1

YOU GIVE ME FEVER!!!

By Lester A. Deniega, MD Thermosensitive neurons (Anterior hypothalamus)

FEVER
(Pedia2 Module4/ Lecture Date: June 15, 2006)
Thermoregulatory responses:
 Redirection of blood to and from Cutaneous
• Fever definition vascular beds
o Elevation of body temperature to above normal  Increased or decreased sweating
(98.40F) or 370C orally or 99.80F or 37.60C  ECF volume regulation
rectally)  Behavioral changes
• Challenge to fever • Why Fever Occurs
o To establish the causative agent – distinguish viral Exogenous pyrogens: e.g.infectious agents, drugs
from bacterial disease
o Identify the site of a localized infection White blood cells
(macrophages, monocytes, neutrophils)
• Temperature Variability
o Individual to individuals Cytokines e.g. IL-1, TNF
o In each individual
o Diurnal variation in temperature Hypothalamus in brain
o Oral, axillary or rectal temperatures
Prostaglandins
o Responses among children and adults
o Physiologic states causing fever: FEVER
 digestion
 exercise • Fever patterns
 ovulation o Intermittent – high spikes with return to normal
 pregnancy o Remittent – like intermittent but temperature never
 warm environment returns to normal
 emotion o Sustained – like remittent but with less marked
o Pathologic causes swings of temperature
 Infection o Relapsing – several days of fever alternating with
 Inflammation e.g. connective tissue disease periods of normal temperature
 Neoplasms
 Vaccines • Fever patterns suggesting specific diseases
 Dehydration o Sustained - typhoid fever
o Remittent – abscess
• Common causes of fever o Relapsing – B. recurrentis; Hodgkin’s disease
o Minor illness (noninf.)
 URTI
 Viral exanthems • Spectrum of fever syndromes
 Gastroenteritis o Fever without localizing signs
o Major illnesses o Fever of short duration associated with infection
 Bacterial meningitis o Recurrent and prolonged fever associated with
 UTI infection
 Pneumonia o Fever with a rash
 Malaria o Fever in association with a chronic disease
o Fever associated with a collagen disease
• Mechanisms of a Protective Effect of Fever o Fever associated with malignancy
o Enhanced neutrophil migration o Drug fever
o Increased production of antibacterial substances by o Factitious fever
neutrophils o Hospital-acquired
o Increased production of interferon
o Increased antiviral and antitumor activity of • Fever associated with a chronic disease
interferon
o Increased T-cell proliferation Chronic disease Complications
o Decreased growth of microorganisms in iron-poor
environment  Congenital heart  Bacterial
“Fever”: Infectious Disease Clinics Of North America, 1995 disease endocarditis
 Cyanotic heart
• Extreme hyperpyrexia and hypothermia (>410C) disease  Cerebral abscess
 Rheumatic fever  Bacterial
Extreme pyrexia Hypothermia endocarditis,
 Elderly recurrence of RF
 Central fevers  Shunt infection,
(neoplastic,  Cold  Shunted
sepsis
exposure hydrocephalus
trauma or  Urinary tract
infection)  Hypothyroidis  Chronic renal
m infection
 Drug fever disease
 Overwhelming  Opportunistic
 Heat stroke  Congenital or
infection organisms, fungi,
 HIV acquired
 Sepsis in CRF parasites
 Malignant immunodeficiency
 Overzealous  Concealed
hyperthermia abscess
treatment with  Recent surgery
 Malignant
antipyretics
neuroleptic
syndrome • Drug fever
o 1-2% of prolonged fevers
• Pathogenesis of fever o Penicillin
Exogenous pyrogens: o Sulphonamides
Microbes, microbial toxins, Other microbe products o Cephalosporins
o Amphotericin B
Endotoxins o Anticonvulsants
o Atropine
PML, Monocytes, Macrophages o Blood and plasma derived products
• History
Endogenous pyrogens: IL-1;IL-6;TNF-a & IFN –B and Y Specific points of importance:
 2
o Child’s appetite, thirst, sleep pattern, weight loss,
play activities, motor abilities and behavior
o Water supply and methods of preparing food and MANAGEMENT OF FEVER
formula
o Area of residence or areas visited - knowledge of • Why Treat Fever
epidemiology  Comfort to the child
o Health of immediate family-members, caregivers  Prevention of febrile convulsions
and relatives  Decreased parental anxiety
o Contact with pets, birds and other animals.  Helpful when child has underlying illness e.g.
o Medication history pursued heart disease
o Past history of surgery, congenital defects, chronic
illness and infections
o Family history for genetic disorders

PHYSICAL EXAMINATION
• American Academy of Pediatrics Recommendations
Should be systematic, meticulous and convincing to the parents  A child older than 6 months of age who has a
temperature below 38.30C probably does not
• Observe general appearance, demeanor need to be treated for fever, unless the child is
• Localize the lesions or note for any specific local signs or uncomfortable. Observe her behavior. If she is
eating and sleeping well and is able to play,
symptoms
you may wait to see if the fever improves by
• Look for subtle signs of CNS involvement
itself.
• Note for skin rashes and classify  Keep the room comfortably cool
• Occult blood in stools  Dress child in light clothing
• Muscles and skeletons carefully palpated for generalised  Encourage child to drink fluids such as water,
or localised tenderness or swelling. Note for joint diluted fruit juices, or a commercially prepared
tenderness and function oral electrolyte solution
• Enlargement: liver, spleen,lymph node  Be sure that she does not overexert herself
• After full examination of abdomen,chest and heart, focus  Medications can be given to reduce
attention on EENT temperature if child is uncomfortable
• Pelvic examination for sexually active females
 Be sure to follow the correct dosage and
medication schedule as any medication can be
• Tell-tale clues dangerous if you give your child too much.
 Ibuprofen should only be used for children
Red weeping eyes Periarteritis nodosa older than 6 months of age. It should not be
Bulbar conjunctivitis Leptospirosis given to children who are vomiting constantly
Lack of sweating moderate to severe dehydration; or are dehydrated.
anhydrotic ectodermal dysplasia  Do not use aspirin to treat your child's fever.
Palpebral EBV infection, TB and SLE, Aspirin has been linked with side effects such
conjunctivitis Catscratch disease as an upset stomach, intestinal bleeding and,
Choroid tubercles TB most seriously, Reye syndrome.
Sinus tenderness sinusitis  Do not use cold water to sponge your child, as
Muscle tenderness Trichinosis, viral infections, this could cause shivering. That could increase
Collagen-vascular diseases her temperature.
Sore trapezius muscle subdiaphragmatic abscess  Never add alcohol to the water. Alcohol can be
Dental examination abscesses absorbed into the skin or inhaled, causing
Normal pulses despite Factitious fever serious problems such as a coma.
high fever  Do not try to reduce your child's temperature
to normal too quickly. This could cause the
• Findings that Localize Infection temperature to rebound higher.

Sore throat Streptococcal tonsillitis; • Antipyretics: Paracetamol (acetaminophen)

diphtheria  Dose: 10 – 15 mg/kg/dose q 4 hrs
Cough, rusty sputum Pneumonia  Least toxic
Severe joint pain/swelling pyogenic arthritis  Toxic range is 10 times the normal dose range
Severe pain in head and back Meningitis  Well tolerated
of the neck with stiffness  Very few allergic reactions
Severe pain in a bone Osteomyelitis
Tender liver amebic liver abscess; • Specific Treatment
viral hep o Not all fevers are caused by infections
Ill-defined skin and soft tissue Cellulitis; o Not all infections are bacterial in origin
inflammation pyomyositis o Some bacterial infections are better treated by other
Bloody diarrhea Shigella; means e.g. abscess
Campylobacter
• Considerations in Choosing an antibiotic
• Approach to Diagnosis of Infectious Disease o The microorganism
o All abnormalities and pathophysiologic changes are  Bacteriological results interpreted in the light of
documented clinical findings
o The anatomical site of infection is determined o The host e.g. genetic factors, physiologic functions,
o Identification of etiologic agent site and severity of infection and allergy
 Many pathogens tend to infect specific tissues o The antibiotic – pharmacokinetic properties
or organs  Monotherapy vs. Antibiotic combinations
o Only when agent is identified can a tentative  Whenever an alternative is available, the
diagnosis become definitive cheaper antibiotic selected

• Investigations /3na/secb08
o Nonspecific e.g. WBC and differential, ESR,
Imaging studies
o Laboratory investigations in microbiology
 Direct microscopy
 Culture & sensitivity testing
 Detection of antigen/antibody