Fever

Presented by-Peeyush Padmesh

Moderated by-Dr(Professor) Shitanshu Srivastava
 Defination

• Fever is defined as a rectal temperature ≥38°C

(100.4°F), and a value >40°C (104°F) is called
hyperpyrexia.
• Body temperature fluctuates in a defined normal
range (36.6-37.9°C [97.9-100.2°F] rectally),
• highest point is reached in early evening and the
lowest point is reached in the morning.
• Any abnormal rise in body temperature should be
considered a symptom of an underlying condition
 Pathogenesis of fever
• Body temperature is regulated by
-thermosensitive neurons located in the preoptic
or anterior hypothalamus that respond to changes in
blood temperature
-by cold and warm receptors located in skin and
muscles.
• Thermoregulatory responses-
-Redirecting blood to or from cutaneous
vascular beds,
- increased or decreased sweating,
-regulation of extracellular fluid volume via
arginine vasopressin,
-behavioral responses, such as seeking a
warmer or cooler environmental temperature.
Three different mechanisms can produce fever:
• Pyrogens(endogenous and exogenous pyrogens
that raise the hypothalamic temperature set point)

• heat production exceeding loss(salicylate poisoning

and malignant hyperthermia.), and

• defective heat loss(ectodermal dysplasia or victims

of severe heat exposure.)
 Pyrogens

Endogenous pyrogens

• include the cytokines interleukins 1 and 6, tumor necrosis

factor α, and interferons β and γ.

• Stimulated leukocytes and other cells produce lipids that

also serve as endogenous pyrogens.

• The best-studied lipid mediator is prostaglandin E2, which

attaches to the prostaglandin receptors in the
hypothalamus to produce the new temperature set point.
• Along with infectious diseases and drugs, malignancy and
inflammatory diseases can cause fever through the
production of endogenous pyrogens.

• Some substances produced within the body are not pyrogens

but are capable of stimulating endogenous pyrogens.
- antigen–antibody complexes in the presence of
complement,
- complement components,
-lymphocyte products,
- bile acids, and androgenic steroid metabolites.
• Exogenous pyrogens (substances that come from
outside the body)
• mainly infectious pathogens and drugs.
• Microbes, microbial toxins, or other products of
microbes are the most common exogenous pyrogens
and stimulate macrophages and other cells to
produce endogenous pyrogens.
• Endotoxin is one of the few substances that can
directly affect thermoregulation in the hypothalamus as
well as stimulateendogenous pyrogen release.
 Etiology

• 4 categories-
infectious
inflammatory
neoplastic
miscellaneous

MC cause of acute fever

-self-limiting viral infections(common cold and gastroenteritis),
and
-uncomplicated bacterial infections(otitids
media,sinusitis,pharyngitis)
 Patterns of fever

• Neonates may not have a febrile response and may

be hypothermic despite significant infection
• Older infants and children younger than 5 years old
may have an exaggerated febrile response with
temperatures of up to 105°F (40.6°C) in response to
either a serious bacterial infection or an otherwise
benign viral infection
• The fever pattern does not distinguish fever caused
by bacterial, viral, fungal, or parasitic organisms from
that resulting from malignancy, autoimmune
diseases, or drugs.
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
• Intermittent fever-exaggerated circadian rhythm that
includes a period of normal temperatures on most
days; extremely wide fluctuations may be termed
septic or hectic fever.
• Sustained fever -persistent and does not vary by
more than 0.5°C (0.9°F)/day.
• Remittent fever-persistent and varies by more than
0.5°C (0.9°F)/day.
• Relapsing fever- characterized by febrile periods that
are separated by intervals of normal temperature;
- tertian fever occurs on the 1st and 3rd
days(malaria caused by Plasmodium vivax), and
-quartan fever occurs on the 1st and 4th days
(malaria caused by Plasmodium malariae.
• Biphasic fever -a single illness with 2 distinct periods
(camelback fever pattern)
- poliomyelitis is the classic example.
-also characteristic of other enteroviral infections,
leptospirosis ,dengue fever, yellow fever, Colorado tick
fever, spirillary rat bite fever (Spirillum minus), and the
African hemorrhagic fevers (Marburg Ebola, and Lassa
fevers)
• Periodic fever-fever syndromes with a regular
periodicity ( cyclic neutropenia and periodic fever,
aphthous stomatitis, pharyngitis, and
adenopathy)

Factitious fever, or self-induced fever- caused by

intentional manipulation of the thermometer or
injection of pyrogenic material.
• The double quotidian fever (or fever that peaks
twice in 24 hr) -classically associated with
inflammatory arthritis.
• In general, a single isolated fever spike is not
associated with an infectious disease. Such a spike
can be attributed to the infusion of blood products
and drugs, as well as to some procedures, or to
manipulation of a catheter on a colonized or infected
body surface.
Temperatures in excess of 41°C (105.8°F) are most
often associated with a noninfectious cause.
- central fever (resulting from central nervous
system dysfunction involving the hypothalamus),
-malignant hyperthermia,
-malignant neuroleptic syndrome
-drug fever
-heat stroke.
 Clinical features

• from no symptoms at all to extreme malaise.

• feeling hot or cold,
• display facial flushing, and experience shivering.
• Fatigue and irritability may be evident.
• Parents often report that the child looks ill or pale
and has a decreased appetite
Changes in heart rate, most commonly tachycardia,
accompany fever.

Normally heart rate rises by 10 beats/min per 1°C (1.8°F) rise

in temperature for children >2 mo of age.

Relative tachycardia(pulse rate is elevated disproportionately

to the temperature, )- caused by noninfectious diseases or
infectious diseases in which a toxin is responsible for the
clinical manifestations.
.
• Relative bradycardia (temperature–pulse
dissociation), when the pulse rate remains low in the
presence of fever, can accompany typhoid fever,
brucellosis, leptospirosis, or drug fever.

• Bradycardia in the presence of fever also may be a

result of a conduction defect resulting from cardiac
involvement with acute rheumatic fever, Lyme
disease, viral myocarditis, or infective endocarditis
 Evaluation of fever

• Thorough history:
- onset,
-other symptoms,
- exposures (daycare, school, family, pets, playmates),
- travel,
- medications,
- other underlying disorders,
-immunizations
• Physical examination: complete, with focus on localizing
symptoms
• Laboratory studies on a case-by-case basis:
• Rapid antigen testing
• Nasopharyngeal: respiratory viruses by polymerase chain reaction
• Throat: group A Streptococcus
• Stool: rotavirus
• Blood: complete blood count, blood culture, C-reactive protein,
sedimentation rate, procalcitonin
Urine: urinalysis, culture
• Stool: Hemoccult, culture
• Cerebrospinal fluid: cell count, glucose, protein, Gram stain,
culture
• Chest radiograph or other imaging studies on a case-by-case basis
 Management of fever
• Treating fever in self-limiting illnesses for the sole
reason of bringing the body temperature back to
normal is not necessary in the otherwise healthy child
• Fever with temperatures <39°C (102.2°F) in healthy
children generally does not require treatment
• Antipyretic therapy - Other than providing
symptomatic relief, antipyretic therapy does not
change the course of infectious diseases.
• Good hydration -first step to replace fluids lost due to
the increased metabolic demands of fever.
• Fever caused by specific underlying etiologies resolves
when the condition is properly treated. Examples-
- administration of intravenous immunoglobulin to treat
Kawasaki disease
- administration of antibiotics to treat bacterial
infections.
• Physical interventions to reduce body temperature
-Tepid sponging is not recommended for the treatment
of fever.
-Children with fever should not be underdressed or
over-wrapped.
 Fever without focus
• refers to a rectal temperature of 38°C (100.4°F) or
higher as the sole presenting feature.
• Subcategories-
-fever without localizing signs- duration of
<1 wk and without localizing signs
-fever of unknown origin- fever documented
by a healthcare provider and for which the cause could
not be identified after 3 wk of evaluation as an
outpatient or after 1 wk of evaluation in the hospital
 Fever without focus
• Diagnostic challenge in children less than 36 months
of age due to higher risk of occult bacteremia and
serious bacterial infection(SBI)
• Etiology and evaluation of feevr depends upon age
of child,hence 3 group
-Neonates or infants to 1 mo of age,
-infants >1 mo to 3 mo of age, and
-children >3 mo to 3 yr of age.
 Neonates

• Display limited signs of infections(d/t immature immune

response)
• Neonates with fever and not looking ill have 7 % risk of
havi SBI(bacteremia,meningitis,pneumonia,septic
arthiritis,entritis,UTI)
• MC cause of SBI in india-HiB and Streptococcus
pneumoniae(also-staph aureus,[Link],listeria
monocytogenes,HSV)
• All febrile neonate should be hospitalized-
• blood,urinr ,csf should be cultured
• emperical IV antibiotics
 1-3 months of age
• MC cause-self limiting seasonal viral illness(RSV and
Influenza A during winters and Enterovirus in
summers
• Following conditions of SBI should also be ruled out-
otitis media,pneumonia ,skin and soft tissue
infections,omphalitis,UTI)
• MC [Link],Group B
streptococci,[Link],HiB,Nesseria
meningitidis,enterococci
• MC infection-pyelonephritis
MANAGEMENT
• febrile children must be evaluated for sepsis by-
CBC,LP,blood culture,urine analusis and cc/s,chest
radiograph
• Ill appearing infants require immediate hospitalization
and prompt parenteralempirical antimicrobial
therapy(ampicillin with either cefotaxime or ceftriaxone)
• Well appearing infant-watchful observation with 24-
hour follow-up(csf obtained before abx if deteriorates)
 3-36 month old children
• 30% of febrile children have no localizing signs
• MC cause-viral infections
• SBI-d/t [Link],Neisseriaa,HiB
• HiB was major cause of occult bacteremia before
univerasal immunization with conjugate vaccine
• Risk factors-
• rectal temp>39C(102.2 F)
• WBC COUNT>15000/mm cube
• raised ESR
• elevated CRP
• Pattern of sequelae of occult bacteremia -related to
host factors and the offending organism
• Without therapy, occult bacteremia by
pneumococcus can resolve spontaneously without
sequelae, can persist, or can lead to localized
infections such as meningitis, pneumonia, cellulitis,
pericarditis, osteomyelitis,
• Hib bacteremia -higher risk for localized serious
infection than by S. pneumoniae
Management
• toxic-appearing febrile children -hospitalization and
antimicrobial therapy after specimens of blood,
urine, and CSF are obtained for culture

• Well looking children with <39°C (102.2°F) -observed

as outpatients without performing diagnostic tests or
administering antimicrobial agents.
• nontoxic-appearing with a rectal temperature
of ≥39°C (102.2°F)-options-
-obtaining a blood culture and empirical antibiotic
therapy (ceftriaxone, a single dose of 50 mg/kg, not to
exceed 1 g); if the WBC count is >15,000/μL,
-obtaining a blood culture and beginning empirical
ceftriaxone; or
-obtaining a blood culture and observing as
outpatients without empirical antibiotic therapy, with
return for reevaluation within 24 hr
Fever of unknown origin
Etiology
 History

AGE –
> 1-5 yrs - common causes are RTI,UTI,diarrhoea and
osteomyelitis –
>5-10 yrs-measles,mumps,chicken pox,typhoid –
>10yrs- TB, typhoid ,rheumatic fever
GENDER –
> Females-urinary tract infections,pelvic infections
> Males-allergic fever(hay fever), typhoid ,
tuberculosis,malaria
ADDRESS
-endemic regions for malaria and japanese
encephalitis,epidemics,out breaks in that area
CHIEF COMPLAINTS
- History of fever and other symptoms should be
taken in chronological order,
give clue towards system involved
eg:- fever,dysuria ,loin pain –UTI fever ,
drowsiness ,convulsions - meningitis, encephalitis
Onset
acute-measles,mumps,acute sinusitis
insidious-typhoid,malignancies
Grade
low grade-TB,HIV,sinusitis,diptheria
high grade-Dengue,malaria,typhoid
Age
• Children >6 yr-respiratory or genitourinary
tract infection, localized infection (abscess,
osteomyelitis), JIA, or, rarely, leukemia.
• Adolescent patient- inflammatory bowel
disease, autoimmune processes, lymphoma,
or tuberculosis, in addition to the causes of
FUO found in younger children.
• Epidemics in resident area
• Pets - toxoplasmosis,visceral larva migrans
• Contact with animals – leptospirosis,brucellosis • Tick
bites-relapsing fever, Q fever
• Blood transfusion - malaria,hepatitis-B
• Migrating joint pains - Rheumatic fever
• Loss of weight-malignancies
• History of recurrent fever,oral thrush -
immunocompromised
• Joint pains,rash,photosensitivity - autoimmune
PHYSICAL EXAMINATION
• Careful and complete examination
• Repetitive examination to pick up subtle or new signs
• Look for the child’s general appearance, built and
nourishment
• for temperature pattern ,
• pulse rate –relative bradycardia in typhoid, meningitis dengue,
• Skin – look for rashes , petechiae, splinter hemorrhages,
subctaneous nodules
Eye
Palpebral conjunctivitis-measles,TB,infect mononucleosis
Bulbar conjunctivitis-kawasaki ds,leptospirosis
• Proptosis – orbital tumor , thyrotoxicosis, orbital infection ,
wegener granulomatosis , metastases(neuroblastoma)
• Roth’s spots – infective endocarditis
• Uveitis – sarcoidosis, JIA, SLE, kawasaki disease,vasculitis
• Chorioretinitis – CMV, toxoplasmosis , syphilis
• Tenderness to tapping over sinuses-sinusitis
• Oral cavity-
Hyperemia of pharynx Tender tooth –> periapical abscess
Recurrent oral candidiasis –> disorder of immune system
• Neck –
Enlargment or tenderness of thyroid gland –thyroiditis
• Heart- Murmur – infective endocarditis
• Abdomen –
Splenomegaly – malaria, kala azar , CML
Abdominal tendernes- pelvic abccess
Loin tenderness - pyelonephritis
Hepatomegaly- liver abscess , primary or metastatic malignancy
• Hyperemia of pharynx-
-streptococcal infectn,EBV virus,CMV
infectn,toxoplasmosis,salmonellosis,tularemia
• Muscle and bone –
- Point tenderness- occult osteomyelitis or bone
marrow invasion from neoplasms
-Painful and swollen joints – arthritis – rheumatic
fever
• Rectal examination – pelvic abscess,adenitis
Management-
• Treat the underlying cause
• Antimicrobial agents should not be used as
antipyretics, and empirical trials of medication
should generally be avoided.(exception-
antituberculous treatment in critically ill children
with suspected disseminated tuberculosis)
• Antipyretics are indicated after complete evaluation
to control fever ass. with adverse symptoms
Fever in under 5s: assessment and initial
Management(NICE Guidelines)
Clinical guideline
Published: 22 May 2013
[Link]/guidance/cg160
 Why this guideline matters
Feverish illness in children:
• is the most common reason for children to be taken
to the doctor
• is a cause of concern for parents and caretaker
• can be a result of a simple self-limiting infection or a
life-threatening infection
• can have no apparent source.
Detection of fever In children aged 4 weeks
to 5 years
• measure body temperature by:
-electronic thermometer in the axilla
-chemical dot thermometer in the axilla or
-infra-red tympanic thermometer.

• Use an electronic thermometer in the axilla for

children younger than 4 weeks
 Clinical assessment of the child with fever

• Assess children with feverish illness for the presence or

absence of symptoms and signs that can be used to predict
the risk of serious illness using the traffic light system

• Measure and record temperature, heart rate, respiratory

rate and capillary refill time as part of
• the routine assessment of a child with fever.

• Recognise that children with tachycardia are in at least an

intermediate-risk group for serious illness
• Advanced Paediatric Life Support (APLS)[1] criteria
below to define tachycardia:[new 2013]
• Age Heart rate (bpm)
<12 months >160
12–24 months >150
2–5 years >140
 The safety net
• The safety net should be one or more of the
following:
• verbal and/or written information on warning
symptoms and how further healthcare can be
accessed
• arranging further follow-up
• liaising with other healthcare professionals, including
out-of-hours providers, to ensure direct access for
the child if required