FEVER FRIEND or FOE? Basil J. Zitelli, MD Children s Hospital of Pittsburgh. FEVER - FRIEND or FOE? FEVER - FRIEND or FOE?

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1 FEVER - FRIEND or FOE? Basil J. Zitelli, M.D. FEVER - FRIEND or FOE? Basil J. Zitelli, M.D. Disclosure: Dr. Zitelli has no conflict of interest, financial agreement, or working affiliation with any group or organization. 1

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3 Fever Homeostasis Fever mediated possibly via IL-6 through IL-1 Naturally occurring cryogens provide negative feedback Arginine vasopressin, TNF, α MSH 3

4 Since the advent of modern clinical thermometry by Wunderlich in 1871, the ritual of temperature taking has been surpassed only by Alexander Graham Bell s invention in 1874 as the major curse of pediatrics. David S. Smith, 1970 Fever Phobia T <38 o C is a fever 48% T <40 C is harmful to CNS 43% Treat T <38 C 21% Awaken sleeping febrile child to give antipyretics 53% Parents obtained beliefs from actions of physicians and nurses Kramer (1985) Schmitt (1980) Fever is only a symptom, and we are not sure that is an enemy. Perhaps it is a friend. Du Bois (1948) 4

5 Advantages of Fever? Evolutionary advantage of fever Human use of hyperpyrexia Hot baths and malarial fever beneficial in syphilis Hyperthermia to treat gonococcal endocarditis Fever has better outcome in peritonitis, GN bacteremia, pneumococcal meningitis 5

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7 Adaptive Value of Fever Host Defense Mechanisms Increased macrophage migration Increased lymphocyte activity Increased killer cell activity Iron sequestration 7

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9 Adverse Effects of Fever Febrile convulsions Increased insensible water loss Hypermetabolism Discomfort Disadvantages of Antipyretic Therapy Elimination of a diagnostic clue Allergic or idiosyncratic reactions Presence of toxic drugs in home Acetaminphen (100 mg/cc drops vs 32mg/cc susp; tabs 325 adult vs 160 chewable Delays diagnosis Effects of antipyretics on the immune system 9

10 Aspirin Inhibits: Antibody formation and response DNA thymidine incorporation Granulocyte adherence Phagocytosis Inhibits neutralizing Ab to rhinovirus Associated with Reye syndrome Acetaminophen Immune enhancing and inhibiting effects May prolong varicella rash Acetaminophen prophylaxis for immunizations had significant blunting of GMC titers to pneumococcus, H flu, diphtheria, tetanus and pertussis (Prymula, Lancet 2009;374:1339) Use in utero and childhood may increase incidence of asthma (Perzanowski MS Thorax 2010;65:118) 10

11 Ibuprofen Inhibits numerous poly functions Treatment Groups Comfort Placebo Sponging with tepid water alone Ice water and acetaminophen Alcohol, water, acetaminophen Good Fair Poor

12 Alternating Ibuprofen and acetaminophen? Ibuprofen inhibits glutathione In renal ischemia or hypovolemia, oxidative metabolites of acetaminophen accumulate in the kidney producing toxicity 12

13 Education Works 30% - 35% decreased visits for fever 20 % - 25% decreased visits for acute problems Summary Do not participate in fever phobia Treat fever with specific indication: Therapy will not obscure / delay diagnosis Existing hypermetabolic states Patient discomfort 13

14 Fever is a mighty engine which nature brings into the world for the conquest of her enemies. Sydenham