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Fever

Fever

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Published by Asty Arumsary

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Published by: Asty Arumsary on Oct 24, 2012
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ASTI EL 2FEVER From Wikipedia, the free encyclopediaFever
(also known as
pyrexia
, or a
febrile response
from theLatinword
, meaningfever, and
archaically
 
known as
ague
) is a frequentmedical symptomthat describes an increase in internal body temperatureto levels that are above normal (the common oralmeasurement of normal human body temperatureis 36.8±0.7 °C or 98.2±1.3 °F). Fever ismost accurately characterized as a
temporary elevation
in the body’s
thermoregulatoryset-point
, usually by about 1-2°C. Fever 
differs
fromhyperthermia, which is an increase in body temperature over the body’s thermoregulatory set-point (due to
excessive heat
 production or 
insufficient
 thermoregulation,or both).Carl Wunderlichdiscovered that fever is not a disease but a symptom of disease.The elevation in thermoregulatory set-point means that the
previous
"normal bodytemperature" is consideredhypothermic, and
effector
mechanisms kick in. The person whois developing the fever has a cold sensation, and an increase inheart rate,muscle toneand
 
attempt
to
counteract
the
perceived 
thereby
 
reaching
the newthermoregulatory set-point.When a patient has or is suspected of having a fever, that person's body temperature ismeasured using thermometer. At a first
glance
, fever is present if:
temperature in the anus (rectum/rectal) or in the ear (otic) is at, or higher than 38degrees Celsius (100.4 degrees Fahrenheit)
oral temperature (in the mouth) is at, or higher than 37.5 degrees Celsius (99.5degrees Fahrenheit)
axillary
temperature (underarm) is at, or higher than 37.2 degrees Celsius (99degrees Fahrenheit)However, there are many variations in normal body temperature, and this needs to be
considered
when measuring fever. The values given are for an
otherwise
healthy, non-fasting adult,
dressed
comfortably, indoors, in a room that is kept at a normal roomtemperature, during the morning, but not shortly after arising from sleep. Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at leastthe
previous
fifteen minutes.
 
Body temperature normally fluctuates over the day, with the lowest levels at 4A.M. and thehighest at 6P.M.
Therefore
, an oral temperature of 37.5C would
strictly
 be a fever in themorning, but not in the afternoon. Normal body temperature may differ as much as 0.4C(0.7F) between individuals or from day to day. In women, temperature differs at various points in themenstrual cycle, and this can be used for family planning(although it is only one of the variables of temperature). Temperature is increased afte
meals
, and psychological factors (like the first day in the hospital) also influence body temperature.There are different locations where temperature can be measured, and these differ intemperature variability.Tympanic membrane thermometersmeasure radiant heat energy from the tympanic membrane (infrared). These may be very convenient, but may also showmore variability.Children develop higher temperatures with activities like playing, but this is not fever  because their set-point is normal. Elderly patients may have a decreased ability to generate body heat during a fever, so even a low-grade fever can have serious underlying causes ingeriatrics.
 Mechanism
Temperature is regulated in thehypothalamus, in response to PGE2. PGE2 release, in turn,comes from a trigger, a pyrogen. The hypothalamus generates a response back to the rest of the body, making it increase the temperature set-point.
Hyperthermia
: Characterized on the left. Normal body temperature (thermoregulatory set- point) is shown in green, while the hyperthermic temperature is shown in red. As can beseen, hyperthermia can be conceptualized as an increase above the thermoregulatory set- point.
Hypothermia
: Characterized in the center: Normal body temperature (thermoregulatoryset-point) is shown in green, while the hypothermic temperature is shown in blue. As can be seen, hypothermia can be conceptualized as a decrease below the thermoregulatory set- point.
Fever
: Characterized on the right: Normal body temperature (thermoregulatory set-point)is shown in green. It reads “New Normal” because the thermoregulatory set-point has risen.This has caused what was the normal body temperature (in blue) to be consideredhypothermic.
Pyrogens
Substances that induce fever are called
 pyrogens
. These are bothinternalor endogenous, and
external 
or 
exogenous
, such as the bacterial substanceLPS.
 
Endogenous
The cytokines (such asinterleukin 1) are a part of theinnate immune system, produced by  phagocytic cells,and cause the increase in the thermoregulatory set-point in thehypothalamus. Other examples of endogenous pyrogens areinterleukin 6(IL-6), and thetumor necrosis factor-alpha.These cytokine factors are released into general circulation where they migrate to thecircumventricular organsof the brain, where the blood-brain barrieis reduced. The cytokine factors bind withendothelial receptorson vessel walls, or interact with localmicroglial cells. When these cytokine factors bind, they activate thearachidonic acid   pathway.
Exogenous
One model for the mechanism of fever caused by exogenous pyrogens includeslipopolysaccharide(LPS), which is a cell wall component of gram-negative bacteria.An immunological protein calledLipopolysaccharide-Binding Protein(LBP) binds to LPS.The LBP-LPS complex then binds to theCD14receptor of a nearbymacrophage.This  binding results in the synthesis and release of various endogenouscytokinefactors, such asinterleukin 1 (IL-1), interleukin 6 (IL-6), and the tumor necrosis factor-alpha. In other words, exogenous factors cause release of endogenous factors, which, in turn, activate thearachidonic acid pathway.
PGE2 release
PGE2 release comes from thearachidonic acidpathway. This pathway (as it relates tofever), is mediated by theenzymes phospholipase A2(PLA2),cyclooxygenase-2(COX-2), and prostaglandin E2 synthase. These enzymes ultimately mediate the synthesis and releaseof PGE2.PGE2 is the ultimate mediator of the febrile response. The set-point temperature of the body will remain elevated until PGE2 is no longer present. PGE2 acts on neurons in the preoptic area(POA) through the EP3 subtype of PGE receptors and the EP3-expressingneurons in the POA innervate thedorsomedial hypothalamus(DMH), the rostralraphe   pallidus nucleus in themedulla oblongata(rRPa) and theparaventricular nucleusof the hypothalamus(PVN). Fever signals sent to the DMH and rRPa lead to stimulation of thesympatheticoutput system, which evokes non-shivering thermogenesis to produce bodyheat and skin vasoconstriction to decrease heat loss from the body surface. It is presumedthat the innervation from the POA to the PVN mediates the neuroendocrine effects of fever through the pathway involving pituitary glandand variousendocrine organs.

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