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FEVER

LEARNING OBJECTIVES

At the end of this tutorial you should be able to:

1. Define fever
2. Form a differential diagnosis for fever
3. Take a history from a patient with fever, focussing on features which will aid in determining
aetiology. .
4. Examine patients with fever including examining for clinical features suggestive of
underlying aetiology.
5. Choose and justify appropriate investigations of the patient with fever.

DEFINITION: Fever is an elevation of body temperature that exceeds the normal daily variation and
occurs in conjunction with an increased in the hypothalamic set point (37 - 39 ºC).

Hyperpyrexia: Fever > 41.5ºC is called hyperpyrexia. This extra-ordinarily high fever occurs in
patients with severe infections most commonly with central nervous system haemorrhages.

PATHO-PHYSIOLOGY:

The term pyogen is used to describe any substance that causes fever. Exogenous pyogens are derived
from outside the patient. Most are microbial products, toxins or whole micro-organisms. The classic
example of an exogenous pyrogen is the lipopolysaccharide endotoxin produced by gram negative
bacteria.
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Differential Diagnosis

Bacterial 1. Infective endocarditis

2. Tuberculosis
3. Brucellosis
4. Leptospirosis
5. Abscess
6. Q fever
7. Cat scratch disease

Viral 1. Influenza
2. Glandular fever
3. HIV
4. CMV

Fungal 1. Candidiasis
2. Aspergillosis
3. Pneumocystis carnii

Protozoal 1. Malaria
2. Amoebiasis
3. Toxoplasmosis

Neoplasia 1. Renal cell carcinoma

2. Lymphoma
3. Leukaemia
4. Hepatoma

Connective Tissue 1. SLE

Disease 2. Polyarteritis nodosa
3. Rheumatoid arthritis
4. Temporal arteritis

Granulomatous disease 1. Sarcoidosis

2. Crohn's disease

Others 1. Myocardial infarction

2. Pulmonary embolism
3. Familial Mediterranean
Fever
4. Post-immunisation
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HISTORY:

A meticulous history should be performed to determine the likely cause of fever.

1. Localising Symptoms: Are there urinary symptoms suggestive of a urinary tract infection. Is
there a productive cough suggestive of a lower respiratory tract infection. History of jaundice
to suggest ascending cholangitis or hepatitis.
2. Localised Pain: If there is a sore throat one should suspected pharyngitis or a viral upper
respiratory tract infection. If there is headache, meningitis and encephalitis should be
suspected. Abdominal pain could suggest pyelonephritis, cholecystitis or appendicitis. Joint
pain might suggest rheumatic fever, rheumatoid arthritis or septic arthritis.
3. Rash: The presence of a rash should make one thick of a drug reaction, meningococcaemia
and subacute bacterial endocarditis.
4. Foreign Travel: Important in the determination of fever in the returning traveller.
5. Occupation: Exposure to animals, toxic fumes etc.

EXAMINATION:

A meticulous physical examination should be performed involving all organ systems (beyond the
scope of this chapter).

INVESTIGATIONS:
Bloods:
1. CBC: The following abnormalities may be present:
(a) Neutrophilia: Bacterial infections
(b) Neutropaenia: May be present with some viral infections, particularly parvovirus B19, drug
reactions, SLE, typhoid and infiltrative diseases of the bone marrow including lymphoma,
leukaemia and tuberculosis.
(c) Lymphocytosis: May occur with viral disease as well as typhoid and brucellosis. Atypical
lymphocytes are seen in EBV, CMV and HIV infection.
(d) Monocytosis: Seen with typhoid, tuberculosis, brucellosis and lymphoma.
(e) Eosinophilia: May be associated with parasitic infection, hypersensitivity drug reactions,
Hodgkin's disease and adrenal insufficiency.

2. U&E: Should be evaluated in all patients presenting with. Raised urea in patients with
dehydration (insensible loss secondary to pyrexia). Acute renal failure secondary to
distributive shock may be a feature.
3. LFTs: Important in patients with suspected ascending cholangitis or hepatitis.
4. ESR/CRP: Inflammatory markers are raised non-specifically in infection.
5. Blood Cultures: Necessary in all patients (three sets in suspected infective endocarditis).
6. EBV/CMV/HSV/Hepatitis/HIV Serology: If suspected.
7. Other Serology: Q fever, brucellosis and leptospirosis if suspected.
8. ASO Titre: Rheumatic fever
9. D-Dimers: If pulmonary embolism suspected (interpret with caution as may be raised non-
specifically with infection).
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10. Troponin/CK: Myocardial infarction (troponin may be raised non-specifically with acute
renal failure or sepsis).
11. ABG: Assess the degree of respiratory failure in patients presenting with respiratory
symptoms. A metabolic acidosis may be a feature in severe sepsis (lactate acidosis) or in
patients with concurrent acute renal failure.

Atypical Bloods (Connective Tissue Disease):

1. ANF: ANF is positive in patients with systemic lupus erythematosus (anti-dsDNA antibodies
are positive in 80% of patients with SLE).
2. Rheumatoid Factor: Rheumatoid arthritis
3. ANCA: In patients with suspected polyarteritis nodosa

Microbiology

1. Urine: A urinalysis (leukocytes and nitrates) should be performed as well as urine culture and
sensitivity for possible urinary tract infection.
2. Sputum: Patients presenting with a productive cough should give a sputum sample for gram
staining and culture and sensitivity. ZN staining should be performed in suspected cases of
tuberculosis.
3. Stool C&S: Of particular importance in the returning traveller and patients presenting with
diarrhoea. Look for ova and parasites.

Imaging:

1. CXR: Looking for evidence of respiratory tract infection, tuberculosis etc.

2. Abdominal USS: If cholecystitis, ascending cholangitis, hepatitis or intra-abdominal abscess.
3. CT TAP: In occult infection or suspected malignancy

Other

1. TOE: For the diagnosis of infective endocarditis

2. Bone Marrow Aspirate: Leukaemia, myeloma
3. Lumbar Puncture: Meningitis/Encephalitis