Download Pathophysiology of Fever

APPROACH TO A
PATIENT WITH FEVER
ASSOC. PROF. DR. ÖZLEMTANRIÖVER
OBJECTIVES
1. Identify significant signs and symptoms and
correlation with fever.
2. Define and explain the etiology and
pathophysiology of fever.
3. To identify the patterns of fever.
LET’S START WITH A CASE
General Data
A 56 year-old, female, patient
Married with 2 children
Market shopkeeper from Kadikoy, İstanbul
CHIEF COMPLAINT : FEVER
History of Present Illness:
3 weeks
2 weeks
Day of
consultation
and admission
• Fever
• Persistence of fever
• Self medication with Paracetamol,
Ibuprofen, and Amoxicillin
• Persistence of fever
QUESTIONS TO ASK
• How was the temperature taken? How often?
• Impact on the patient’s lifestyle?
• People the patient had contacted with who
manifested the same signs and symptoms.
• Associated symptoms
PAST MEDICAL HISTORY
• No other medical or surgical illness requiring
hospitalization
• No history of blood transfusion
• No history of illicit drug use
• No history of tattoo piercing
PAST MEDICAL HISTORY
• Childhood illness?
• Measles? Mumps? Chickenpox? Scarlet fever?
Acute rheumatic fever?
• Major Adult illness?
• Hepatitis? Myocardial infarction? Parasitic
disease? Other infections?
• Immunizations?
• Influenza? Cholera? Typhus? Hepatitis B? BCG?
Typhoid?
• Past medications?
• Allergies?
• Recent health examination?
OBSTETRIC & GYNECOLOGIC HISTORY
• Menarche- 13 years old
• Menopause- 50 years old
• Any complications in pregnancy or labor,
postpartum or with the infant?
• Multiple sex partners?
• Date of most recent Pap smear and result?
• Hormone therapy? Dose and duration?
FAMILY HISTORY
• No family history of hypertension, diabetes mellitus,
cancer, pulmonary tuberculosis
• Autoimmune disease, blood disorders?
PERSONAL AND SOCIAL HISTORY
•Market shopkeeper
•Non smoker, non passive smoker
•Non alcoholic beverage drinker
•Likes eating street foods
•No travel to endemic areas
MISSING DATA:
1. What is the patient’s usual diet? Preferred foods?
2. Food preparation?
3. Source of drinking water?
4. How is the patient’s home condition?
5. Any household pets?
INFECTIOUS
• Systemic
• Bacteremia, sepsis, meningitis, endocarditis
• Respiratory
• URI, sinusitis, otitis media, pharyngitis, pneumonia,
bronchiolitis
• Abdominal
• Urinary tract infection, abscess (liver, kidney,
pelvis)
• Bone/joint infection
INFLAMMATORY
•
•
•
•
•
Kawasaki disease
Juvenile inflammatory arthritis
Lupus
Inflammatory bowel disease
Henoch-Schonlein purpura
OTHERS
• CNS dysfunction
• Drug fever
REVIEW OF SYSTEMS (ROS)
General
• No sign of weight loss
• Body malaise, fatique, night sweats?
Skin, hair, nails
• No rashes
• Bruising, lesions, dryness, pruritus?
Head and Neck
• No headache
• Dizziness, syncope, trauma?
Eyes
• No blurring of vision
• Discharge?
Ears
• No ear discharge, tinnitus
• Otalgia?
REVIEW OF SYSTEMS
Nose
• No data given
• Nasal discharge?
Breast
• No data given
• Lumps, nodules, pain?
Chest and Lungs
• No cough, difficulty of breathing
• Dyspnea, sputum, hemoptysis?
Cardiac
• No chest pain, palpitation
Gastrointestinal
• No diarrhea, constipation, melena, hematochezia
• Dysphagia, hematemesis, flatulence ?
REVIEW OF SYSTEMS
Genitourinary
• No dysuria, frequency, urgency, pollakuria, polyuria
• Pain, hematuria, changes in urine?
• Lesions, discharges, pain?
Lymph node
• No given data
• Enlargement, pain?
Musculoskeletal
• No joint pains
• Joint stiffness, restriction of motion, swelling?
Endocrine
• No heat or cold intolerance, polydipsia, polyphagia
PHYSICAL EXAMINATION
• Conscious, coherent, obese, oriented as to time, place and
person
• BP = 110/80 mmHg
• PR = 80 beats per min (bpm) regular
• RR = 22 per minute
• Temperature = 39.5C
• Height = 1.5m
• Weight = 70kg
• BMI = 31
• No skin rashes
• Anicteric sclera
• Hepatosplenomegaly
PHYSICAL EXAMINATION
• Pulse rhythm, amplitude, contour
• Respiration regularity, rhythm, depth, breath sounds
• Heart sounds
• Abdominal tenderness
• Inspection and palpation of lymph nodes
• Pelvic examination
SIGNIFICANT FEATURES
Subjective Data
• AÖ, 56 years old,
female, married,
market shopkeeper
Prolonged intermittent,
low to moderate fever
lysed by ibuprofen and
paracetamol
• Fond of eating street
foods
• No travel to endemic
areas
Objective Data
• Pulse temperature
disproportion
(PR=80bpm;Temp=39.5C)
• RR= 22/ min
• No skin rashes
• Anicteric sclera
• Hepatosplenomegaly
• Unremarkable head,
neck, ear, nose, throat,
eyes, chest and lungs,
heart and blood vessels,
breast and axilla, GI, GU,
musculoskeletal.
• Based on the Medical history and physical
examination, the patient manifests with prolonged
fever secondary to ……..?
CHIEF COMPLAINT:
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.”
Harrison’s Principles of Internal Medicine, 17th edition
Fever classification
Grade
oC
low grade
38–39
moderate
39–40
high-grade
40–42
hyperpyrexia
>42
oF
100.4–102.2
102.2–104.0
104.0–107.6
>107.6
FEVER PATTERNS
INTERMITTENT
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
D1
D2
D3
D4
Intermittent: marked by a daily temperature drop into the normal
range and then a rise back to above normal
REMITTENT
40.5
40
39.5
39
38.5
38
37.5
37
36.5
D1
D2
D3
D4
Remittent: A fever with diurnal variation of more than 1.1 0C but
with no normal readings
CONTINUOUS
39.6
39.5
39.4
39.3
39.2
39.1
39
38.9
38.8
38.7
38.6
D1
D2
D3
D4
Continuous: A fever with a diurnal variation of 0.5 to 10C
RELAPSING
39.5
39
38.5
38
37.5
37
36.5
36
D1
D2
D3
D4
Relapsing: Febrile episodes are separated by intervals of normal
temperature; bouts of fever occurring every five to seven
days
SEPTIC
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
D1
D2
D3
D4
Septic: An intermittent fever that fluctuates widely, typically producing
chills and sweating
FEVER - TYPES
PATHOPHYSIOLOGY OF FEVER
• Pyrogen
• the term is used to describe any substance that causes
fever
Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106
PATHOPHYSIOLOGY OF FEVER
• Cytokines
• small proteins (molecular mass,10,000 to 20,000 Da) that
regulate immune, inflammatory, and hematopoietic
processes
• Pyrogenic cytokines:
• IL-1, IL-6, tumor necrosis factor (TNF), ciliary neurotropic
factor (CNTF), and interferon (IFN)
.
Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106
PATHOPHYSIOLOGY OF FEVER
• The synthesis and release of endogenous pyrogenic
cytokines are induced by a wide spectrum of
exogenous pyrogens (bacterial, fungal or viral
sources)
Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106
PATHOPHYSIOLOGY OF FEVER
• Cellular sources of pyrogenic cytokines include:
monocytes, neutrophils, and lymphocytes
Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106
PHYSIOLOGY OF FEVER
• Exogenous pyrogen Activated leukocytes
Endogenous pyrogen (IL1,TNF,…)
Acute Phase Response
• Preoptic area of anterior hypothalamus (PGE2)
increase of set point =>
• Brain cortex
• Vasoconstriction
heat conservation
• Muscle contraction heat production
FEVER
INDUCTION OF FEVER
Infection, microbial
toxins, mediators of
Inflammation, immune
reactions
Microbial toxins
Cyclic
AMP
Monocytes / macrophages,
endothelial cells, others
Pyrogenic cytokines IL-1,
IL-6, TNF, IFN, ciliary
neurotrophic factors
PGE2
Hypothalamic
endothelium
Fever
Heat conservation,
heat production
Elevated
thermoregulatory
set point
Circulation
Harrison’s Principle of Internal Medicine 17 th edition
DISCOMFORT DUE TO FEVER
• 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
PATHOPHYSIOLOGY OF FEVER
• Tachycardia usually accompanies fever
PULSE RATE is PROPORTIONAL to
TEMPERATURE
Source: DeGowin’s Diagnostic Examination (8th Edition), p. 61-62
Pathophysiology of Fever
“For every 10C rise in temperature, pulse increases by 10 bpm.
Pulse temperature dissociation
typhoid,
brucellosis,
leptospirosis,
viral myocarditis,
diphtheria,
rheumatic carditis,
bacterial endocarditis“
WWW.RATIONALMEDICINE.COM
-allergic reactions
-stimulation of the body's
immune response
-autoimmune diseases
- cancer
- drug reactions
- hormonal disorder
- hypothalamic tumors
-too much exposure to the sun
autoimmune diseases
allergic reactions
cancer
drug reactions
hormonal disorder
hypothalamic tumors
Non - infectious
No joint pains
No skin rashes
autoimmune diseases
allergic reactions
cancer
drug reactions
hormonal disorder
hypothalamic tumors
Non - infectious
No difficulty breathing
No skin rashes
allergic reaction
cancer
drug reactions
hormonal disorder
hypothalamic tumors
Non - infectious
No significant weight
loss
No family history of
cancer
cancer
drug reactions
hormonal disorder
hypothalamic tumors
Non - infectious
drug reactions
No illicit drug use
No skin rashes
hormonal disorder
hypothalamic
tumors
Non - infectious
No heat or cold
intolerance
No significant weight
loss
hormonal disorder
hypothalamic tumors
Non - infectious
No heat or cold
intolerance
No significant weight
loss
hypothalamic
tumors
Non - infectious
Non - infectious
Prolonged fever with
hepatosplenomegaly
Infectious origin
Tuberculosis
Brucellosis
Typhoid Fever
Pulse fever
disproportion
Prolonged fever with
hepatosplenomegaly
Infectious origin
Tuberculosis
Brucellosis
Typhoid
Fever
Dissemination of the bacteria through the
macrophages via the lymphatics and
colonize reticuloendothelial tissue.
Hepatospleno
megaly
Use of antibiotic
before seeking
medical help
Pulse Fever
disproportion
Prolonged fever
Incubation period of the
agent
TYPHOID FEVER
PHARMACOTHERAPY
Problem
Goal
Solutions
• Decrease fever
•Antipyretics
• Find cause of
fever and eliminate
Typhoid Infection •Eliminate infective •antibiotics
agent
with broader
range
Persistent fever
despite of
medication
SUMMARY OF THE LECTURE
APPROACH TO FEVER
• Personal History:
•
•
•
•
Age
Occupation
Place of origin,Travel History
Habits
•
•
•
•
Sexual Practices
Injection Drug Abuse
Excessive Alcohol Use
Consumption of Unpasteurized Dairy Products
APPROACH TO FEVER
• Underlying Diseases:
•
•
•
•
Splenectomy
Surgical Implantation of Prosthesis
Immunodeficiency
Chronic Diseases:
• Cirrhosis
• Chronic Heart Diseases
• Chronic Lung Diseases
APPROACH TO FEVER
• Drug History:
• Antipyretics
• Immunosuppressants
• Antibiotics
• Family History:
• TB in the Family
• Recent Infection in the Family
APPROACH TO FEVER
• Associated Symptoms:
• Shaking chills
• Ear pain,Ear drainage,Hearing loss
• Visual and Eye Symptoms
• Sore Throat
• Chest and Pulmonary Symptoms
• Abdominal Symptoms
• Back pain, Joint or Skeletal pain
APPROACH TO FEVER
• Physical Examination:
• Vital Signs
• Neurological Exam.
• Skin Lesions,Mucous Membrane
• Eyes
• ENT
• Lymphadenopathy
• Lungs and Heart
• Abdominal Region
(Hepatomegaly,Splenomegaly)
• Musculoskeletal
LABORATORY STUDY
IN PATIENT WITH FEBRILE ILLNESS
• 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
INDICATIONS OF HOSPITALISATION
IN PATIENT WITH FEBRILE ILLNESS
• People who are clinically unstable or are at risk for
rapid deterioration
• Major alterations of immunity
• Need for IV Antimicrobials or other fluids
• Advanced age
QUESTIONS?
• Assoc. Prof. Dr. Özlem TANRIÖVER
Tel: (216)5783742
E-mail: [email protected]