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THERMOREGULATION
The internal core temperature is homeostatically maintained at 100 0F (37.80C). The normal body
temperature varies among individuals and varies throughout the day, ranging from 35.5 0C in the
morning to 37.70C in the evening.
Thermoregulatory concept (!) : Internal core (organs, CNS, and muscles) and outer shell (skin
and subcutaneous fat)
The temperature within the internal core is subject to precise regulation maintain its homeostatic
constancy --> 37.80C. In contrast, the temperature in outher shell is cooler, and it helps to maintain
the cores thermal constancy.
Heat input to the body must balance heat output to maintain a constant total heat content and
thus a stable core temperature.
The core temperature is monitored by central thermoreceptors, while the outer shell temperature is
monitored by peripheral thermoreceptors.
The posterior region of hypothalamus is activated by cold, triggers reflexes that mediate heat
production and conversion
The anterior region is activated by warmth, initiate reflexes that mediate heat loss
Non-shivering thermogenesis is mediated by epinephrine and thyroid hormone, both of which
increase heat production by stimulating fat metabolism
The hypothalamus is the bodys thermostat.
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Temperature-decreasing mechanisms
Vasodilation of skin blood vessels
Sweating. An additional 1oC increase in body
temperature causes enough sweating to
remove 10 times the basal rate of body to
produce heat
Decreases in heat production, shivering and
thermogenesis are inhibited
Temperature-increasing mechanisms
Vasoconstriction of skin blood vessels
Piloerection, sympathetic stimulation causes
the arrector pili muscles attached to the hair
follicles to contract , which brings the hairs to
an upright stance
Increases in thermogenesis, by promoting
shivering,
sympathetic
excitation,
and
thyroxine secretion
Demam
Definisi
Demam adalah peningkatan suhu tubuh yang diakibatkan oleh inflamasi atau infeksi (Sherwood).
Demam yang berarti peningkatan suhu tubuh diatas batas normal, dapat diakibatkan karena
abnormalitas pada otak maupun toxin mikroba yang mempengaruhi pusat termoregulator (Guyton).
Demam didefinisikan sebagai suhu rektal 380C and suhu 400C disebut hyperpyrexia.
Pyrogen
Pyrogen adalah zat yang menyebabkan kenaikan suhu tubuh. Terdapt 2 tipe pyrogen, exogenous
dan endogenous. IL-1 yang dilepaskan dari neutrophils dan macrophages dikenal sebagai
endogenous pyrogens untuk membedakan mereka dari exogenous pyrogens yang diproduksi
patogen
Pyrogens bekerja langsung di hypothalamus. Pelepasan endogenous pyrogens oleh sel sel
inflamatori terjadi setelah fagositosis, setelah paparan terhadap bacterial endotoxin, atau setelah
paparan terhadap antigen-antibody complexes.
Endogenous
Cytokines : IL-1, IL-6, TNF-,
and IFN-, IFN-
Stimulated leukocytes
Exogenous
Infectious pathogens :
microbes, microbial toxins,
or other product of
microbes
Drugs : vancomycin,
amphotericin B, and
allopurinol
Cells that produce lipid
(PGE2)
Antigen-antibody complexes
in the presence of
complement, lymphocyte,
bile acids, and androgenic
steroids capable for
stimulating endogenous
Malignancy can produce
them
Inflammatory diseases can
produce them
Etiologi
1. Infeksi : bakteri, virus, protozoa, parasit
2. Non-infeksi
a. Inflamasi
b. Neoplastic
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c. Miscellanous : AMI, pulmonary embolism, phlebitis, dry gangrene, cerebrovascular accidents,
acute pancreatitis, pulmonary hemorrhage, acute respiratory distress syndrome, diare noninfeksi, pleural effusions, renal infarcts, C. difficile diare
d. Penyakit imunologis rheumatologis
e. Obat
f. Penyakit endokrin dan metabolik
g. Jejas jaringan
Fase Klinis
1. Prodormal phase : nonspecific complaints, such as mild headache and fatigue, general malaise, and
fleeting aches
2. Cold or chill phase : shivering (heat production), although the temperature is higher,
vasoconstriction, and piloerection, the skin is pale and is covered with goose flesh, feeling of being
cold, put to curl up in position
3. Fever phase : cutaneous vasodilation, skin becomes warm and flushed
4. Defervescence phase : initiation of sweating
Type
Type
Intermittent
Description
An exaggerated circadian rhytm that
includes a period of normal temperatures
on most days; extremely wide fluctuations
may be termed septic or hectic fever
Remittent
Persistent
0.50C/day
Relapsing
It is characterized by febrile periods that
are separated by intervals of normal
temperature
A single illness with 2 distinct periods
(camelback fever pattern)
Biphasic
Continuous
and
varies
by
more
than
Persistent and does not varies by more
than 0.50C/day
Diseases
Abscesses, malaria falciparum,
miliary TB, peritonitis, gramnegative sepsis, endocarditis,
Kawasaki disease, toxic shock
syndrome
TBC, p. falciparum malaria, viral
URTI,
ARF,
legionella,
mycoplasma
Relapsing
fever,
dengue,
malaria, smallpox, yellow fever,
brucellosis
Leptospirosis,
dengue
fever,
colorado thick fever, smallpox,
yellow
fever,
poliomyelitis,
chikungunya fever
Typhoid fever, scarlet fever,
brucellosis, drug fever, fastitious
fever
Pathogenesis
Certain disease states, through the elaboration of exogenous pyrogens, stimulate monocytes and
macrophages to produce endogenous pyrogens such as IL-1, IL-6, TNF-, and interferon-. These
pyrogenic cytokines act at the endothelial surface of the circumventricular organ of the preoptic
area of the anterior hypothalamus (PO/AH) to induce the production of PGE2, which elevates the
bodys thermal set point.
Physiologic and behavioral responses may be invoked to raise body temperature to a new set point.
This febrile response must be considered in the context of an overlapping acute-phase response as
a global nonspecific response to the original insult. Intrinsic central antipyretics and systemic
antipyretics exert their effects by decreasing levels of PGE2, decreasing the set point and
lowering body temperature.
Endogenous cryogens or antipyretics : arginine vasopressin (AVP), -melanocyte-stimulatinghormone (-MSH), and corticotropin-releasing factor are released from the brain, and systemic antiinflammatory cytokines
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Benefits
A
raised
body
temperature
kills
many
microorganisms and has adverse effects on the
growth and replication of others.
It decreases serum levels of iron, zinc, and copper,
all of which are needed for bacterial replication.
The body switches from burning glucose to a
metabolism based on lipolysis and proteolysis,
thereby depriving bacteria of a food source.
Anorexia and somnolence reduce the demand for
muscle glucose.
It also causes lysosomal breakdown and
autodestruction of cells, thus preventing viral
replication in infected cells.
Heat increases lymphocytic transformation and
motility of polymorphonuclear neutrophils, thus
facilitating the immune response.
Notes
A temperature increase of normally 1 0F is
accompanied by an appropriate pulse increase of
10 beats/min
References
1. Sherwood, Lauralee. 2010. Human Physiology, 7 th
ed.
2. Arthur C. Guyton, and John E. Hall. 2006. Textbook
of Medical Physiology, 11th ed.
3. Kathyrn L. McCance et al. 2010. Pathophysiology :
The Biologic Basis for Disease in Adults and
Children, 6th ed. Mosby Elsevier.
4. Kliegman, et al. 2011. Nelson Textbook of
Pediatrics, 19th ed. Elsevier.
5. Braunwald et al. 2005. Harrisons Principles of
Internal Medicine, 16th ed.
6. Burke A. Cunha. 2006. Infectious Diseases in Critical Care Medicine, 2 nd ed.
