1 / 69

FEVER AND FEVER OF UNKNOWN ORİGİN

FEVER AND FEVER OF UNKNOWN ORİGİN. Meral Sonmezoglu , MD . Ass oc Professor of Infectious Dıseases. BODY TEMPERATURE. BODY TEMPERATURE. Heat is derived from biochemical reactions occuring in all living cells (glucose catabolism, ATP)

pero
Download Presentation

FEVER AND FEVER OF UNKNOWN ORİGİN

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. FEVER AND FEVER OF UNKNOWN ORİGİN Meral Sonmezoglu, MD. Assoc Professor of Infectious Dıseases

  2. BODY TEMPERATURE

  3. BODY TEMPERATURE • Heat is derived from biochemical reactions occuring in all living cells (glucose catabolism, ATP) • Shivering is primary means of by which heat is enhanced • Heat is generated primarily in vital organs lying deep within the body core • Distributed thoughout the body via the circulatory system • Heat is lost from body surfaces to teh envirement

  4. BODY TEMPERATURE • The mean oral temperature 36.8 ºC 0.4 ºC • Low level at 6 AM and high level at 4 to 6 PM, with normal daily variation is 0.5 ºC • Rectal temperature 0.4 ºC higher than oral • Unadjusted-mode TM temperature 0.8 ºC lower than rectal • Lower esophageal temperature closely reflect core temperature

  5. THERMOREGULATION

  6. THERMOREGULATION • A processthatinvolves a continuum of neuralstructuresandconnectionsextendingtoandfrom “thehypothalamusandlimbicsystem”throughthelowerbrainstemandreticularformationtothespinalcordandsympatheticganglia • Preopticarea, anteriorhypothalamusandseptum • Neuronslocated in thisareaarethermosensitiveandexertpartialcontroloverphysiologicandthermoregulatoryresponses

  7. FEVER • “A state of elevated core temperature” • Part of the defensive responses of multicellular organisms (host) to the invasion of live (m.o.) or inanimate matter recognized as pathogenic or alien by the host • Febril response (tem rise is a component) is a complex physiological reaction to disease, involving not only a cytokine-mediated rise in core temperature but also the generation acute phase reactants, and activation of numerous physiologic, endocrinologic, and immunologic systems

  8. FEVER and HYPERTHERMIA • Hyperthermia is an unregulated rise in body temperature, • Pyrogenic cytokines are not directly involved and antipyretics are ineffective • Hyperthermia represents a failure of thermoregulatory homeostasis (uncontrolled heat production/ inadequate heat dissipation/defective hermoregulation • In clinical setting, fever is a pyrogen-mediated rise in body temperature above a normal range

  9. FEVER • An AM temperature of > 37.2 ºC or PM temperature > 37.7 ºC define a fever • Elevation of BT that exceeds the normal variation and occurs in conjunction with an increase in the hypothalamic set point • Hyperpyrexia • A fever of > 41.5 ºC • Severe infections but mostly common with CNS hemorrhage

  10. VARIATION IN TEMPERATURE • Anatomic variation • Physiologic variation: Age Sex Exercise Circadian rhythm Underlying disorders

  11. NORMAL BODY TEMPERATURE • Maximum normal oral temperature At 6 AM : 37.2 At 4 PM : 37.7

  12. PHYSIOLOGY OF FEVER • Pyrogens: • Exogenous pyrogens: Bacteria, Virus, Fungus, Allergen,… • Endogenous pyrogen Immune complex, lymphokine,… • Major EPs:IL1, TNF, IL6, CNF (ciliary neurotropic factor)

  13. DISCOMFORT DUE TO FEVER • For each 1 °C elevation of body temperature: • Metabolic rate increase 10-15% • Insensible water loss increase 300-500ml/m2/day • O2 consumption increase 13% • Heart rate increase 10-15/min

  14. ANTIPYRETIC AGENTS • Acetaminophen • Poor cyclooxygenase inhibitor in peripheral but oxidized ( active form ) in brain by the p450 system • Aspirin • NSAID • Affect platelets and GI tract • May deteriorate renal function in patients with renal insufficiency(inhibit renal prostaglandin ) • Glucocorticoid • Inhibit phospholipase A2 • Block the transcription of the mRNA for the pyrogenic cytokines

  15. Delirium New onset of incontinence Weakness Weight loss Loss of appetite or nausea PITFALL • In newborns, the early , patients with CRF, immunocompromise and patients taking glucocorticoids, fever may not be present despite infection or may be hypothermic. • The atypical ( often typical ) presentation of infection in elderly • Key point : loss of function

  16. ATTENUATED FEVER RESPONSE • Fever may not be present despite infection in: • Newborn • Elderly • Uremia • Significant malnourished individual • Taking corticosteroids

  17. PATTERN OF FEVER • Sustained (Continuous) Fever • Intermittent Fever (Hectic Fever) • Remittent Fever • Relapsing Fever: • Tertian Fever • Quartan Fever • Days of Fever Followed by a Several Days Afebrile • Pel Ebstein Fever • Fever Every 21 Day

  18. APPROACH TO THE PATIENTHISTORY

  19. Combined symptoms Fever pattern Medication Surgical or dental procedure Any prosthetic materials or implanted devices Occupation ( animal; fume; infectious agent or infected individuals ) Travel history Unusual hobbies Dietary proclivities Household pets Sexual exposure IV drug abuse, alcoholism Trauma Animal or insect bite Blood transfusion immunization Family history APPROACH TO THE PATIENTHISTORY

  20. APPROACH TO FEVER • Underlying Diseases: • Splenectomy • Surgical Implantation of Prosthesis • Immunodeficiency • Chronic Diseases: Cirrhosis Chronic Heart Diseases Chronic Lung Diseases

  21. APPROACH TO THE PATIENT PHYSICAL EXAMINATION • Head to toe • Finger to hole • Special attention to skin, lymph nodes, eyes, nail bed, CV system, chest , abdomen, musculoskeletal system, and nerve system. • Rectal examination is imperative • Penis, scrotum, testes , foreskin and pelvic examination in women should be examined

  22. APPROACH TO FEVER • Associated Symptoms: • Shaking chills • Ear pain,Ear drainage,Hearing loss • Visual and Eye Symptoms • Sore Throat • Chest and Pulmonary Symptoms • Abdominal Symptoms • Back pain, Joint or Skeletal pain

  23. APPROACH TO THE PATIENT LABORATORY TESTS • Clinical Pathology • CBC+DC+PLT, blood smear, UA, ESR, abnormal fluid accumulation and CSF examination, bone mallow aspiration, stool routine • Chemistry • Electrolyte, BUN, creatinine, LFTs, amylase, CPK and serology… • Microbiology • Gram’s stain and culture • Imaging • Plain film, sonography, CT, MRI and Gallium scan

  24. FEVER OF UNKNOWN ORIGIN

  25. FEVER OF UNKNOWN ORIGIN DEFINITION • Defined by Petersdorf and Beeson in 1961 • Temperature > 38.3 ºC on several occasions • A duration of fever of > 3 weeks • Failure to reach a diagnosis despite 1 week of inpatient investigation • Durack and Street proposed a new system in 1991 • and suggested two changes to the earlier • definition. • Durrack and Street proposed four types of FUO

  26. Classic FUO • Temperature > 38ºC (101ºF) recordedon several occasions occurring for more than three weeks • in spite of investigations on three OPD visits or threedays of stay in hospital or • one week of invasiveambulatory investigations is called classic FUO

  27. Nosocomial FUO • Temperaturemorethan 38.3ºC (> 101°F) is recorded on several occasions in ahospitalized patient who is receiving acute care and inwhom infection was not manifest or incubating onadmission. • Three days ofinvestigations including at least two days incubation ofcultures, is the minimum requirement for this diagnosis

  28. Neutropenic FUO • Temperature of > 38.3ºC (101ºF)on several ocasion is observed in a patient whoseneutrophil count is less than 500/microliter or is expectedto fall to that level in 1 or 2 days • This diagnosis should be considered wheninvestigation including at least two days of incubationof cultures. • It is also called immunodeficientFUO

  29. HIV associated FUO • Temperature of > 38.3ºC (>101ºF) on several occasions is found over a period ofmore than 4 weeks for our patient or more than threedays for hospitalized patients with HIV infection • This diagnosis is considered ifappropriate investigations over three days including twoday of incubation of cultures reveals no source

  30. FUO CAUSE • Big three • Infection (25-30%) • Malignancy (10-30%) • Collagen vascular disorder (10-15%) • Unknown (5-10%)

  31. FEVER OF UNKNOWN ORIGIN: REPORT OF 27 CASES

  32. A clinical review of 449 cases with fever of unknown origin • Out of the 449 FUO cases, definite diagnosis was eventually achieved in 387 patients (86.9%). • The most common causes of FUO were infectious diseases (56.8%), with tuberculosis accounting for 43.6% of cases of infection. • 76 patients were suffered from collagen vascular diseases (CVD): with Still's disease, systemic lupus erythematosus and vasculitis accounting for 34.2% (26/76), 18.4% (14/76) and 13.2% (10/76) of the this category, respectively. • 16.5% (64/449) of the FUO cases were diagnosed as malignancy. • Miscellaneous causes were found in 7.0% of the FUO cases. However, no definite diagnosis had been made in the remaining 62 (13.8%) cases until they discharged from the hospital

  33. Fever of Unknown OriginPK Agarwal*, A Gogia**

  34. Childhood World J Pediatr 2011;7(1):5-10

  35. Infections in childhood World J Pediatr 2011;7(1):5-10

  36. World J Pediatr 2011; 7(1):5-10

  37. FUO MALIGNANCY ASSOCIATED • Hodgkin’s lymphoma • Non-Hodgkin lymphoma • Leukemia • Renal cell carcinoma • Hematoma • Colon carcinoma

  38. FUO AUTOIMMUNE ASSOCIATED • SLE • RA • Adult Still’s disease • Temporal arteritis • Mixed connective tissue disease

More Related