Fever

2 commonest symptom
 nd

Thermostat- hypothalamus

Part of immune response

Definition
 Normal body temperature- 98-100° F
 Core/rectal > oral > axillary by 1° F

 Fever- regulated rise to a new thermoregulatory set-

point mediated by cytokines- IL-1, TNF, IL-6, IFN

 Hyperthermia- an increase in body temperature

over the thermoregulatory set-point, due to excessive
heat production &/or inadequate thermoregulation
Types
 Continuous- above normal throughout the day, with
fluctuation <1° F; e.g. viral fever
 Remittent- above normal throughout the day, with
fluctuation >1° F; e.g. IE
 Intermittent- touches normal during the day; e.g.
abscess, bacteremia, malaria
 Relapsing- short febrile episodes between day(s) of
normal temperature; e.g. malaria, typhoid
 Pel-Ebstein- relapsing fever with bouts of fever
lasting 3-10 days; e.g. Hodgkin’s
Causes
 Infection
 Inflammation- MI, PE, pancreatitis, polytrauma,
postoperative
 Connective tissue diseases- SLE, GCA,
rheumatic fever, Wegener’s, PAN, sarcoidosis
 Cancer- HCC/liver mets, RCC, lymphoma/leukemia,
atrial myxoma
 CNS- trauma or SOL
 Drugs
Pointers for infectious etiology
 Abrupt onset
 High fever +/- chills
 Systemic symptoms- malaise, myalgia
 Specific symptoms- productive cough,
dysentery, dysuria
 Tender LNE
Acute fever in OPD
 Viral- continuous fever, chills uncommon,
non-specific systemic symptoms

 Bacterial- intermittent fever, chills +, specific

systemic symptoms

 Malaria- relapsing fever, with chills/rigors,

non-specific systemic symptoms
Evaluation

History
&
Physical examination
Treatment

Treat fever- paracetamol, cold

sponging
&
Treat etiology/cause
PUO/FUO

Pyrexia/Fever of unknown origin

Definition- Classic FUO
 Fever >101° F on >1 occasion
 Undiagnosed despite
 3 outpatient visits
 3 days in hospital
 1 week of intelligent & invasive
ambulatory investigation
Definition- contd.
 Nosocomial FUO- undiagnosed fever in
patients admitted for at least 24 hours

 Neutropenic FUO- undiagnosed fever in

patient with ANC <500/uL

 HIV associated FUO

Important causes
 Tuberculosis
 Lymphoma
 Sarcoidosis
 Pulmonary embolism
 Infective endocarditis
 Abscess
 Drug-induced
Work-up
 History
 Physical examination
 CBC, LFT, TFT, urinalysis
 Blood cultures
 CxR
 Ultrasound abdomen
 CT scan- chest & abdomen
 Echocardiography
 Gallium-67 scan
 PET scan with radiolabelled FDG
 Bone marrow aspiration &/or biopsy
 Other serological tests- ANA, ADA, ACE etc.
Treatment

Wait till diagnosis, except

Urgent empirical antibiotics in
neutropenic fever