FEVER

• Most common presenting symptom to

clinician.

• May associated with other symptom eg

chills, rigor ,bodyache, generalised
weakness, headache, anorexia etc
• Pyrexia –Greek- pyr meaning fire.

• Febrile- Latin- febris meaning fever.

Normal temperature regulation
in body
Normally heat is continuously produced in
body and being lost to surroundings.

Rate of heat production= rate of heat loss,

person is said to be in heat balance.

When there is disturbance of equilibrium

between the two, then body temperature may
rise-fever, or fall-hypothermia.
• No single core temperature can be
considered normal, there is always a
range.

Core temperature is normally maintained

within a range of 36.0 C-37.5C(97 F-99.5
F).
• At 6 AM 37.0C(98.6 F)
• At 6 PM 37.6 C(99.6F)- increased BMR &
muscle activity.

• An a.m. temperature of >37.2°C

(>98.9°F)
• An p.m. temperature of >37.7°C
(>99.9°F) defines a fever
• Normal diurnal variation-1 F

-Temperature
Rectal>Oral>Axillary
• Temperature regulation-Preoptic area of
anterior hypothalamus
• Physiological thermostat
Factors Determining Rate of Heat
Production

• a. Basal metabolic rate of body

• b. Muscle activity
• c. Effect of thyroid hormones
• d. Effect of epinephrine and
norepinephrine.
Method of Heat Loss from Body
• a. Radiation: Loss of heat from body in
form of infrared rays.

• b. Conduction: Heat is conducted from

body to objects in contact with it, e.g.
chair, bed, etc.
• c. Convection: Heat is lost from body by
air currents surrounding it.

• d. Evaporation: Evaporation of water

(sweat) from body surface serves as an
important protective mechanism in
reducing body temp.
• Fever:- Is an elevation of body
temperature above normal circadian
variation as a result of change in
thermoregulatory centre, located in
anterior hypothalamus.
Relation with Pulse, Resp. , BMI

• With every 1°F rise of temp >100 F

Pulse rate increases 10,
Respiratory rate by 4
BMR by 7
Oxygen consumption increases by 13%.
Stages of fever

4 successive stages -
1. Prodrome
• nonspecific complaints, mild headache,
fatigue, general malaise, aches and pains.

2. Temperature rises
• generalized shaking with chills and feeling
of being cold
• Vasoconstriction, piloerection precede
onset of shivering
• skin is pale
– 3. Flush
• cutaneous vasodilation occurs and
skin becomes warm, flushed

4. Defervescence
• Initiation of sweating.
Pathogenesis of fever

• Pyrogen-Any substance that cause fever

• Exogenous pyrogens -derived from

outside the patient: microbial products,
microbial toxins, or whole microorganisms
Eg - Lipopolysaccharide (endotoxin) of
gram-negative bacteria.
-Enterotoxins of Staphylococcus aureus

They induce host cells, i.e, blood

leukocytes, tissue macrophages to
produce endogenous pyrogens (e.g.,
interleukin-1).
Pyrogenic cytokines- include IL-1, IL-4, IL-6,
TNF, ciliary neurotropic factor (CNTF),
IFN-alpha.

Endogenous pyrogens increase set point

hypothalamic thermoregulatory center
through prostaglandin E2.
Mechanisms of fever
The effects of fever

• Metabolic effects:
– Increased need for oxygen
• Increases heart rate
• Increases respiration
– Increased use of body proteins as an energy
source
– During fever body switches from using
glucose (an excellent medium for bacterial
growth) to metabolism based on protein and
fat breakdown
The effects of fever

It enhance immune function

– Increases motility and activity of WBC
– Stimulates the interferon production and
activation of T cells
• Inhibits growth of some microbial agents:
– Many microbial agents that cause infection
and grow at normal body temperatures.
 Celcius Fareinheit
Hypothermia <35 C <95 F
Subnormal 35-36.7 95-97
Normal 36.7-37.2 98-99
Mild Fever 37.2-37.8 99-100
Moderate Fever 37.8-39.4 100-103
High Fever 39.4-40.5 103-105
Hyperpyrexia >40.5 >105
Types of fever

• Continous fever
-Temperature remains above normal
throughtout the day
-Does not fluctuate more than 1 C in 24 hrs.
Eg lobar pneumonia, UTI, infective
endocarditis, brucellosis
• Remittent fever
Temperature remains above normal
throughout the day
Fluctuate more than 1 C in 24 hrs.

Eg typhoid ,viral upper respiratory tract,

legionella, and mycoplasma infections
• Intermittant fever
Temperature is present for some hours in a
day and remits to normal for remaining
time.
Daily spike-Quotidian
Every alternate day-Tertian
Every third day-Quartan
Eg malaria , kala-azar, septicemia
• Hetic/Septic
Temperature variation between peak and
nadir is more than 5 C.
Eg septicemia
• Pel Ebstein fever
Bouts of febrile and afebrile periods
Temperature takes 3 days to rise, remains
high for 3 days and remits in 3 days,
followed by apyrexia for 9 days.
Eg Hodgkin lymphoma
• Low grade fever
Temperature present daily, mainly in evening
for several days but usually does not
exceed 37.8 C.
Eg tuberculosis
• Aseptic fever-
Malignancies
Acute Myocardial Infacrtion
Sarcoidosis,
Chronic renal failure
Collagen vascular diseases
Drug fever
Radiation sickness
Post surgical patients
• Drug fever
Prolonged fever
Relative bradycardia and hypotension
Perisist 2-3 days even after drug is
withdrawn
Eg penicillins,procainamide,propylthoiuracil,
sulphonamides,anticonvulsant
• Fever with Relative Bradycardia
1. Typhoid fever
2. Meningitis
3. Viral fever (Influenza)
4. Brucellosis
5. Leptospirosis
6. Drug induced fever
• Fever with rigors
Malaria
Kala azar
UTI
Septicemia
Infective endocarditis
Collection of pus in body
Lobar pneumonia
Cholangitis
pyleonephritis
• Fever with rash

1. Rash appearing on 1st day of fever—

Chicken pox.
2. Rash appearing on 4th day of fever—
Measles.
3. Rash appearing on 7th day of fever—
Typhoid.
• Fever with membrane in throat
Diphtheria
Infectious mononucleosis
Agranulocytosis
• Fever with delerium
Encephalitis
Tyhpoid
Meningitis
Hepatic encephalopathy
Hyperpyrexia

• When body temperature > 105 F.

• Cause
1 Pontine haemorhrage
2 Rheumatic fever
3 Menigococcal meningitis
4 Cerebral malaria
5 Septicimia
6 Enchephalitis
Pyrexia of unknown origin

• Persistance of temperature > 101.2 F

• > 3 weeks duration
• Faliure to reach diagnosis even after 1
week of evaluation
• Causes
Abcesses- subphrenic/liver/retroperitoneal
UTI
Endocarditis, hepatobiliary infections, osteomylitis
HIV
Parasitic infections
Malignancy
Collagen vascular disease
Factitious fever
Hyperthyroidism
Sarcoidosis
• Malignancies associated with PUO
Hodgkin’s disease
NHL
Leukaemia
Hepatoma
Renal cell carcinoma
Ca colon
Neuroleptic malignant syndrome

Characterized by-
-Lead pipe muscle rigidity
-Extrapyramidal side effects
-Autonomic dysregulation
-Hyperthermia.
Cental D2 receptor blockage - elevated
hypothalamic set point.

Block of nigrostriatel pathway - muscle

rigidity.
• Cause
Succinylcholine
Phenothiazines
Haloperidol
Fluoxetine, loxapine
Tricyclic benzodiazepines
Metoclopramide, domperidone
Management by cold sponging
Dantrolene(central muscle relaxent)
Drug of choice-bromocriptene