The patient with fever

Assoc. Prof. Simona Dragan

• Definition
• Elevation of body temperature
above normal daily variation
• Normal and adaptive response to
agression
 Measure temperature
• Oral probe
• Normal: 98.2o – 98.8o F
• Low grade fever: 99 – 100.5o F
• Fever: > 100.5o F
• Rectal probe
• Normal 99.2 – 99.8o F
• Low grade fever: 100 – 101.5o F
• Fever: > 101.5o F
> 37,0 oC (axilar)
> 37,8 oC (oral)
> 38,2 oC (rectal)
 Study fever curve

• Procedure
• Take and record the patient’s temperature every 6 to 8 hours
• Study the patterns
• Patterns:
• Continuous (variation < 1o)
• Remittent (variation > 2o over 1 day)
• Intermittent (afebrile periods mixed with fever spikes)
• Quotidian (remittent with daily fever spikes) ex: Plasmodium
• Relapsing (intermittent and cyclic, fever returns every 5-7
days ex: Borrelia sp)
 Diagnostic approach to fever
• History of fever/pattern
• Date of onset
• Periodicity
• Accompanying symptoms
» Chills
» Sweating
» Arthralgias
» Myalgias
• Information on travel/exposure to agents or animals
• History personal or family:
• Blood transfusions
• Immunizations
• Thromboembolic disease, valvular disease, tuberculosis
• Cancer
• Repeated physical examinations:
• Skin
• Eyes
• Nail beds
• Heart
• Abdomen
• Lymph nodes
 Laboratory evaluation
• Elevated ESR, neutrophilia
• Elevated CPR
• Elevated liver functional tests
• Creatinine, bloodglucose, calcemia
• LDH, coagulation
• Proteinuria, urinary sediment
• Blood cultures
• Serology: Salmonella, Brucella, Yersinia
• Increased immunoglobulins: nuclear antibodies,
rheumatoid factor, cryoglobulin
• TSH
• Tumor markers
 Approach algorrhythm
Clinical examination
Laboratory evaluation
Abdominal ultrasound
Chest X-Ray
FUO

known origin unknown origin

targeted investigations worsening of clinical well tolerated

condition/ anemia/
inflammatory
dg.

false track further investigation follow up

 Common causes of intermittent fever

• Infections
• Connective tissue disorders
• Neoplasia ( leukemia, lymphoma)
 Intermittent fever of infectious origin

• Situations:
1. “channel” fever: gram-negative or gram –positive
bacteremia of urinary, biliary or intestinal origin
2. Infection of implants – orthopedic, vascular,
prosthesis, pace-maker
3. Infectious endocarditis
4. Tuberculosis
5. Persistent infection with Yersinia enterocolitica
6. Malaria
 Fever of urinary origin

1. UTI
- Plain X-ray of abdomen
- Intravenous urography
- Cystogram
- Ultrasonography
- Computed tomography
2. Acute nephritic syndrome
- Red blood cell casts
- Antibody titer :ASLO
 UTI – localizing urinary tract infection

Method Comments
Clinical Distinct features of pyelonephritis, perinephric abcess,
cystitis, prostatitis, urethritis
Urinalysis Bacterial cast pathognomonic of pyelonephritis: WBC cast
suggests nonspecific tubulointerstitial inflammation; tissue
may indicate papillary necrosis

Differential culture Controlled voidings plus prostatic secretions or semen;

bladder washout methods or ureteral catheterization to
distinguish upper from lower tract infection

Antibody-coated bacteria Indicate bacterial invasions of tissues (kidney, prostate)

 Fever of biliary origin
Acute cholecystitis
Acute viral hepatitis
Differential diagnosis Hepatocellular carcinoma
Pancreatic carcinoma

Symptoms / signs Laboratory Dg

- Abdominal pain (colicky) - Cholestasis, - Endoscopic retrograde
- Jaundice hyperbilirubinemia cholangiopancreatography
- Dark urines - Elevation of transaminases -Ultrasound endoscopy of
- Blood cultures ducks
- Murphy’s sign
-Ultrasonography
-Procedure of choice to
differentiate extra hepatic /
intrahepatic jaundice (dilated
ducts = extra hepatic
obstruction)
- Gallstones
 Fever of intestinal origin
- Most frequent: sigmoiditis

Symptoms / signs Laboratory Dg

- Elderly - Blood cultures positive - Abdominal CT

- Known diverticulosis - Gram negatives
- Lower abdominal pain - Anaerobes
 Infection of implants – orthopedic, vascular

Symptoms / signs Laboratory Dg

- Local pain -Leucocytosis -Scintigraphy with Gallium

-CPR elevated marked leucocytes
-Blood cultures positive -Cultures from implant
material
(white Staphylococcus)
-Surgery – ablation
 Endocarditis of valvular prosthesis, or
known valvular disease
Symptoms / signs Laboratory Dg

-Change of murmur -Blood cultures -Bacteriology + histology of

-Extracardiac sign: emboli, -TEE biopsy from valve
arthralgias, purpura

Endocarditis or pace-maker
Symptoms / signs Laboratory Dg

-Pain thoracic -Blood cultures -Bacteriology from pace-

-Tricuspid regurge (Staphylococus) maker
-Dyspnea -Pulmonary scintigraphy
-TEE
 Tuberculosis

Symptoms / signs Laboratory Dg

-Elderly -IDR to PPD intensely -Microbiology of urinary and

-Malnourished positive respiratory prelevations
-Immune deficit -Absence of leucocytosis -Culture in special medium
-CT
 Common causes of intermittent fever

• Infections
• Connective tissue disorders
• Neoplasia (leukemia, lymphoma)
 Connective tissue disorders
• Systemic lupus eritematosus
• Rheumatoid arthritis
• Polymiositis
• Arthritis associated to spondylitis: ankylosis spondylitis
• Juvenile arthritis
Symptoms / signs Laboratory Dg

Joint motions -Specify type -Anti double stranded DNA

-Swelling, stiffness -Elevated ESR level
-Crepitus -Elevated CPR -X-Ray
-Monarthritis / symmetric -Latex fixation test for -Joint space narrowing
arthritis /polyarticular onset rheumatoid factor - Synovial fluid
-Major joints -Antinuclear factor measurements
-Shoulder -Microscopic synovial fluid
-Ankle examination
-Knee -CT, MRI
-Hip
-Vertebral column
-Small joints
-Hand, foot
 Common causes of intermittent fever

• Infections
• Connective tissue disorders
• Neoplasia (leukemia, lymphoma)
 Fever in neoplasic disease

• T > 37.8 C at least once daily

• Duration of fever > 2 weeks
• Absence of infection
– Clinical
– Biological
– Imagistic
• Absence of allergy (to drugs, transfusion,
radio/chemotherapy)
• Absence of response to antibiotic therapy done for at
least 7 days
 Neoplasia and hemopathies with
intermittent fever

• Neoplasia
• Colorectal cancer
• Cancer of pancreas
• Grawitz kidney tumor
• Cancer of the ovary
• Metastasis
• Hemopathies
• Hodgkin
• Non-Hodgkin malignant lymphomas
• Acute leukemias
• myelodysplasia
 Clinical case
J.I. , 71 Years [M]
• HT
• Dyslipidemia
3 months ago - progressive weakness
- progressive weight loss (10kg)
- non-productive cough (dry)
- retro-sternal chest pain, more severe with
inspiration
On admission:
- no fever (36.8o C )
- dullness at percussion, abolished breath sounds in left lower
pulmonary lobe
 Chest X-ray: Dense consolidation of left lower lobe
Multiple non-homogeneous infiltrates in medium and lower
right lobes
 Laboratory test

• Hg (g%) 13,9
• Ht (%) 42,4
• L (mmc) 10.800
Gr = 77%, Lf = 18%
• ESR (mm/1h) 83
• Fibrinogen (g/l) 6,8
 Diagnosis
RETICULAR PULMONARY FIBROSIS. BILATERAL BRONCHIECTASIS
COMPLICATED WITH LEFT LOWER LOBE PNEUMONIA
Evolution: complicated

THERAPY: Cephalosporin gen III +

Aminoglicozide +
Metronidazol
• Continous fever
• Acute respiratory failure

40
T e m p e r a tu r a (g r a d e C )

39

38

37

Zile de s pitalizare
 Reconsider diagnosis

• Hemoculture: negative
• CT scan thorax:
Bilateral reticular fibrosis of the 2lower/3rds of
pulmonary parenchima, bronchiectasis.
Extensive consolidation of right lower lobe and
of external 1/3 of middle and lower right lobes
Minimal mediastinal and bilateral tracheo-bronchial
adenopathy
• Bronchofibroscopy/Biopsy:
Broncho-pulmonary “oat cell”carcinoma