DEFINITIONS

Normal body temperature is maintained ( 37.2

0
C/98.9
0
F
in the morning and 37.7
0
C/99.9
0
F in the evening)
because the hypothalamic thermoregulatory center
balances excess heat production from metabolic activity
in muscle and liver with heat dissipation from the skin and
lungs.
Fever : An elevation of normal body temperature in
conjunction with an increase in the hypothalamic set
point. Infectious causes are common.


Hyperpyrexia: Temperatures 41.5
0
C (106.7
0
F) that can
occur with severe infections but more commonly occur
with CNS hemorrhages.
Wunderlich in 1868 observed over 1 million
temperatures over a 16-year period
Temperature >38C suspicious
Normal temperature between 36.3C and
37.5C
Trough at dawn, peak in evening
Elderly have temperature 0.5C lower
SYMPTOMS
Symptoms of febrile illness may be divided into :
a. Constitutional symptoms comprising of fatigue, myalgia, loss of appetite, nausea ,
headache , etc
b. Symptoms suggestive of specific organ involvement
Tonsillo-pharyngeal region - sore throat, cough and painful swallowing
Maxillary/Frontal sinus rhinitis,nasal blockade, headache
Brain and Meninges- headache, vomiting and altered sensorium
Lungs and pleura - cough, sputum production,hemoptysis, breathlessness and
chest pain
Myopericardium- chest pain, breathlessness and palpitation
Liver- intractable vomiting, epigastric or right hypochondrial pain , jaundice
Gall bladder and biliary tract- abdominal pain and vomiting
Appendix- right iliac pain, vomiting and/or constipation or loose stools.
Urinary tract burning micturition and low back pain
Joints- joint pain and swelling.
Soft tissue- focal swelling, reddish discoloration and pain over the soft tissue
Peripheral Lymphnode- Swelling of extremities
Alarming symptoms in a patient with fever include:
a. confusion , altered sensorium, seizure, intractable
headache with vomiting.
b. hemoptysis, breathlessness at rest , intractable
chest pain
c. severe abdominal pain ,malena, hematemesis
d. jaundice
e. decreased urine output or bilateral leg/facial
swelling
f. extensive soft tissue swelling
g. severe constitutional symptoms.
h. gingival bleeding .
Fever of unknown origin (FUO)

1. Classic FUO: Three output visits or 3 days in the
hospital without elucidation of a cause of
fever;or1 week of unproductive intelligent and
invasive ambulatory investigation,temperatures
38.3
0
C (101
0
F) on several occa-sions,and
duration of fever for 3 weeks
2. Nosocomial FUO: At least 3 days of investigation
and 2 days of culture incubation failing to
elucidate a cause of fever in a hospitalized pt
with temperatures 38.3
0
C (101
0
F) on several
occasions and no infection on admission

3. Neutropenic FUO: At least 3 days of
investigation and 2 days of culture incubation
failing to elucidate a cause of fever in a pt with
temperatures 38.3
0
C (101
0
F) on several
occasions whose neutrophil count is <500L or
is expected to fall to that level within 12 days
4. HIV-associated FUO: Failure of appropriate
investigation to reveal a cause of fever in an HIV-
infected pt with temperatures 38.3
0
C (101
0
F) on
several occasions over a period of 4 weeks for
outpatients and 3 days for hospitalized pts.
ETIOLOGY
Most fevers are associated with self-limited infections (usu-ally viral)
and have causes that are easily identified.
Classic FUO: As the duration of fever increases, the likelihood of an
infectious etiology decreases. Etiologies to consider include:
1. Infectione.g.,extrapulmonary tuberculosis; EBV, CMV, or HIV
infection; occult abscesses; endocarditis; fungal disease
2. Neoplasme.g.,lymphoma and hematologic malignancies,
hepatoma, renal cell carcinoma
3. Miscellaneous noninfectious inflammatory diseases
a. Systemic rheumatologic disease or vasculitise.g., Stills
disease, lupus erythematosus
b. Granulomatous diseasee.g., granulomatous hepatitis,
sarcoidosis, Crohns disease
c. Miscellaneous diseasese.g., pulmonary embolism,
hereditary fever syndromes, drug fever, factitious fevers
Nosocomial FUO
Infectiouse.g., infected foreign bodies or catheters, Clostridium
difficilecolitis, sinusitis
Noninfectiouse.g., drug fever, pulmonary embolism
Neutropenic FUO: More than 5060% of pts infected or at risk for
bacterial and certain fungal and viral infections.
HIV-associated FUO: More than 80% of pts infected, but drug fever
and lymphoma also possible etiologies.
PATHOGENESIS
Hypothalamic set point increases; pt feels cold due to
peripheral vasoconstriction and shivering that are
needed to raise body temperature to new set point;
peripheral vasodilation and sweating commence when
set point is lowered again by resolution or treatment of
the fever.
Fever caused by:
Exogenous pyrogens (e.g., lipopolysaccharide
endotoxin)
Endogenous pyrogens (e.g., interleukin 1,tumor
necrosis factor) induced by exogenous pyrogens
Prostaglandin E2 (in CNS, raises hypothalamic set
point; in peripheral tissues, causes myalgias and
arthralgias)
DIAGNOSIS
In most cases, initial history, physical
examination, and lab-oratory tests (including
CBC with differential, ESR, electrolytes, LFTs,
urinalysis, and CXR; CT, MRI, or nuclear
scans as indicated; and appropriate smears
and cultures and sampling of abnormal fluid
collections) lead to a diagnosis, or the pt
recovers spontaneously. If fever continues for
23 weeks and repeat physical examinations
and laboratory tests are unrevealing, the pt is
diagnosed as having FUO.
ANAMNESIS
History taking should always have an objective
which may differ according to the clinical
symptom. In a patient presenting with fever
the objective of history is to
a. Know whether the infection has any organ
localization or not.
b. If the patient has any alarming symptom
which needs admission or urgent referral.
c. to identify associated comorbid conditions.

PHYSICAL EXAMINATION
a. orientation , alertness , conjuctival suffusion, icterus, sub-conjuctival bleed,
conjuctival pallor
b. sinus tenderness,
c. tonsillar enlargement, pharynx, palatal petechiae and dental apparatus
d. cervical nodes, neck stiffness
e. splinter haemmorrhages and clubbing
f. rash / petechiae over extremities or trunk
g. cardiac exam for pericardial rub, regurgitant murmur
h. respiratory exam for significant crackles / wheeze, features of consolidation and
features of pleurisy/ effusion.
i. abdomen for focal tenderness, enlargement of liver, spleen and renal angle
tenderness
and bowel sounds.
j. genital examination if suspected
k. leg swelling, features of soft tissue inflammation.
DISEASES

a. Malaria- fever with chills and spontaneous resolution of
fever after high spikes, jaundice, decreased urine output ,
seizures and altered sensorium.
b. Enteric fever- abdominal symptom in any form is quite
common in 50 percent of individuals[ like constipation,
increased stool frequency or abdominal pain].
c.Leptospirosis- intractable myalgia to the extent of difficult
ambulation, jaundice, dusty eyes and decreased urine output.
d.Dengue- skin petechiae and gingival bleeding are more
common in adults. Intractable joint pain is an uncommon
feature in adults.
e.Other viral fever- associated flu like symptoms. Malaria,
dengue and leptospirosis are more common during monsoon
seasons.