01 Patient With Fever

8/7/2019 01 Patient With Fever

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The patient with fever

Assoc. Prof. Simona Dragan


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Definition Elevation of body temperature

above normal daily variation

Normal and adaptive response toagression


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Measure temperature

Oral probe Normal: 98.2o 98.8o F

Low grade fever: 99 100.5o F

Fever: > 100.5o F

Rectal probe Normal 99.2 99.8o F

Low grade fever: 100 101.5o F

Fever: > 101.5o F

> 37,0 oC (axilar)> 37,8 oC (oral)

> 38,2 oC (rectal)


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Study fever curve

Procedure Take and record the patients temperature every 6 to 8 hours

Study the patterns

Patterns: Continuous (variation < 1o)

Remittent (variation > 2o over 1 day)

Intermittent (afebrile periods mixed with fever spikes)

Quotidian (remittent with daily fever spikes) ex: Plasmodium

Relapsing (intermittent and cyclic, fever returns every 5-7

days ex: Borrelia sp)


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Diagnostic approach to fever

History of fever/pattern Date of onset

Periodicity

Accompanying symptoms

Chills

Sweating

Arthralgias

Myalgias

Information on travel/exposure to agents or animals

History personal or family: Blood transfusions

Immunizations

Thromboembolic disease, valvular disease, tuberculosis

Cancer Repeated physical examinations:

Skin

Eyes

Nail beds

Heart

Abdomen

Lymph nodes


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Laboratory evaluation

Elevated ESR, neutrophilia

Elevated CPR

Elevated liver functional tests

Creatinine, bloodglucose, calcemia

LDH, coagulation

Proteinuria, urinary sediment

Blood cultures

Serology: Salmonella, Brucella, Yersinia

Increased immunoglobulins: nuclear antibodies,rheumatoid factor, cryoglobulin

TSH

Tumor markers


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Approach algorrhythm

Clinical examinationLaboratory evaluation

Abdominal ultrasound

Chest X-Ray

known origin unknown origin

targeted investigations well toleratedworsening of clinical

condition/ anemia/

inflammatory

false track

dg.

further investigation follow up

FUO


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Common causes of intermittent fever

Infections

Connective tissue disorders

Neoplasia ( leukemia, lymphoma)


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Intermittent fever of infectious origin

Situations:

1. channel fever: gram-negative or gram positive

bacteremia of urinary, biliary or intestinal origin

2. Infection of implants orthopedic, vascular,prosthesis, pace-maker

3. Infectious endocarditis

4. Tuberculosis

5. Persistent infection with Yersinia enterocolitica

6. Malaria


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Fever of urinary origin

1. UTI

- Plain X-ray of abdomen

- Intravenous urography

- Cystogram- Ultrasonography

- Computed tomography

2. Acute nephritic syndrome

- Red blood cell casts- Antibody titer:ASLO


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UTI localizing urinary tract infection

Method Comments

Clinical Distinct features of pyelonephritis, perinephric abcess,

cystitis, prostatitis, urethritis

Urinalysis Bacterial cast pathognomonic of pyelonephritis: WBC castsuggests nonspecific tubulointerstitial inflammation; tissue

may indicate papillary necrosis

Differential culture Controlled voidings plus prostatic secretions or semen;

bladder washout methods or ureteral catheterization todistinguish upper from lower tract infection

Antibody-coated bacteria Indicate bacterial invasions of tissues (kidney, prostate)


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Fever of biliary origin

Symptoms / signs Laboratory Dg

- Abdominal pain (colicky)

- Jaundice

- Dark urines

- Murphys sign

- Cholestasis,

hyperbilirubinemia

- Elevation of transaminases

- Blood cultures

- Endoscopic retrograde

cholangiopancreatography

-Ultrasound endoscopy of

ducks

-Ultrasonography

-Procedure of choice to

differentiate extra hepatic /

intrahepatic jaundice (dilated

ducts = extra hepatic

obstruction)

- Gallstones

Acute cholecystitis

Acute viral hepatitis

Differential diagnosis Hepatocellular carcinoma

Pancreatic carcinoma


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Fever of intestinal origin

- Most frequent: sigmoiditis


- Elderly

- Known diverticulosis

- Lower abdominal pain

- Blood cultures positive

- Gram negatives

- Anaerobes

- Abdominal CT


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Infection of implants orthopedic, vascular


- Local pain -Leucocytosis-CPR elevated

-Blood cultures positive

(white Staphylococcus)

-Scintigraphy with Galliummarked leucocytes

-Cultures from implant

material

-Surgery ablation


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Endocarditis of valvular prosthesis, or

known valvular disease


-Change of murmur

-Extracardiac sign: emboli,

arthralgias, purpura

-Blood cultures

-TEE

-Bacteriology + histology of

biopsy from valve

Endocarditis or pace-makerSymptoms / signs Laboratory Dg

-Pain thoracic

-Tricuspid regurge

-Dyspnea

-Blood cultures

(Staphylococus)

-Pulmonary scintigraphy

-TEE

-Bacteriology from pace-

maker


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Tuberculosis


-Elderly-Malnourished

-Immune deficit

-IDR to PPD intenselypositive

-Absence ofleucocytosis

-Microbiology of urinary andrespiratory prelevations

-Culture in special medium

-CT


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Infections


Neoplasia (leukemia, lymphoma)


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Systemic lupus eritematosus

Rheumatoid arthritis

Polymiositis

Arthritis associated to spondylitis: ankylosis spondylitis

Juvenile arthritis


Joint motions

-Swelling, stiffness

-Crepitus

-Monarthritis / symmetric

arthritis /polyarticular onset

-Major joints

-Shoulder

-Ankle

-Knee

-Hip

-Vertebral column

-Small joints

-Hand, foot

-Specify type

-Elevated ESR

-Elevated CPR

-Latex fixation test for

rheumatoid factor

-Antinuclear factor

-Anti double stranded DNA

level

-X-Ray

-Joint space narrowing

- Synovial fluid

measurements

-Microscopic synovial fluidexamination

-CT, MRI


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Infections


Neoplasia (leukemia, lymphoma)


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Fever in neoplasic disease

T > 37.8 C at least once daily

Duration of fever > 2 weeks

Absence of infection

ClinicalBiological

Imagistic

Absence of allergy (to drugs, transfusion,

radio/chemotherapy) Absence of response to antibiotic therapy done for at

least 7 days


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Neoplasia and hemopathies with

intermittent fever

Neoplasia Colorectal cancer

Cancer of pancreas

Grawitz kidney tumor

Cancer of the ovary

Metastasis

Hemopathies

Hodgkin Non-Hodgkin malignant lymphomas

Acute leukemias

myelodysplasia


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Clinical case

HT

Dyslipidemia

3 months ago - progressive weakness

- progressive weightloss (10kg)

- non-productive cough (dry)

- retro-sternal chest pain, more severe with

inspiration

On admission:

- no fever (36.8o C )

- dullness at percussion, abolished breath sounds in left lower

pulmonary lobe

J.I. , 71 Years [M]


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Chest X-ray: Dense consolidation ofleft lowerlobe

Multiple non-homogeneous infiltrates in medium and lower

right lobes


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Laboratory test

Hg (g%) 13,9

Ht (%) 42,4

L (mmc) 10.800

Gr = 77%, Lf = 18%

ESR (mm/1h) 83

Fibrinogen (g/l) 6,8


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Diagnosis

RETICULAR PULMONARY FIBROSIS. BILATERAL BRONCHIECTASISCOMPLICATED WITH LEFT LOWER LOBE PNEUMONIA

Evolution: complicated

THERAPY: Cephalosporin gen III +

Aminoglicozide +

Metronidazol Continous fever

Acute respiratory failure

37

38

39

40

1 2 3 4 5 6 7 8 9 10

11

12

Zile de spitalizare

Temperatura(gra


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Reconsider diagnosis

Hemoculture: negative

CT scan thorax:

Bilateral reticular fibrosis of the 2lower/3rds of

pulmonary parenchima, bronchiectasis.Extensive consolidation of right lower lobe andof external 1/3 of middle and lower right lobes

Minimal mediastinal and bilateral tracheo-bronchial

adenopathy Bronchofibroscopy/Biopsy:

Broncho-pulmonary oat cellcarcinoma

Date post:	09-Apr-2018
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01 Patient With Fever

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