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FEBRILNI PACIENT
Temperatura
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Acetalsalicilna kislina: NE pri otrocih
(Reyev sindrom)
Acetaminofen: NE pri pacientih z
boleznimi jeter
NSAID: NE pri pacientih z ishemicnimi
boleznimi srca (Koronarna
vazokonstrikcija)
Body temperature is regulated by the
hypothalamus,and prostaglandin E2 acts on this
region to stimulate fever.
Fever most commonly occurs in the evening as a
consequence of the diurnal variation of body
temperature.
Fever may be protective and should be reduced
only in patients with ischemic heart disease or
pulmonary disease, in elderly patients, and in
children who have a history of febrile seizures.
Acetylsalicylic acid, nonsteroidal antiinflammatory drugs, and acetaminophen
(agents that reduce prostaglandin E2 production),
are the preferred method for reducing fever and
need to be given on a regular schedule.
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Kdaj naj damo antipiretike?
-Pri pacientih z boleznimi srca (ishemija zaradi povecane frekvence srca + vecje zahteve po kisiku)
-Pacienti z resnimi boleznimi pljuc (ne morejo zadostiti povecanim potrebam po kisiku)
-Starejsi pacienti z omejeno mentalno kapaciteto (lahko pride do letargije in zmedenosti)
-Otroci z zelo visoko temperaturo (lahko pride do temperaturnih krcev)
TEMPERATURA NEZNANEGA IZVORA (FUO)
Temperatura neznanega izvora (FUO)
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Fever must persist for more than 3 weeks in
order to exclude self-limiting viral illnesses.
Temperature must be more than 38.3⁰C to
exclude normal variations in core body
temperature set point.
No diagnosis reached after 3 days of testing.
(1) Pregled
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Thoroughly examine skin for embolic lesions.
Palpate all lymph nodes. (Limfom, infekcija)
Perform a complete joint examination. (Artritis)
Listen carefully for cardiac murmurs. (SBE)
Abdominal exam should assess liver and spleen
size and should palpate for masses and areas of
tenderness. (Hepatom, infekcije žolčnega trakta)
Palpacija ščitnice (Tiroiditis)
Major Causes of Fever of Unknown Origin
“Big 3”
1. Infection
2. Neoplasm
3. Autoimmune disease
“Little 6”
1. Granulomatous disease
2. Regional enteritis
3. Familial Mediterranean fever
4. Drug fever
5. Pulmonary emboli
6. Factitious fever
(2) Testi
(Sutton’s law) “Go where the money is”
-Krvna slika in diferencialna krvna slika
-Krvni razmaz po Giemsi in Wrightu
-Testi funkcije jeter
-Antinuklearna protitelesa in revmatoidni faktor
-Sedimentacija eritrocitov
-Analiza urina
-Hemokultura (vsaj 3 vzorci)
-Urinokultura
-Sputum, kostni mozeg, PCR (CMV, Epstein-Barr)
-Titer protiteles v razmaku 3-4 tedne (če imamo v mislih že
določenega patogena)
-PPD test na koži
-Tomografija prsnega koša in abdomna
Key points
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INFEKCIJA
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NEOPLASME
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AVTOIMUNE
BOLEZNI
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Temperatura v intenzivni
enoti
DRUGI VZROKI
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Infection is the most common cause of FUO in patients under 65 years of
age.
Epidemiology (animal exposure, insect bites, outdoor camping, travel,
exposure to infected humans) is helpful.
Physical exam may provide useful clues, particularly inspection of skin,
nail beds, and fundi, and cardiac auscultation.
Abdominal abscess, miliary tuberculosis, and disseminated fungal
infections can be fatal.
Prior antibiotic administration interferes with diagnosis.
Lymphoma is the most common neoplasia causing FUO.
Pel–Ebstein fever strongly suggests Hodgkin lymphoma.
Preleukemia can present as FUO in the elderly.
Primary hepatoma can be associated with FUO; however, metastatic
liver disease usually does not cause fever.
Renal cell carcinoma occasionally causes FUO.
Atrial myxoma can mimic subacute bacterial endocarditis.
1. Sistemski lupus eritematozus
2. Stillova bolezen (lahko zamešaš z bakterijsko okužbo)
3. Hypersensitivity angiitis
4. Revmatična polimialgija s temporalnim artritisom
5. Poliarteritis nodoza
6. Mixed connective tissue disease
7. Subakutni tiroiditis (mehka ščitnica)
Regional enteritis can present with fever in the absence of
gastrointestinal symptoms.
Pulmonary emboli can present with fever in the absence of respiratory
symptoms.
Discontinue all medications in the patient with FUO.
Consider factitious fever in the female health care worker with a
medical textbook at the bedside and recurrent polymicrobial bacteremia.
No diagnosis is made in an increasing percentage
of modern cases.
Zdravila: Antihistamines, Isoniazid, Barbiturates,
Nitrofurantoin, Chlorambucil, Penicillins, Dilantin, Procaine
amide, Hydralazine, Quinidine, Ibuprofen, Salicyclates,
Iodides. Thiouracil, Aldomet, Mercaptopurine
Fever is extremely common in intensive care unit patients.
A systematic approach to diagnosis is critical.
Key sites of infection include these:
a) Lungs (critical to differentiate colonization from
infection)
b) Intravenous and intra-arterial lines
c) Urinary tract (at high risk secondary to
prolonged bladder catheterization)
d) Wounds (particularly in the early postoperative
period)
e) Sinuses (in patients with nasotracheal tubes)
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Neinfekcijski vzroki: pulmonarna embolija, temperatura zaradi
zdravil, stara krvavitev.
Empiric antibiotics need to be streamlined based on culture results.
Prolonged broad-spectrum antibiotic coverage predisposes to colonization
with highly resistant bacteria, fungemia, Clostridium difficile colitis, and
drug allergies.
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1. Absces
2. Osteomielitis (vretenca, mandibula, sinusi)
3. Subakutni bakterijski endokarditis (murmur usually
present, beware of previous antibiotics, visoka SE)
4. Infekcije žolčnega trakta (may have no right upper
quadrant tenderness)
5. Infekcije urinarnega trakta (in absence of related
symptoms)
6. Tuberkuloza (especially miliary disease)
7. Spirohete (leptospirosis, Borrelia)
8. Bruceloza (animal exposure, unpasteurized cheese)
9. Rikecioza
10. Chlamydia
11. Epstein–Barr virus, cytomegalovirus
12. Glivična infekcija (Cryptococcus, histoplasmosis)
13. Paraziti (malaria, toxoplasmosis, trypanosomiasis)
1. Limfom (especially Hodgkin, Pel–Ebstein fever: en teden
visoka vročina, naslednji teden brez vročine…)
2. Levkemija (aleukemic or preleukemic phase)
3. Hipernefrom (high sedimentation rate)
4. Hepatom (generally not metastatic liver disease)
5. Miksom atrijev
Still’s disease is associated with high fevers, evanescent skin rash,
leukocytosis, high serum ferritin, and elevated erythrocyte sedimentation
rate (ESR). A diagnosis by exclusion.
Polymyalgia rheumatica and temporal arteritis are found in elderly
patients and cause proximal muscle weakness, visual symptoms, and a
high ESR.
Subacute thyroiditis should be considered if the thyroid is tender.
Kikuchi’s disease often presents with fever and lymphadenopathy.
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Vzrok