Microsoft word - 07 - fever.docx

7) Fever– A Clinical Approach - Dr. Sabir
• An oral temperature exceeding 37.2°C in the early morning and 37.7°C in the late afternoon or evening (Rectal temperatures are higher by approximately 0.6°C ) Diurnal variation
• The mean diurnal temperature oscillation is approximately 0.5°C, with women generally having slightly higher normal temperatures than men. Temperature is lowest in the early morning and highest in the late afternoon or early evening. The diurnal rhythm is usually preserved with a fever What is fever?
• 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 Hyperthermia
• Hyperthermia—not mediated by cytokines—occurs when body metabolic heat production or environmental heat load exceeds normal heat loss capacity or when there is impaired heat loss; heat stroke is an example. Body temperature may rise to levels (> 41.1 °C) capable of producing irreversible protein denaturation and resultant brain damage; no diurnal variation is observed. • Antipyretics are effective in treating fever but are unlikely to affect hyperthermia. Neuroleptic malignant syndrome is a rare and potentially lethal idiosyncratic reaction to major tranquilizers
(haloperidol, fluphenazine). Treatment: dantrolene ± bromocriptine or levodopa
Serotonin syndrome: occurs within hours of ingestion of agents that increase levels of serotonin in the CNS, including
serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, pethidine, dextromethorphan,
bromocriptine, tramadol, and lithium. Treatment: central serotonin receptor antagonist—cyproheptadine or
chlorpromazine ± a benzodiazepine.
Fever- Patterns
• Intermittent type – temp return to normal once during most days • Remittent type – temp do not return to normal each day • Sustained/Continuous – temp do not vary more than 1 degree F /day • Relapsing - recurrent over days to weeks Classical PUO
3. Cause not diagnosed after 3 OP visits or 3 days of PUO – causes
• INFECTIONS – 40% • MALIGNANCY –30% • CONNECTIVE TISSUE D- 20 % • UNDIAGNOSED – 10 % • Infection: amoebic liver abscess, brucellosis, TB, Typhoid, IE….etc • Malignancy: solid tumors (pancreas, lung, sarcoma, colon…etc) • Systemic dis: SLE, Reiter’s, granulomatous hepatitis…etc • Miscellaneous: drug fever, factitious fever, hyperthyroidism, Behcet’s dis, FMF…etc Drug fever
• Any drug may be responsible • Examples: nitrofurantoin, phenytoin, hydralazine, methyldopa, quinidine, quinine, procainamide • Very rarely caused by: digoxin, aminoglycosides • Peripheral eosinophilia is a clue but present only in 25% Fever with hepatosplenomegaly
• Malaria • Typhoid • Lymphoma • Leukemia • Disseminated tb • Infective endocarditis • Brucellosis • Kala azar • Tb • Temporal arteritis • Carcinoma • Lymphomas • Abscess • Myeloproliferative disorder Fever & low platelets
Diagnostic tests



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