PENATALAKSANAAN DEMAM

( Approach to Fever )

Dr. Paul.N. Harijanto, Sp.PD-KPTI
Divisi Penyakit Tropik & Infeksi
Departemen Penyakit Dalam ,
RSU Bethesda Tomohon/ FK UNSRAT Manado
Fever is one of the most common
reason for caregivers to seek medical
attention
Up to 22% of the visits to the
emergency department by children
are for fever
DEFINITION OF FEVER
Fever is an elevation of body
temperature that exceeds the normal
daily variation, in conjunction with an
increase in hypothalamic set point
VARIATION IN TEMPERATURE
Anatomic variation
Physiologic variation:
Age
Sex
Exercise
Circadian rhythm
Underlying disorders


NORMAL BODY TEMPERATURE
Maximum normal oral temperature
At 6 AM : 37.2
At 4 PM : 37.7
PHYSIOLOGY OF FEVER
Pyrogens:
Exogenous pyrogens:
Bacteria, Virus, Fungus, Allergen,
Endogenous pyrogen
Immune complex, lymphokine,
Major EPs: IL1, TNF, IL6
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
Method of Temperature Measurement
Rectal gold standard
Oral reflect core
temperature in older child
able to cooperate; is
altered by ingestion of
hot or cold food or liquids
Axillary reflects surface
temp ; low sensitivity
Tympanic accurate;
commonly used
Definition of fever
Normal - 98.6 F (37 C) with a diurnal
fluctuation between 97 and 100.4
Mild Fever- 100.5 to 101.2F (38-38.5C)
Moderate Fever 101.2 to 105F (39-40.5C)
High Fever - > 105F (40.5C)
Harmful Fever - > 107F

Effects of Fever
The effects of fever in otherwise healthy
children include discomfort,dehydration
and seizures. Usually fever is non-harmful
and self-limited.
Children with underlying medical
problems are more likely to experience
complications of fever.

Normal Temperatur Tubuh
Di ukur secara ORAL
Paling rendah jam 6.00 pagi, 37,2C (98,9F)
Paling tinggi jam 18.00 sore, 37.7 C (99,9F)
Normal variasi 0,5 C 1 C
Rectal temperatur lebih Tinggi 0,4 C
Di urnal variation
Wanita lebih tingi pria
DEFINISI
Demam/ Fever : > 37,7 C
Hyperpyrexia : > 41.1 C
Malaria :
Temp > 41C Malaria Berat
PASIEN DENGAN DEMAM
Brapa lama Demam ?
DEMAM
Demam
Akut
< 14 hari
Demam
Kronik
> 14 hari
Infeksi kronik :
TBC, Endokarditis, HIV/AIDS
Lepra
Malignancy :
Leukemia, Limfoma
Imunologik :
SLE, RA,
Duration of Fever ( Lama Demam )
1 3 days 3 - 7 days
8 14days
> 14 days ( 2 weeks )
Chronic Infection
TBC
Endocarditis
Lepra
HIV
Imunological Dis :
SLE
RA
Sarcoidosis
Malignancy :
Leucaemia
Lymphoma
Simple fever
Viral infec.:
Resp.
Epstein Bar
Influenzae
GIT
Exercises
Dehydration
Injury/ Trauma
Allergic
Most of Infection :
Bacterial Infection :
Typhoid fever
Pneumonia
Pyelonephritis
Sepsis
Parasitic :
Malaria
Viral systemic:
Dengue/ DHF
J-Encephalitis
Myocarditis
TIPE DEMAM
Tipe Karakter Contoh
Kontinyu Terus menerus tinggi
beda 0,5-1 C
Tifoid, DHF, drug fever
Intermiten Temp turun sampai
normal setiap hari
Infeksi piogenik,
limfoma, TBC,
Remiten Fluktuasi harian > 2C,
tapi tak pernah normal
Malaria
Berulang
(Relaps)
Suhu turun sampai
normal bbrp hari
meningkat lagi
Malaria
CONSEQUENCES OF THE GENERAL CLINICAL RESPONSES TO INFECTION AND INFLAMMATION
Sign/symptom Metabolic effect Benefit for host
Fever
Increased energy consumption is required to
cause and maintain body temperature above
normal
Beneficial effect on survival at moderate increases
(102104F (3940C)). May be detrimental with
more marked increases (e.g. >107F (>42C))
Enzyme reactions are accelerated
Anorexia
Decreased nutrient intake requires
catabolism of body stores for new protein
synthesis
No apparent benefit in infection
Amino acids are converted to glucose by
way of hepatic gluconeogenesis
May permit survival during the healing process after
trauma
Lethargy
Decreased voluntary activity reduces energy
needs
Benefits of rest documented in some infections
(poliovirus, Coxsackie B4 virus) in which exercise
increases severity of clinical manifestations

Allows metabolic support to be directed to host
defense responses
Myalgia
Result of muscle activity and muscle
catabolism to breakdown muscle protein
releases amino acids into the circulation
Generates heat to elevate body temperature

Provides source of amino acids for increased protein
synthesis of host defense molecules and cells
PENYEBAB DEMAM
INFEKSI :
BAKTERI
VIRUS
PARASIT
JAMUR
MALIGNANCY
IMMUNOLOGIK
DIMANA INFEKSINYA ?
ORGAN/SYSTEM TERLIBAT
-Respiratory
-Gastro-intestinal
-Uro-genital
-Upper respiratory
-Ear-nose-throat
-Eyes
-CNS
NO
YES
MALARIA
DENGUE
TETES
TEBAL/
RDT
Hb, Leuko ,
Trombo, Ht
PENYEBAB ?
LEUKO GRAM +
GRAM ve; VIRUS, PARASIT
Differential Leukosit
Eos : parasit
Neutro : bakteri
Limfo : gram -; virus
Mono : virus
Tatalaksana pada Pasien
1. Anamnesa : Lama & keluhan lainnya
Obat, tindakan bedah/dental
Prostetic material/ implanted device
Riwayat pekerjaan : kontak dgn binatang,
bahan toxic, antigen/ agent infectious
Tempat tinggal/ riwayat perjalanan
Riwayat imunisasi/ obat prophylaktis
Hobby, kebiasaan, perilaku tertentu
Riwayat keluarga/ lingkungan
Ethic tertentu
Clinical History
HISTORY
Travel history - Bioterrorism & fever
Occupational
PHYSICAL EXAMINATION :
Temperature - Spleen
Mouth - Lymph nodes
Eyes
Making a decission : - Is the patient ill ?
Laboratory Investigation
MANAGEMENT : Isolation & Treatment

Fever in Returning Travellers
COMMON
Malaria
No Diagnosis made
Respiratory Infection
Diarrheal Disease
Urinary Tract Infection
Viral Hepatitis
UNCOMMON
Dengue
Thyphoid
Tuberculosis
Acute HIV Infection
Acute Schistosomiasis
Rickettial infec.
Amoebiasis

Pemeriksaan Fisik :
Tanda vital
Pengukuran temperatur aksiler tidak akurat
Skin ( rash)
Kelenjar limfe
Mata
Kardiovaskuler & respiratory
Abdomen : Hepar & Lien, ascites,
Muskuloskeletal( Artritis), saraf
Rectal Examination
Penis, prostate, scrotum, testes
Wanita : pem.gynaecologik
LABORATORIUM :
Leukosit & Differential
Hb, Trombosit, PCV,LED
Malaria smear
Urinalisis
Bacterial smear
Tes Antigen
Tes Serologik
Microskopic tinja
Kimia Darah :
Elektrolit, gula darah, ureum, kreatinin,
LFT
Mikrobiologik :
Radiologik
DANGER POINT IN ACUTE FEVER
Petechial/ purpuric rash
Travel (risk of malaria)
Chills/ rigors
Extreme of age
Neurologic sign
Asplenia
Hypogammaglobinaemia
Post bone marrow transplant
TREATMENT OF FEVER

Most fevers are associated with
self-limited infections, most
commonly of viral origin.
TREATMENT OF FEVER
Reasons not to treat fever:
The growth and virulance of some organisms
Host defense-related response
Fever is an indicator of disease
Adverse effect of antipyretic drugs
Iatrogenic stress
Social benefits
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
TREATMENT OF FEVER
Reasons to treat fever:
The elderly individual with pulmonary or cardiovascular
disease
The patient at additional risk from the hypercatabolic state
(Poor nutrition, Dehydration)
The young child with a history of febrile convulsions
Toxic encephalopathy or delirium
Pregnant women (contraversy)
For the patient comfort
Hyperpyrexia
Treatment Fever
Oral Aspirin ( Anak # ReyeS Syndr)
Acetaminophen
NSAID ( ibuprofen, diclofenac )
Non-drugs :
Cooling : blangket, Fan, AC, Teppid sponge, ice bath.
IV Fluid
Internal cooling : gastric/ peritoneal lavage with
ice, hemodyalisis
IV dantrolene sodium 1 2,5 mg/kg BB/ 6 jam
Procainamide
Treatment Strategies
Acetaminophen is generally a first-line
antipyretic due to being well tolerated
with minimal side effects.
Pediatric dose: 10-15mg/kg q4-6h (2400mg/day);
adult: 650mg q 4 h(4000mg)
Can be hepatotoxic in high doses; can upset stomach
FEVER & RASH
Centrally distributed Maculopapular Eruptions :
Measles, German measles, Primary HIV, Infec.
Mononuc.,leptospirosis, Typhoid, Rheumatic fever, SLE, Lyme
Peripherial Eruptions :
Secondary Syphylis, Hand Foot Dis, Endocarditis
Confluent Desquamtive Erythemas
Scarlet fever, TSS, Toxic epidermal necrolysis, Kawasaki dis.
Vesiculobullous Eruptions :
Hand foot Dis, Varicella, Diss. Herpes infec.,
Urticarial Eruptions
Urticarial vasculitis
Nodular Eruptions
Diss. Eruption
Purpuric Eruptions :
Viral Haemorhagic fever ( DHF), acute meningococaemia,
Eruptions with Ulcers & Eschars
Tularemia, Anthrax
ACUTELY ILL FEBRILE PATIENT
History:nonspecific, onset, progression,
host factor ( immune status), source of
infection
Physical Examination :
Specific Presentations ;
SEPSIS
NEUROLOGIC INFECTIONS ( Bacterial
meningitis, Brain abcess, Cerebral Malaria, )
FOCAL SYNDROME WITH FULMINANT COURSES
DETEKSI DINI KASUS MALARIA
DEMAM TIFOID
Limpa, Hati, Kel. Limfe,
Ikterik, Petekien, Urin, Gangguan kesadaran
DEMAM DENGUE MALARIA
Mikrosk/ QBC / Rapid test
Demam/Riwayat Demam,
Sakit kepala
Pengobatan Malaria
Anamnesa
Pemeriksaan Fisik
Trias Malaria
Riwayat Perjalanan
Berkemah/Berburu/
Riwayat Pakai Obat Malaria
Pendatang/Pelancong
Keadaan non-imun
Keluhan Abdomen
Bradikardi relatif
Rose spot
Nyeri Otot
Rash petekien
Tes Rumpel Leede
Perdarahan
LEPTOSPIROSIS
Nyeri Otot
Nyeri Betis

Trias Malaria
Pucat/ anemis
Splenomegali
PAKATUAN WO PAKALAWIREN
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT Manado
RSU Bethesda -Tomohon
Telp.:
0431-356829 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com
Sampai Baku Dapa !