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Fever– A Clinical approach Dr Sabir Definition 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 o Intermittent type – temp return to normal once during most days o Remittent type – temp do not return to normal each day o Sustained/Continuous – temp do not vary more than 1 degree F /day o Relapsing - recurrent over days to weeks Fever - types Classical PUO 1. FEVER – more than 38.3º C 2. At least 3 wk 3. Cause not diagnosed after 3 OP visits or 3 days of hospitalization. TYPES OF PUO: ACUTE, NOSOCOMIAL, HIV ASSOCIATED NEUTROPENIC PUO PUO – causes INFECTIONS – 40% MALIGNANCY –30% CONNECTIVE TISSUE D- 20 % UNDIAGNOSED – 10 % DDx Infection: amoebic liver abscess, brucellosis, TB, Typhoid, IE….etc Malignancy: soild 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 HIGH ESR TB TEMPORAL ARTERITIS CARCINOMA LYMPHOMAS ABSCESS MYELOPROLIFERATIVE DISORDER FEVER & LOW PLATELETS VIRAL FEVERS LEUKEMIA LYMPHOMA MYELOPROLIFERATIVE DISORDER DRUG FEVER SLE HIV INFECTION DIAGNOSTIC TESTS ANA,ANTI- Ds DNA – SLE BONE SCAN- OSTEOMYELITIS, METASTASIS ECHO HEART – ATRIAL MYXOMA, IE SMEAR TEST + VE – MALARIA, VIRAL CULTURE + IN EBV, CMV INFECTIONS BLOOD CULTURE + IN IE, SEPSIS AGGLUTININ TEST + IN SALMONELLA , BRUCELLOSIS