DEMAM
Jonathan Tandaju
406182107
Definition
Fever Elevation of body temperature (>37.2°C/98.9°F in the morning and
>37.7°C/99.9°F in the evening) + with an increase in the hypothalamic set point
Hyperthermia uncontrolled ↑ in body temperature that exceeds the body
ability to lose heat
Fever of unknown origin (FUO) generally refers to temperatures >38.3°C on
several occasions over a defined period, with unrevealing investigations into its
cause.
• In normal temperature environment human metabolic rate produces more heat
than is necessary to maintain core body temperature in the range of 36.5 – 37.5 o C
• Hypothalamic thermoregulatory center balances excess heat production (derived
from metabolic activity in muscle and liver) with heat dissipation (from skin and
lungs)
• Oral temperature (36.8 ±0.4), rectal temperature 0.4 higher, axillary temperature 0.5
lower
• > 41,5 ºC hyperpyrexia (severe infections , CNS hemorrhages)
• Normal daily variation is typically 0.5ºC
• Elderly ↓ ability to develop fever, with modest fever event in severe infections
Pathogenesis
• The hypothalamic set point increases vasoconstriction (i.e., heat
conservation).
• The pt feels cold as a result of blood shunting to the internal organs.
• Mechanisms of heat production (e.g., shivering, increased hepatic
thermogenesis) raise the body temperature to the new set point.
• When the set point is lowered again (resolution or treatment) heat loss
(e.g., peripheral vasodilation and sweating) commence.
• Set point ↑ neurons in vasomotor activated vasoconctriction
commences (shunting blood away from periphers to the internal organs),
(↓ heat loss from skin)
• Shivering ↑ heat production from muscles (not required if heat
mechanisms ↑ blood temperature sufficiently
• Behavioural adjustments putting more clothing (↓ heat loss)
Etiology
• Etiology Most fevers are associated with self-limited infections (usually
viral) and have causes that are easily identified.
• Hyperthermia Exogenous heat exposure (e.g., heat stroke) and
endogenous heat production (e.g., drug-induced hyperthermia, malignant
hyperthermia) are two mechanisms danger.
History
• Duration, pattern
• Chronology events preceding fever, including exposure to other infected individuals / to vectors of disease
• Associated symptoms
• Sick/Sexual Contacts
• Travel within past year
• Recent hospitalizations
• Chemotherapy
• Trauma
• Presence of prosthetic
Clinical Features
• High core temperature in association with an appropriate history (heat
exposure, certain drug treatments) and dry skin, hallucinations, delirium, pupil
dilation, muscle rigidity, and/or elevated levels of creatine phosphokinase
• It can be difficult to distinguish fever from hyperthermia. The clinical
history is often most useful (e.g., a history of heat expo- sure or treatment with
drugs that interfere with thermoregulation).
• Hyperthermic pts have hot, dry skin; antipyretic agents do not lower the
body temperature.
Physical examination
• A consistent site for taking temperatures should be used.
• Temperature–pulse dissociations (relative bradycardia) should be noted, if
present (sometimes present, for example, with typhoid fever, brucellosis,
leptospirosis, factitious fever).
• Close attention should be paid to any rash, with precise definition of its
salient features.
• Same site should be used
consistently to monitor a febrile
disease
• *{newborns, elderly patients,
patient taking glucocorticoids,
treated with anticytokine may
have infection in the absence of
fever due to a blunted febrile
response}
Diagnostic studies
• Laboratory test : CBC, CRP, ESR
• Imaging
Other tests as indicated by history and physical exam
• Objectives reduce the elevated hypothalamic set point and second to facilitate
heat loss
• Reducing fever with antypyretics also reduces systemic symptoms ( headache,
myalgias, and arthralgias)
• Oral aspirin and NSAID effectively reduce fever but can adversely affect plateles
and gastrointestinal tract ( acetaminophen is preferred )
• Treatment of fever in some patients is highly recommended
• Fever increases the demand for oxygen ( 13% O2 consumption, for every 1ºC
over 37ºC) and can aggravate the condition of patients with preexisting
impairment of cardiac, pulmonary, or CNS function.
• ↑ 1ºC ↑ HR 10 bpm, ↑ RR 2-4 bpm
Non infectious causes include :
• Pulmonary embolism
• Intracranial hemorrhage
• Cerebrovascular accident
• Neuroleptic malignant
syndrome
• Malignant hyperthermia
• Thyroid storm
• Transfusion reaction
• Malignancy
• Autoimmune disorders
• Drug fever
Treatment of Fuo
• The emphasis in pts with classic FUO is on continued observation and
examination
• Vital-sign instability, neutropenia, and immunosuppressive conditions
may prompt earlier empirical anti-infective therapies.
• The use of glucocorticoids and NSAIDs should be avoided unless
infection has been largely ruled out and unless inflammatory disease is
both probable and threatening.
Treatment of Hyperthermia
• • Physical cooling by external physical means (e.g., sponging, fans, cooling blankets,
ice baths).
• • IV fluids, given the risk of dehydration
• • Pharmacologic agents
• – Malignant hyperthermia, neuroleptic malignant syndrome, and drug-induced
hyperthermia should be treated with dantrolene (1–2.5 mg/kg IV q6h for at least 24–48 h
• .
