APPROACH TO FEVER BY: ILYANA JAMALUDIN

SUPERVISOR: DR LIM KC
OUTLINE
 Case scenarios
 Introduction
 Causes of fever
 Leukocytosis
 Systematic approach to patients with fever
 Management of new onset fever in the hospitalized patients
 Take home message
CASE SCENARIO 1. What else would you like to ask the
patients?
1
• 50y.o Indonesian, chronic 2. Relevant investigations to send?
smoker
• Presented with fever, cough,
LOW for past 2/52
• Lungs: right upper zone coarse
crepitation
• Not in respiratory distress, vital
signs stable
 3. Possible diagnosis?

WBC 12, ESR 110

CASE SCENARIO 1. Where are the possible sites of infection?
2
2. What are the possible non-infectious
• 80y.o lady causes of fever in this patient?

• Admitted under ortho for

closed fracture of left femur –
conservative mx
• Referred to medical as patient
developed fever in the ward
CASE SCENARIO
3
• 65y.o gentleman
• Just discharged from cardio
ward 1/52 ago treated for
1. Possible diagnosis?
STEMI Killip 4
• Presented to ED with fever,
chills & rigor 2. What is your choice of antibiotics?
• Examination: left arm swollen,
tender and erythematous 3. Other relevant investigations?
(previous branula insertion site)
USG Doppler left arm:
Long segment thrombosis involving left
basilic, median cubital vein, cephalic
and axillary veins. No evidence of
collection

Blood C&S: Staphylococcus Aureus,

Sensitive to oxacillin
CLINICAL APPROACH
TO FEVER
INTRODUCTION
FEVER 37.8 C
What is normal body temperature? At any time
- varies throughout the day
- normal oral temperature 36 – 37.4 C
- adult 18 – 40y.o:
 upper limit of normal temperature 37.2 C at 6am, 37.7 C overall
 average rectal temp: 0.5 C higher
 average axillary temp: 0.5 C lower
- fever? Body temperature > 37.8 C
CAUSES OF FEVER
Fever Infection
INFECTION - bacterial, viral, fungal, parasite

MALIGNANCY - lymphoma, renal/liver Ca

CONNECTIVE TISSUE DISEASE - SLE, PAN, Adult Still's

Disease

DRUG REACTION - Phenytoin, Rifampicin,

Azathioprine

OTHERS - Thyroid storm, Neuroleptic Malignant Syndrome, Gout

ANOTHER WAY OF LOOKING
AT THE CAUSES OF FEVER

New onset fever during Fever/unwell from home?

hospital admission
FEBRILE
PATIENT

Immunocompetent? Immunocompromised?
LEUKOCYTOSIS
 an increase in the total number of WBCs d/t any cause
 infection is the common cause
 other conditions – malignancies, inflammatory conditions, drugs, stress, and trauma
 leukocytosis > 50,000 cells/mm3  need TRO leukemia
 at times, leukopenia can be the presenting feature of certain infections  e.g
influenza, infectious mononucleosis, HIV
SYSTEMATIC APPROACH TO
PATIENTS
 History
WITH FEVER
 Identify potential sources
- Review localizing symptoms & signs
- Top to bottom approach
 Relevant Investigations/focused testing
 Treatment
HISTORY
 Immune status: is the patient immunocompromised? (e.g. as a result of leukemia,
chemotherapy, steroid use, HIV)
 Medical history: k/c/o illness that may have caused fever e.g. tumor fever from
lymphoma or fever from lupus flare
 Medication history: is the patient taking OTC drugs? e.g. neuroleptics,
anticholinergics, antibiotics, steroids
 Social history:
 Travel history
 High risk behaviour
 Occupation/Hobby
 Pets/animal contact
TOP-TO-BOTTOM APPROACH
PHARYNGITI
MENINGITIS SINUSITIS OTITIS
S

- Headache - Facial pain - Ear pain - Sore throat

- Neck stiffness - Runny nose - Ear discharge - Injected throat
- Altered mental - Sinus tenderness - Diminished
status - Anosmia hearing
- Seizure
 ENDO/
PNEUMONIA ABDOMEN UTI
PERICARDITIS

- Cough - Chest pain - Abd pain - Dysuria

- SOB - Lethargy - nausea/vomiting - Increase
frequency/urgency
- CXR findings - Flu-like symptoms - Diarrhea - Suprapubic pain
- CVS exam: - Ascites - Loin pain
murmur - Altered bowel
- ECG- Widespread habit
ST elevation
 CATHETER
PELVIC CELULITIS JOINT INFECTION
RELATED

- Lower abdomen - Erythema - Pain - Pain

pain - Pain - Warmth - Pus
- PV discharge - Intradialytic
- Swelling - Swelling
- Dyspareunia hypotension
- Joint effusion
RELEVANT INVESTIGATIONS
Blood Tests Body fluids Imaging

• FBC • Sputum • CXR

• Coag/DIVC screen • Urine • USG
• RP/LFT/CK • CSF • CT Scan
• ABG • Pleural/ascites • Echo
• ESR/CRP fluid
• Blood C&S • Joint aspirate
• Virology tests • Stool
• Serology tests • AFB/MTB C&S
MANAGEMENT OF NEW
ONSET FEVER IN THE
HOSPITALIZED PATIENTS
 New onset fever is common BUT, WHERE IS THE SOURCE? Lungs
 Non infectious causes; PE, drug fever
 Empiric antibiotic need to be streamlined Pressur
IV line
based on culture result e sore possible
source of
 Prolonged broad-spectrum antibiotic coverage infection
predisposes colonization with highly resistant bacteria,
fungaemia, C. Difficile colitis Wound/
CBD surgical
site
Post Operative Patients
 wound infection must first be
excluded
 immediate post-op period (24-48H):
streptococcus pyogenes can cause
septic shock & severe bacteremia with
only minimal purulence
 later post-op period: staphylococcus
aureus including MRSA
 Nosocomial pathogens: pseudomonas,
Klebsiella, E. Coli
 Empirical antibiotic therapy should
include gram +ve & gram –ve coverage
Intubated/post stroke/ill patients
 at risk to develop pneumonia- bacteria
colonizing the nasopahrynx more
readily gain entry to the bronchi and
pulmonary parenchyma in intubated
patients
 sputum gram stain help to differentiate
colonization from true infection
 single organism + > 10 neutrophils per
high-power field  suggest infection
 parameters that are helpful to
differentiate colonization from true
infection; oxygenation/ABG, CXR, PCT
if available
IV Line Bladder catheterization

 possible pathogens: S. Aureus,  nearly all patients with CBD develop

Staphylococcus epidermidis, and gram- bacterial colonization within 30 days
negative rods
 to send UFEME and urine C&S as part
 initial antibiotic coverage should of fever w.up
include vancomycin and a 3rd gen
cephalosporin
 prolonged hospital stay and multiple
antibiotics are at risk to develop
fungaemia
TAKE HOME MESSAGES
 Fever infection
 Infections can present with fever or without fever
 Infections can present with leukocytosis / leukopenia
 Find and treat the underlying cause; comprehensive history taking and physical
examinations are key
 Sometimes antibiotics is not the ONLY answer; need source control/surgical
intervention too
REFERENCES
THANK YOU