Fever. Department of Nephrology Poznań University of Medical Sciences

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1 Fever Department of Nephrology Poznań University of Medical Sciences

2 EQUIPMENT Mercury Thermometer Forehead Thermometer Electronic Thermomter Ear Thermometer Infra-Red Camera

3 NORMAL BODY TEMPERATURE Commonly accepted value: 37.0 C (98.6 F) orally 37.7 C (99.6 F) rectally The morning rectal temperature varies from 36.1 to over 37.2 C for men from 36.1 to over 37.7 C for women There is no single normal value for everyone! It is very helpful if the usual normal range for any individual is known so comparisons can be made when illness occurs

4 NORMAL BODY TEMPERATURE The normal morning value for any one individual would be followed by a diurnal variation with a rise higher than the morning value.

5 NORMAL BODY TEMPERATURE Research on temperature of parts of the body, other than oral and rectal: the skin of the forehead the nasopharynx the esophagus the tympanic membrane the skin of infants the umbilicus of infants The tympanic membrane and the esophagus provide temperature levels more indicative of the influence on the hypothalamic centers than temperatures recorded in more peripheral portions of the body.

6 VARIATIONS OF TEMPERATURE IN DIFFERENT PARTS OF BODY Oral Temperature: commonly used in practice if correctly taken, may be more indicative of fluctuations of body temperature than rectal readings easily falsely lowered by mouth breathing, drinking or eating cold substances falsely elevated by hot food or drink, chewing (activity of muscles of mastication), smoking and increased salivary gland activity Rectal Temperature: 1-2 C higher than oral temperature (this relationship is not constant) used especially in children, in adults with suspected shock, or where oral reading is not valid for reasons given above

7 VARIATIONS OF TEMPERATURE IN DIFFERENT PARTS OF BODY Axillary or Groin Temperature: in well nourished persons this approximates oral temperature in thin and emaciated subjects, lower than oral temperature and not reliable Urine Temperature: in a fresh urine specimen, collected in vessels previously warmed to body temperature very reliable indicator of body temperature averages C below rectal temperature foolproof method for checking on spurious or malingered body temperature elevations if the collections are properly made

VARIATIONS OF TEMPERATURE IN DIFFERENT PARTS OF BODY Tympanic Membrane: tympanic thermometry is being utilized increasingly the readings are more consistent than oral or rectal recordings.

8 VARIATIONS OF TEMPERATURE IN DIFFERENT PARTS OF BODY Tympanic Membrane: tympanic thermometry is being utilized increasingly the readings are more consistent than oral or rectal recordings. consistent and only 0.2 C lower than esophageal readings which are valuable but impractical to utilize for routine clinical activities more accurately reflect the central temperature in man at the thermoregulating centers in the brain than oral, skin or rectal temperatures especially helpful for continuous recording of body temperature during surgical operations while the patient is under anesthesia

9 MEDICAL THERMOGRAPHY Thermography is a technique by which infrared radiation from the skin of the human body can be recorded via a special camera and device which converts infrared radiation to visible light which can be photographically recorded as a "thermograph". Warmer areas and colder areas can be recognized by a different color Thermography records areas of increased or decreased skin temperature. Heat production from the skin: increased in areas of increased vascularity or metabolism (i.e inflammation, malignancy, etc.) diminished over areas of benign processes (i.e. scar tissue, vascular obstructions, etc.)

10 MEDICAL THERMOGRAPHY A surprising number of conditions can be detected or suspected. Much interest has centered on its use to detect: breast cancer and other breast diseases other types of cancer placental localization certain orthopedic conditions peripheral vascular disease aid in skin grafts carotid artery disease In recent years, thermography use is increasingly being more refined.

11 PHYSIOLOGICAL VARIATIONS IN NORMAL BODY TEMPERATURE Digestion of food - rise 1.0 to 2.0 C Vigorous Exercise - rise to C (return to normal within thirty minutes with rest or shower) Diurnal Variation - low point early a.m.; peak in late afternoon, early evening; variation varies - usually 0.5 to 1.0 C Menstrual Cycle - rise of C rectally at time of ovulation with drop back at menstruation; absent with amenorrhea Pregnancy - continuation of above rise for about the first four months of pregnancy Warm Environment - slight increase (1.0 C) Cold Environment - very slight drop in healthy adults; marked drop in infants and very old adults Emotion - slight temporary rise with emotion

12 INFLUENCE OF AGE Infants much more susceptible to environmental changes than older children or adults easy to lose heat and get hypothermia with fever rise may have convulsions rather than a chill diurnal variations may not be established until 2nd year rise with infection not as striking as in older children Children temperature response to many ordinary ills (especially infections or toxic agents) more bizarre and marked than in adults exercise elevation of mild degree common

13 INFLUENCE OF AGE Old People normal temperature may be subnormal by standards of young adults circulation is feeble temperature often does not respond to infections or toxic agents as for younger people easier to miss an infection easier to get hypothermia on exposure to cold environment temperatures occasionally diurnal variation may be reversed

14 CONTROL OF NORMAL BODY TEMPERATURE Normal body temperature range is maintained by balance between factors which increase heat production and increase heat loss. HEAT PRODUCTION Amount of clothing Metabolism of food Diminished skin circulation Tensioning of muscles Normal muscular activity Warm environment HEAT LOSS Radiation (60%) transfer to cooler objects by EM waves. Convection (12-15%) to air about body and that moving in and out of the respiratory tract. Vaporization (20-27%) from skin and respiratory tract even without gross sweating.

by: cooler environment less clothing increased skin circulation Loss of

15 HEAT LOSS Greatly increased by: vigorous exercise shivering (chills) disease (by producing shaking chill) sweating panting Aided and increased by: cooler environment less clothing increased skin circulation Loss of balance between heat production and heat loss can either raise or lower body temperature.

16 BODY TEMPERATURES UNDER DIFFERENT CONDITIONS

17 DEFINITION OF FEVER Often defined as increase in body temperature over the normal range which is caused by disease More exactly any rise above normal body temperature due to disease and not from environmental exposure, pregnancy, emotion, exercise, eating or other such physiological factors The clinical thermometer is an instrument of precision within limits!

18 MECHANISM OF FEVER Mechanism of fever from disease is complex brief definition: fever is produced by action of certain substances (endogenous or exogenous pyrogens) acting on thermoregulatory centers in the hypothalamus the anterior center is concerned with heat dissipation by vasodilation and sweating related to parasympathetic activity the posterior center is concerned with conserving heat by vasoconstriction and shivering and related to sympathetic activity The normal balance between the anterior center and the posterior center is upset to produce a positive heat balance and raise the body temperature.

19 MECHANISMS OF FEVER

20 FEVER KEY CONCEPTS

21 FOUR STAGES OF FEVER Fist Stage: Prodrome Mild headache Fatigue General malaise Fleeting aches and pain Second Stage: Chill Temperature is rising Unconfortable sensation of being chilled Vasoconstriction and piloerection Onset of generalized shaking Pale skin covered with goose flesh Feeling of being cold

22 FOUR STAGES OF FEVER Third Stage: Flush Shivering ceases Sensation of warmth develops Cutaneous vasodilation occurs Skin becomes warm and flushed Bad taste in mouth Fourth Stage: Defervescence Initiation of sweating Skin is warm and moist Temperature is rapidly lowered

23 DEFINITION OF TYPES OF FEVER AND FEVER CURVES In clinical practice, especially for patients admitting to a hospital, the "body temperature" is recorded 2 or more times a day and plotted on a temperature chart. This permits a visual recording of the low and high values for the 24 hours. The type of fever curve produced is another helpful indicator of diagnosis and prognosis, along with the history, physical examination and laboratory data, or specialized studies. The following definitions of types of fever or fever curves will be helpful as background knowledge.

24 DEFINITION OF TYPES OF FEVER AND FEVER CURVES Pyrexia - synonymous with fever. Habitual Pyrexia - average temperature elevated minimally and constantly over normal range in a person otherwise healthy. Diurnal Variation - daily rhythmic change in body temperature, varying C with lowest point in early a.m. and peak in afternoon or evening. Chill - uncontrollable muscular shivering (and other physiological phenomena) which produces a sharp rise in body temperature. Ague - synonymous with repeated chills. Rigor - synonymous with chill. Hyperpyrexia or Hyperthermia - means body temperature higher than 41.0 C

25 DEFINITION OF TYPES OF FEVER AND FEVER CURVES Hectic (or Septic) Fever - an intermittent fever with large daily swings in body temperature, usually accompanied by chills and sweats. Remittent Fever - significant variations in temperature level (more than the diurnal variation) each day, but no drop to a normal level of temperature (i.e.: acuterheumatic fever, pulmonary tuberculosis, etc.) Continuous (or Sustained) Fever - fever sustained at a high level in which daily diurnal variations are no wider than usual for the individual (i.e.: pneumococcal lobar pneumonia before treatment, rickettsial diseases, certain types of drug fever, etc.) Spurious (or False) Fever - elevation in the thermometer reading produced by trickery on part of the patient; also called factitious fever or fever of malingering.

26 DEFINITION OF TYPES OF FEVER AND FEVER CURVES Psychogenic (or Emotional) Fever - elevation in temperature produced by emotional stimulus (i.e.: slight elevation of temperature on the day of admission to hospital with normal temperature thereafter, or rise in temperature while students are taking complicated or important examinations) Catheter Fever - passage of catheter, cystoscope, etc. through infected urethra is followed by fever in short time due to transitory bacteremia; more severe forms accompanied by a chill Charcot's (Hepatic) Intermittent Fever - is due to cholangitis with intermittent biliary obstruction due to a ball valve stone often lying in the Ampulla of Vater; fever occurs periodically; bile duct narrowed by stricture or tumor, or by a polyp may also be a cause

27 DEFINITION OF TYPES OF FEVER AND FEVER CURVES Pel-Ebstein Type of Fever - rare type seen in Hodgkins disease, somewhat comparable type may be seen in Brucellosis (Undulant Fever); a form of relapsing fever but with longer febrile and afebrile periods and slower rises and falls in the fever curve Thirst Fever - a type of fever curve seen in dehydrated infants in very warm climates characterized by marked elevation in the morning with return to normal by the evening Quartan (Tertian) Fever - in the quartan (tertian) type of malaria, the chill and fever occur every third (second) day; a form of relapsing fever curve; the regularity of this fever pattern may suggest the diagnosis Tertian malaria Plasmodium vivax 48-hour interval Quartan malaria Plasmodium malariae 72-hour interval

DOUBLE QUOTIDIAN FEVER CURVE Patient gets two spikes of fever every day, generally once in the morning and once in the evening Kala-Azar Juvenile Rheumatoid Arthritis Adult Onset Juvenile Rheumatoid

28 DOUBLE QUOTIDIAN FEVER CURVE Patient gets two spikes of fever every day, generally once in the morning and once in the evening Kala-Azar Juvenile Rheumatoid Arthritis Adult Onset Juvenile Rheumatoid Arthritis Gonococcal Endocarditis Meningococcal Endocarditis Miliary Tuberculosis Rarely in other infections Common Peripheral Manifestations of Infective Endocarditis. Splinter hemorrhages (Panel A) are normally seen under the fingernails. They are usually linear and red for the first two to three days and brownish thereafter. Conjunctival petechiae (Panel B). Osler's nodes (Panel C) are tender, subcutaneous nodules, often in the pulp of the digits. Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles.

29 RELAPSING TYPE FEVER CURVE Short febrile periods of variable duration (usually with sharp rise and fall in temperature) are interspersed by periods of one or more days of normal temperature. Malaria Chronic Meningococcal Septicemia Rat-bite Fever Charcot's (Hepatic) Intermittent Fever Relapsing Fever - tick borne due to Borrelia duttoni It should not be confused with the following: Saddle-Back Fever (biphasic temperatue curve) Undulant Type Fever (Hodgkins disease, Brucellosis) Septic Fever (daily fever swings with sweats)

"SADDLE BACK" (BIPHASIC) TYPE OF FEVER CURVE A form of relapsing

separated by a period free of fever for a short period.

30 "SADDLE BACK" (BIPHASIC) TYPE OF FEVER CURVE A form of relapsing fever curve limited to two febrile episodes of one or more days each separated by a period free of fever for a short period. Recurrence or progression of clinical features occur with the second febrile episode. It has been noted in: dengue fever yellow fever Colorado tick fever lymphocytic-choriomeningitis poliomyelitis certain other virus diseases

HECTIC FEVER WITH REVERSED DIURNAL GRADIENT "TYPHUS

highest temperature peak occurs in the early a.m. hours and the lowest in the evening hours.

(especially of the miliary type), salmonella

31 HECTIC FEVER WITH REVERSED DIURNAL GRADIENT "TYPHUS INVERSUS" Reversal of the normal diurnal pattern the highest temperature peak occurs in the early a.m. hours and the lowest in the evening hours. This type of fever curve suggests tuberculosis (especially of the miliary type), salmonella bacteremia and rarely other causes.

32 METAL FUME FEVER SYNDROME OF MONDAY NIGHT CHILL AND FEVER Due to inhalation of zinc oxide fumes (zinc has a low melting point and volatilizes at 500 C). On exposure for the first time, one gets a mild headache, malaise and muscle aches, anorexia and mild cough. Later in the day, frequently after work, there may be a chill, fever and sweats. Continued exposure produces immunity which is lost when individual does not work over a weekend or holiday. Episodes recur on first day back to work. A bizarre clinical picture of chills and fever each Monday night after leaving work. Fumes of certain other metals may do this.

COMPLICATIONS OF FEVER Fever, aside from the disease producing it, may produce certain complications which are reversible when temperature returns towards normal.

33 COMPLICATIONS OF FEVER Fever, aside from the disease producing it, may produce certain complications which are reversible when temperature returns towards normal. The most important of these are: delirium (the threshold at which it occurs varies greatly, more readily produced in infants, the aged, alcoholics) convulsions (most-common in infants under age 2) headache (related to dilatation of certain cerebral arteries as a result of the fever, also certain specific types of infections are likely to cause this symptom) herpes (especially when temperature rises sharply) febrile albuminuria

34 COMPLICATIONS OF FEVER Chill or rigor (with sharp rise in body temperature, and sweats with rapid drop in body temperature) may also be considered as a complication of fever. They may be dangerous in debilitated persons. Fever may contribute to: causing anemia influence certain liver function tests increase of the body metabolic rate significant effects on cardiac and pulmonary function To most physicians, fever is considered a valuable clue of some abnormal state of body function or disease process.

FEVER OF UNKNOWN ETIOLOGY F.U.O. A not uncommon clinical problem in hospital practice is evaluation of a patient who has had a persistent and unexplained fever for two or more weeks.

35 FEVER OF UNKNOWN ETIOLOGY F.U.O. A not uncommon clinical problem in hospital practice is evaluation of a patient who has had a persistent and unexplained fever for two or more weeks. Before undertaking a detailed diagnostic workup, the following two possibilities should be checked: Factitious fever Drug fever i.e.: Fever From Sulfonamides Atropine Pyrexia Syndrome of Erythema and Fever of the Ninth Day (arsphenamine ) Fever Due to Sympathectomy or Use of Autonomic Drugs Unexplained Fever with Early Penicillin Treatment of Gonorrhea As a Sign Suggesting Co-existent Syphilis

36 FACTITIOUS FEVER Failure to consider this possibility as an explanation of an obscure fever has proved embarrassing to many physicians. It can easily be ruled out first without directly mentioning it by the simple procedure of personally taking the temperature with your own thermometer. Simulation of a fever by thermometer trickery is not too unusual and should be suspected, when: the pulse reading fails to rise with temperature peaks lack of a characteristic daily diurnal curve lack of chills & sweats with sharp rises and falls in temperature exceptionally high readings

37 DRUG FEVER If a patient with persistent unexplained fever has been on medication therapy, one must consider that the rise in body temperature may be due to an adverse effect of the medication. It is well to withdraw all medication for 24 to 48 hours and note whether fever diminishes. Some medications produce fever only after a latent interval, some after persistent use, and some from very small doses in susceptible persons. Mechanisms: pharmacologic action of the drug itself immunological reaction to the medication tissue reaction as a result of a local reaction pyrogens or bacterial organisms may be introduced at the time of injection

38 SUDDEN FEVER IN BED PATIENT UNDER OBSERVATION WHO WAS PREVIOUSLY AFEBRILE A common clinical situation is a rise in temperature of a bed patient whose temperature curve had previously, under observation, been normal. When this situation occurs think first of: changes in thermometer technique: new nurse new thermometer failure to "shake" it down changes from oral to rectal temperature etc. urinary tract infection common respiratory infection bronchopneumonia pulmonary infarction disease of leg veins

39 CAUSES OF FEVER OF NON-INFECTIOUS ORIGIN It is well to emphasize size, by the list which follows, how frequently fever may be of non-infectious origin: Lesions of CNS (experimental punctures, hemorrhage, tumor) Drugs Dehydration Deficiency diseases Therapeutic fever produced by physical apparatus Coronary occlusion with myocardial infarct Injections (foreign protein) Hyperthyroidism Dissecting aneurysm Malignant tumors Cardiac decompensation Pernicious anemia Skin diseases Blood dyscrasias (leukemia, Hodgkins disease, etc.) Free hemorrhage in any body cavity (pleura, peritoneum, etc.)

40 CAUSES OF FEVER OF NON-INFECTIOUS ORIGIN Gout Diabetic acidosis Serum sickness Variations during menstrual cycle Habitual pyrexia Exercise Hot climate Wyatt Syndrome Gastrointestinal bleeding Infarction of any organ Periodic disease Riley-Day Syndrome Sympathectomy Angiitis etc. etc. etc. The preceding list is by no means complete, but collected merely to show how broad the diagnostic possibilities are for explaining fever on a basis other than an infectious disease.

41 PSYCHOGENIC FEVER Fever may be produced by an emotional and possibly an hysterical mechanism. The slight elevation of temperature commonly seen during the first day of a hospital admission is an example. Apparently many types of psychic stimuli can do it. Fever has been reported in some cases of neurocirculatory asthenia.

42 HYPERTHERMIA = HYPERPYREXIA Hyperthermic fever - temperature above 41 C (prompt treatment indicated!) Irreversible damage occurs when temperature reaches 46 C Temperature of 41 C or over are so unusual that they are strongly diagnostic and suggest: thermometer trickery heat stroke intravenous pyrogen reaction rarely severe infections (<5%) occasional occurrence with fever therapy malignant hyperthermia during anesthesia occasionally in miscellaneous conditions, especially those which damage the cerebral centers controlling temperature regulation, or with disorders of metabolism

43 HEATSTROKE Heat pyrexia, sunstroke, heatstroke, thermal fever, etc. are all terms meaning the same condition. Cessation of sweating in a warm environment, especially in those with old age, alcoholism or chronic illness is the precipitating factor. The clinical picture includes: marked elevation of body temperature (41-43 C) hot, dry and flushed skin strong pulse coma possibly convulsions petechiae may be noted terminally: shock-like state and pulmonary edema Prompt therapy to lower the body temperature!!!

44 MALIGNANT HYPERTHERMIA DURING ANESTHESIA Malignant Hyperthermia (MH) is a lifethreatening, acute pharmacogenetic disorder, developping during or after a general anaesthesia. Both a genetic predisposition, and one or more triggering agents are necessary to evoke MH. Triggering agents include all volatile anaesthetics (Chloroform, Ether, Halothane, Isoflurane) and depolarizing muscle relaxants (Suxamethonium). The classical MH crisis shows a hypermetabolic state, caused primarly by the muscles of the sceletal system. Values over 43 C have been reported. MH is a dangerous disease, and anyone who is involved with anaesthesia should have up to date knowledge about MH.

45 FEVER INSPIRATION FOR THE ARTISTS THE END

Basics of Physical examination Measuring Vital signs

Basics of Physical examination Measuring Vital signs Agenda Alterations in body temperature Body weight measurement Pulse and Bp ECG Normal temperature: Body Temperature. Basics Meas. in - axillary 36,5