
Allerg...
 All drugs can produce Drug INDUCED fever except DIGOXIN
 Bradycardia, hypotension, Skin rash, pruritus +,
 Eosinophili...
 Fever out of proportion to
clinical picture
 Associated findings:
Rigor (43%), Myalgia (25%), Rash
(18%), Headache (18...
 Onset and duration:
Onset: 1-3 weeks after the start of
therapy
Duration: remits 2-3 days after
therapy is stoped
 Classic FUO
 Nosocomial FUO
 Neutropenic FUO
 HIV-Associated FUO
 Definition:
Fever of 38.3 C or higher on
several occasions
Fever of more than 3 weeks
duration
Diagnosis uncertain, d...
 Definition:
Fever of 38.3 or higher on
several occasions
Infection was not manifest or
incubating on admission
Failur...
 Definition:
Fever of 38.3 or higher on
several occasions
Neutrophil count is <500/mm3
or is expected to fall to that
l...
 Definition:
Fever of 38.3 or higher on
several occasions
Fever of more than 3 weeks for
outpatients or more than 3
day...
Infections 22-58%
Neoplasms up to 30%
Noninfectiouse
inflammatory diseases
up to 25%
Miscellaneous causes up to 25%
Undiag...
 Localized pyogenic infections
 Intravascular infections
 Systemic bacterial infections
(Tuberculosis, Brucellosis,…)
...
 Hodgkin’s disease
 Non-hodgkin’s lymphoma
 Leukemia
 Renal cell carcinoma
 Hepatoma
 Colon carcinoma
 Atrial myxoma
 Collagen vascular/
hypersensitivity
diseases
Lupus
Still’s disease
Temporal
arteritis (Giant
cell arteritis)
 Granul...
 Drug fever
 Factitious fever
 FMF
 Recurrent pulmonary
emboli
 Subacute thyroiditis
 Diagnosis should be considered in any FUO,
especially in:
Young women
Persons with medical training
If the patients c...
Undiagnosed 19%
Miscellaneous 13%
Factitious 9%
Granulomatous hepatitis 8%
Neoplasm 7%
Infection 6%
No fever 27%
 To lower the body temperature
 To completely eradicate the pathogen
73
 Most fevers are associated with self-limited
infections, most commonly of viral origin.
 For each 1 °C elevation of body
temperature:
Metabolic rate increase 10-15%
Insensible water loss increase
300-500ml/m...
 Reasons to treat fever:
The elderly individual with pulmonary or
cardiovascular disease
The patient at additional risk...
 Reasons not to treat fever:
 The growth and virulance of some organisms
 Host defense-related response
 Fever is an i...
 Persons who are clinically unstable or are at
risk for rapid deterioration
 Major alterations of immunity
 Need for IV...
Objectives of treating fever
 reduce the elevated hypothalamic set point
 facilitate heat loss
.
ANTIPYRETICSANTIPYRETICS
 drugs that reduce fever
 drugs that cause a lowering of the elevated
hypothalamic set point
...
 Acetaminophen is generally a first-line antipyretic
due to being well tolerated with minimal side
effects.
 Pediatric d...
 a poor cyclooxygenase inhibitor in peripheral
tissue and is without noteworthy anti-
inflammatory activity
 oxidized by...
Membrane Lipid
Arachidonic Acid
Phospholipase A2
EndoperoxidesHydroperoxides
TXA
PGE, PGEF
PGILeukotrienes
Cyclooxygenas
e...
84
 Use of antimicrobial therapy directed against
the pathogen
85
 agents used to destroy or inhibit the growth of
other microorganisms
 used to inactivate microbial cells
 limit toxici...
 Selective toxicity
 Inhibition of cell wall synthesis
 Β-lactams (Penicillin and Cephalosporin)
 Vancomycin
 Inhibit...
 Widespread sensitization of the population
 Changes in the normal flora of the body
 Masking serious infection without...
 ALL WE KNOW IS STILL INFINITELY
LESS THAN ALL THAT REMAINS UNKNOWN….
-WILLIAM HARVEY -
Evaluation of a patient with fever
Evaluation of a patient with fever
Evaluation of a patient with fever
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Evaluation of a patient with fever

Presented in IMA Perambra by Dr.Jithesh.K,MD(c).Senior consultant Physician

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Evaluation of a patient with fever

  1. 1. Dr.Jithesh.K, MD (Gen. Medicine) Consultant Physician Baby Memorial Hospital 1
  2. 2. 2
  3. 3.  Mean oral temperature  36.8 ± 0.4 °C or 98.2 ± 0.7 °F  low levels at 6 A.M. and higher levels at 4 to 6 P.M.  Maximum normal oral temperature  37.2 ° C or 98.9 ° F at 6 A.M.  37.7 ° C or 99.9 ° F at 4 P.M.  Normal daily temperature variation  0.5 ° C or 0.9 ° F Reference: Harrison’s Principles of Internal Medicine, 16th ed. 3
  4. 4.  Oral temperature  Accurate and convenient  usually quoted at 37°C (98.6°F)  Place thermometer under tongue, then close both lips  Mercury: 3-5 minutes ; Electric: 10 seconds Reference: Bates’ Guide to Physical Examination and History Taking4
  5. 5.  Axillary temperature  Reads 1°C lower than oral temperature  Takes 5-10 minutes to register  Lower accuracy  Place the thermometer under the armpit and fold the arm across the chest to hold the thermometer in place. Reference: Bates’ Guide to Physical Examination and History Taking5
  6. 6.  Rectal temperature higher than oral temperatures by 0.4 to 0.5°C patient lies on one side with the hip flexed Select a rectal thermometer with a stubby tip, use a lubricant, and insert it about 3-4 cm into the anal canal for about 3 minutes Reference: Bates’ Guide to Physical Examination and History Taking6
  7. 7.  Tympanic Membrane temperature measures core body temperature higher than the normal oral temperature by 0.8°C measure radiant heat energy from the tympanic membrane and nearby ear canal Position the probe in the canal and wait 2 to 3 seconds 7
  8. 8. Range °C Hypothermia <36 Normal 37 Low Grade or Mild 38.2-39 Moderate or Average 39 – 40 High-Grade 40 – 41.5 Severe > 41.5 8
  9. 9.  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. a protective mechanism of the body
  10. 10.  FEVER is a Diagnostic Clue  It is an essential host defense mechanism  Associated with or without localizing signs  It can be due to Infection, inflammation or neoplasm
  11. 11.  Fever may not be present despite infection, inflammation and neoplasm in: Newborn Elderly Uremia Significant malnourished individual Taking corticosteroids
  12. 12. INCREASE IN HYPOTHALAMIC SETPOINT  Feeling of cold despite an increase in body temperature  Vasoconstriction in hands and feet  Shivering  Increase in heart rate & muscle tone (increases about 18 beats per minute for each degree Celsius increase in temp.)  Behavioral adjustments
  13. 13. WHEN HYPOTHALAMIC SET POINT IS AGAIN RESET DOWNWARD  Intense sweating  Hot skin (vasodilatation)
  14. 14. Harrison’s Principles of Internal Medicine, 16th Edition Infection, microbial toxins, mediators of inflammation, immune reactions Microbial toxins FEVER Monocytes/macrophages, endothelial cells, others Pyrogenic cytokines IL-1, IL- 6, TNF, IFN Cyclic AMP PGE₂ Hypothalamic endothelium Elevated thermoregulatory set point Heat conservation, heat production Circulation 14
  15. 15. Reference: Fever: From Symptom to Treatment (1978) 15
  16. 16.  Sustained (Continuous) Fever:UTI,Pneumonia,Typhus,brucellosis  Intermittent Fever (Hectic Fever);Malaria,Kalaazar,septicaemia..  Remittent Fever:IE  Relapsing Fever: Tertian Fever;P.Vivax Quartan Fever;P.Ovale,P.Malariae Pel Ebstein Fever (Days of Fever Followed by a Several Days Afebrile);Hodgkins Lymphoma
  17. 17.  Infection,Inflammation and Neoplasm  Exogenous pyrogens: derived from outside an individual and may include LPS and toxins.  Endogenous pyrogens: originating inside the body and may include pyrogenic cytokines,IL-1, IL-6, TNF.  Brain lesions  Compression of the hypothalamus by a brain tumor.  Operations in the region of the hypothalamus
  18. 18.  Below 97 degree F – Hypothermia  98.4 degree F - Normal  98 to 102 degree F – INFECTIONS  102 degree to 105 degree F – “NO MAN’S LAND”  106 degree and above – Non- infectious fever (Hyperpyrexia)
  19. 19.  Heat production exceeds heat loss, and the temperature exceeds the individuals set point
  20. 20.  Heat stroke: Exercise, Anticholinergic  Drug induced: Cocaine, Amphetamine,MAO inh.  Neuroleptic malignant syndrome:Phenothiazine  Malignant hyperthermia: Inhalational anesthetics  Endocrinopathy: thyrotoxicosis, pheochromocytoma
  21. 21.  History  Antipyretics are not effective  Skin is hot but dry
  22. 22. “THERE IS NO SUBSTITUTE FOR OBSERVING THE PATIENT, TALKING TO HIM AND THINKING ABOUT HIM.”
  23. 23. 26
  24. 24. 27
  25. 25.  RESPIRATORY SYMPTOMS – URTI ,LRTI,PTB etc  URINARY SYMPTOMS – UTI,APN,CYSTITIS  ABDOMINAL SYMPTOMS – DYSENTRY,ABSCESS,ACUTE ABDOMEN  ARTHRITIS SYMPTOMS –RA,SLE,AS  CARDIOVASCULAR SYMPTOMS- IE,pericarditis  TRAVEL HISTORY  DIETARY HISTORY  OCCUPATIONAL HISTORY
  26. 26.  MALARIA  DENGUE FEVER  VIRAL FEVERS  TYPHOID  TUBERCULOSIS  SCHISTOSOMIASIS - eg Egypt ENDEMIC AREAS
  27. 27.  BIRDS – SARS, PSITTACOSIS  ANIMALS CONTACT- TOXOPLASMOSIS (CAT), BRUCELLOSIS (CATTLE),LEPTOSPIROSIS (RAT)  UNCOOKED MEAT/SEA FOOD/ - HEPATITIS –A & E,SALMONELLA  UNPASTEURIZED MILK – SALMONELLA,Instestinal TB,BRUCELLOSIS  HIGH RISK BEHAVIOURS - STDS,HIV,HBV,HCV,IV ABUSE
  28. 28. Fever
  29. 29.  Physical Examination: Vital Signs Skin Lesions,Mucous Membrane Lymphadenopathy Eyes Lungs and Heart Abdominal Region (Hepatomegaly,Splenomegaly) Neurological Exam. ENT Musculoskeletal
  30. 30. 33
  31. 31.  VIRAL FEVERS – LEUCO & THROMBO CYTOPENIA  INFLUENZA – URTI SYMPTOMS  POLYMYOSITIS – PROXIMAL M WEAKNESS, MUSCLE PAIN & TENDERNESS, CPK HIGH  MENINGOCOCCAL INFECTION -Rash  SEPSIS
  32. 32.  TUBERCULOSIS  LYMPHOMA  ABSCESS  BRUCELLOSIS  INFECTIVE ENDOCARDITIS  ALCOHOL WITHDRAWAL SYNDROME
  33. 33.  RELATIVE BRADYCARDIA  TYPHOID FEVER  MALARIA  MENINGITIS  LEPTOSPIROSIS  VIRAL  DRUG FEVER  RELATIVE TACHYCARDIA  TOXINS
  34. 34.  EYE PAIN – TEMPORAL ARTERITIS  WATERY EYES- PAN,CONJUNCTIVITIS  DRY EYES – SLE,RA  SC HGE –Leukaemias,SBE  CONJUNCTIVITIS – TB,SLE  CONJUNCTIVAL SUFFUSION- LEPTOSPIROSIS  UVEITIS- TB,SLE,SARCOIDOSIS
  35. 35.  DENGUE  RICKETTSIAL INFC.  LYME’S DISEASE  JRA  MEASLES/RUBELLA  CHICKEN POX/HZ 38
  36. 36.  LEPTOSPIROSIS  HEPATITIS- DRUGS (ATT) ,VIRAL  ALCOHOLIC HEPATITIS  CIRRHOSIS OF LIVER  HEPATOMA  VIRAL FEVERS  MALARIA
  37. 37.  LEUKEMIA – ALL , CLL  LYMPHOMA – MEDIASTINAL INVOLVEMENT  HIV INFECTION – ORAL CANDIDIASIS,THIN BUILT,  TOXOPLASMOSIS- WITH LIVER,SPLEEN  DISSEMINATED TUBERCULOSIS – WITH LIVER ,SPLEEN  BRUCELLOSIS- WITH LIVER,SPLEEN
  38. 38.  MILIARY TB  LYMPHOMA  HIV INFECTION  SYPHILIS  Local infections
  39. 39.  MALARIA  TYPHOID  LYMPHOMA  LEUKEMIA  DISSEMINATED TB  INFECTIVE ENDOCARDITIS  BRUCELLOSIS  KALA AZAR
  40. 40.  ENCEPHALITIS +/- MENINGITIS  MENINGISM- TYPHOID  HIV  BRUCELLOSIS  CNS NEOPLASMS  TOXIC encephalopathy
  41. 41.  TONGUE- RELAPSING FEVER  TRAPEZIUS – SUB DIAPHRAGMATIC ABSCESS  STERNAL – METASTASIS, PRE –LEUKEMIA  SPINAL – BRUCELLOSIS,TYPHOID,SBE,OM  THIGH- POLYMYOSITIS,BRUCELLOSIS  CALF – POLYMYOSITIS, RMSF
  42. 42.  SEPSIS  Leptospirosis/Dengue  H1N1/SARS INFECTION  HANTA VIRUS INFECTION  CEREBRAL MALARIA (P FALCIPARUM )
  43. 43.  TB  TEMPORAL ARTERITIS  CARCINOMA  LYMPHOMAS  ABSCESS  MYELOPROLIFERATIVE DISORDER
  44. 44.  DENGUE FEVER  VIRAL FEVERS  LEUKEMIA  LYMPHOMA  MYELOPROLIFERATIVE DISORDER  DRUG FEVER  SLE  HIV INFECTION
  45. 45.  Assess the extent and severity of the inflammatory response to infection  Determine the site(s) and complications of organ involvement by the process  Determine the etiology of the infectious disease
  46. 46.  CBC (diff.)+ESR  Urine R/E  RBS  RFT and L.F.T.  PBS Routine / Malaria  Two Blood Cultures,10ml each in 30 min. Interval from two different sites  CXR  U/A (in selected patients)  TFT (with caution and only when indicated)
  47. 47.  PNEUMONIAS  TB  CA LUNG/ABSCESS  LYMPHOMAS- MEDIASTINAL INVOLVEMENT  SARCOIDOSIS  AUTOIMMUNE DISEASES
  48. 48.  ABSCESS  HEPATOMA  HYPERNEPHROMA  LYMPHOMA  PELVIC TUMORS
  49. 49.  BLOOD CULTURE and Bone marrow aspiration C&S - IE,SEPSIS  ANA PROFILE – CONNECTIVE TISSUE DISORDERS  AGGLUTININ TEST -SALMONELLA , BRUCELLOSIS ,RICKETTSIAL  ELISA IGM AB - LEPTOSPIRA ,DENGUE,LYME’S  SMEAR TEST – MALARIA, LEUKAEMIAS  ECHO HEART – ATRIAL MYXOMA,IE,PERICARDITIS  BONE SCAN- OSTEOMYELITIS,METASTASIS  VIRAL CULTURE - EBV,CMV INFECTIONS  DISEASE SPECIFIC INVESTIGATIONS- Mx Test , PCR etc
  50. 50.  Biopsies: Bone marrow Lymph node Skin lesion Liver Temporal artery
  51. 51. 54
  52. 52. LEPTOSPIROSIS
  53. 53. 56
  54. 54.  PATHOGENEGIS Contamination of the drug with a pyrogen or microorganism Pharmacologic action of the drug itself Allergic (hypersensitivity) reaction to the drug
  55. 55.  All drugs can produce Drug INDUCED fever except DIGOXIN  Bradycardia, hypotension, Skin rash, pruritus +,  Eosinophilia eg) pencillin, sulpha, ATT
  56. 56.  Fever out of proportion to clinical picture  Associated findings: Rigor (43%), Myalgia (25%), Rash (18%), Headache (18%),  Leukocytosis (22%), Eosinophilia (22%), Serum sickness,Proteinuria Abnormal liver function test
  57. 57.  Onset and duration: Onset: 1-3 weeks after the start of therapy Duration: remits 2-3 days after therapy is stoped
  58. 58.  Classic FUO  Nosocomial FUO  Neutropenic FUO  HIV-Associated FUO
  59. 59.  Definition: Fever of 38.3 C or higher on several occasions Fever of more than 3 weeks duration Diagnosis uncertain, despite appropriate investigations after at least 3 outpatient visits or at least 3 days in hospital
  60. 60.  Definition: Fever of 38.3 or higher on several occasions Infection was not manifest or incubating on admission Failure to reach a diagnosis despite 3 days of appropriate investigation in hospitalized patient
  61. 61.  Definition: Fever of 38.3 or higher on several occasions Neutrophil count is <500/mm3 or is expected to fall to that level in 1 to 2 days Failure to reach a diagnosis despite 3 days of appropriate investigation
  62. 62.  Definition: Fever of 38.3 or higher on several occasions Fever of more than 3 weeks for outpatients or more than 3 days for hospitalized patients with HIV infection Failure to reach a diagnosis despite 3days of appropriate investigation
  63. 63. Infections 22-58% Neoplasms up to 30% Noninfectiouse inflammatory diseases up to 25% Miscellaneous causes up to 25% Undiagnosed up to 30%
  64. 64.  Localized pyogenic infections  Intravascular infections  Systemic bacterial infections (Tuberculosis, Brucellosis,…)  Fungal infections  Viral infections  Parasitic infections
  65. 65.  Hodgkin’s disease  Non-hodgkin’s lymphoma  Leukemia  Renal cell carcinoma  Hepatoma  Colon carcinoma  Atrial myxoma
  66. 66.  Collagen vascular/ hypersensitivity diseases Lupus Still’s disease Temporal arteritis (Giant cell arteritis)  Granulomatouse diseases Crohn’s disease Sarcoidosis Idiopathic granulomatous e disease
  67. 67.  Drug fever  Factitious fever  FMF  Recurrent pulmonary emboli  Subacute thyroiditis
  68. 68.  Diagnosis should be considered in any FUO, especially in: Young women Persons with medical training If the patients clinically well Disparity between temperature and pulse Absence of the normal diurnal pattern
  69. 69. Undiagnosed 19% Miscellaneous 13% Factitious 9% Granulomatous hepatitis 8% Neoplasm 7% Infection 6% No fever 27%
  70. 70.  To lower the body temperature  To completely eradicate the pathogen 73
  71. 71.  Most fevers are associated with self-limited infections, most commonly of viral origin.
  72. 72.  For each 1 °C elevation of body temperature: Metabolic rate increase 10-15% Insensible water loss increase 300-500ml/m2/day O2 consumption increase 13% Heart rate increase 10-15/min
  73. 73.  Reasons to treat fever: The elderly individual with pulmonary or cardiovascular disease The patient at additional risk from the hypercatabolic state (Poor nutrition, Dehydration) The young child with a history of febrile convulsions Toxic encephalopathy or delirium Pregnant women (contraversy) For the patient comfort Hyperpyrexia
  74. 74.  Reasons not to treat fever:  The growth and virulance of some organisms  Host defense-related response  Fever is an indicator of disease  Adverse effect of antipyretic drugs  Iatrogenic stress  Social benefits
  75. 75.  Persons who are clinically unstable or are at risk for rapid deterioration  Major alterations of immunity  Need for IV Antimicrobials or other fluids  Advanced age
  76. 76. Objectives of treating fever  reduce the elevated hypothalamic set point  facilitate heat loss .
  77. 77. ANTIPYRETICSANTIPYRETICS  drugs that reduce fever  drugs that cause a lowering of the elevated hypothalamic set point  The antipyretic potency of various drugs is directly correlated with the inhibition of brain cyclooxygenase.
  78. 78.  Acetaminophen is generally a first-line antipyretic due to being well tolerated with minimal side effects.  Pediatric dose: 10-15mg/kg q4-6h (2400mg/day);  Adult dose: 650mg q 4 h(4000mg)  Can be hepatotoxic in high doses; can upset stomach
  79. 79.  a poor cyclooxygenase inhibitor in peripheral tissue and is without noteworthy anti- inflammatory activity  oxidized by the p450 cytochrome system, and the oxidized form inhibits cyclooxygenase activity  the inhibition of another enzyme, COX-3 82
  80. 80. Membrane Lipid Arachidonic Acid Phospholipase A2 EndoperoxidesHydroperoxides TXA PGE, PGEF PGILeukotrienes Cyclooxygenas e Lipoxygenase - Corticosteroids NSAIDs - 83
  81. 81. 84
  82. 82.  Use of antimicrobial therapy directed against the pathogen 85
  83. 83.  agents used to destroy or inhibit the growth of other microorganisms  used to inactivate microbial cells  limit toxicity to the host and maximize chemotherapeutic activity affecting invading microbes only. 86
  84. 84.  Selective toxicity  Inhibition of cell wall synthesis  Β-lactams (Penicillin and Cephalosporin)  Vancomycin  Inhibition of cell membrane function  Polymyxins  Inhibition of protein synthesis  Macrolides  Chloramphenicol  Tetracycline  Aminoglycosides  Inhibition of nucleic acid synthesis  Rifampin  Metronidazole 87
  85. 85.  Widespread sensitization of the population  Changes in the normal flora of the body  Masking serious infection without eradicating it  Direct drug toxicity  Development of drug resistance 88
  86. 86.  ALL WE KNOW IS STILL INFINITELY LESS THAN ALL THAT REMAINS UNKNOWN…. -WILLIAM HARVEY -

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