Fever
Fever: Definition
• Fever is an elevation of body temperature that exceeds the normal
daily variation and occurs in conjunction with an increase in the
hypothalamic set point.
• Studies have found that the maximum normal oral temperature is
37.2ºC (98.9ºF) at 6 A.M. and 37.7ºC (99.9ºF) at 4 P.M.; these values
define the 99th percentile for healthy individuals.
• Hence, an A.M. temperature of >37.2ºC (>98.9ºF) or a P.M.
temperature of >37.7ºC P.M. (>99.9ºF) would define a fever.
• The normal daily temperature variation is typically 0.5ºC (0.9ºF).
Mechanism
• When the hypothalamic set point is raised, the body is perceived to
be cooler than the new set point.
• Shivering is initiated to generate heat. Blood is shunted from the
periphery to the core to conserve heat and sweating is diminished.
The generated heat will raise the body temperature to match the
elevated set point.
• When the hypothalamic set point is lowered, either as part of the
normal diurnal fluctuations that occur during an infection or in
response to antipyretic agents, heat is lost by evaporation (sweating)
and radiation (cutaneous vasodilation).
Mechanism
• A fever of >41.5ºC (>106.7ºF) is called hyperpyrexia. This
extraordinarily high fever can develop in patients with severe
infections but most commonly occurs in patients with central nervous
system (CNS) haemorrhages.
• The conversion formula is:
TºF = 9/5 (TºC) + 32
TºC = 5/9 (TºF) – 32
• For axillary, oral and rectal temperature, there is an approximately
0.8ºF or 0.4ºC difference between each site and the next higher one.
For convenience, it is rounded up to 1ºF or 0.5ºC.
Types of Fever
A) Based on Duration of Fever:
• 1. Acute fevers (<7 days): infectious diseases such as malaria and viral-
related upper respiratory tract infection
• 2. Sub-acute fevers (usually not more than 2 weeks in duration):
typhoid fever and intra-abdominal abscess
• 3. Chronic or persistent fevers (>2 weeks duration): chronic bacterial
infections such as tuberculosis, viral infections like HIV, cancers and
connective tissue diseases. However, any cause of acute fever can
become persistent or chronic if untreated.
B) Based on Height of Fever:
Normal and febrile body temperature ranges (rectal temperatures).
a: Hyperpyrexia in severe malaria is defined as rectal temperature above 40 °C.
C) Based on Pattern of Fever:
Based on Pattern of Fever:
• 1. Sustained or Continuous Fever: Fever that oscillates less than 1 ºC
or ~1.5 ºF daily; doesn’t touch normal
Typhoid fever
Drug fever
Typhus
Neoplasms
Based on Pattern of Fever:
• 2. Intermittent Fever: Fever that falls to normal each day.
Quotidian (24 hour periodicity): P. falciparum
Double quotidian (12 hour periodicity): Kala-azar,
Gonococcal arthritis, Juvenile RA, Some drug fevers (carbamazepine)
• 3. Hectic or Septic Fever: When remittent or intermittent fever shows large variation
between the peak and nadir
Kawasaki disease
Pyogenic infections
• 4. Periodic or Cyclic Fever: Episodes of fever recurring at regular intervals
Tertian (48 hour periodicity): P. vivax, P. ovale
Quartan (72 hour periodicity): P. malariae
Based on Pattern of Fever:
• Pel-Ebstein Fever: bouts of fever lasting 3 to 10 days followed by
asymptomatic periods of the same length (Hodgkin’s disease)
• Relapsing fever (every 10-14 days): Borrelia recurrentis
• Undulant fever (gradual increase in temperature that remains high for
a few days, and then gradually decreases to normal): Brucellosis
• 6. Recurrent Fever: Illness involving the same organ (e.g. urinary tract)
or multiple organ systems in which fever recurs at irregular interval
• Familial Mediterranean fever
Defervescence
• In differentiating malaria from typhoid fever, effective antimalarial
therapy leads to fever defervescence by crisis (within hours) whereas in
typhoid fevers resolution occurs by lysis (gradually over days) following
effective antibiotics.
• It has been suggested that fevers due to cancers can be distinguished
from those due infectious diseases using the Naprosyn test. When
Naprosyn (Naproxen 375 mg twice daily), or other NSAIDS, is given for 3
days, fevers due to cancers display a rapid and sustained decline while
little or no change is observed in fevers due to infectious diseases.
However, Naprosyn test is unhelpful in differentiating neoplastic from
non-infectious disorders such as connective tissue diseases.
PUO
Definition
• Petersdorf and Beeson defined pyrexia of unknown origin (PUO) in
1961. It is defined as:
• A temperature greater than 38.3°C on several occasions.
• Accompanied by more than three weeks of illness.
• Failure to reach a diagnosis after one week of inpatient investigation.
PUO
• This has now been modified to include patients who are diagnosed after two outpatient visits or
three days in hospital.
• The term 'fever of unknown origin' (FUO) is also sometimes used. PUO and FUO are used
interchangeably in the scientific literature. PUO is used throughout this article for the sake of
consistency.
• Additional categories were introduced in 1991, including:
• Nosocomial PUO in hospital patients with fever of 38.3°C on several occasions, caused by a
process not present or incubating on admission, where initial cultures are negative and diagnosis
unknown after three days of investigation.
• Neutropenic PUO, which includes patients with fever as above with <1 x 109 neutrophils, with
initial negative cultures and diagnosis uncertain after three days.
• HIV-associated PUO, which includes HIV-positive patients with fever as above for four weeks as
outpatients or three days as inpatients, with an uncertain diagnosis after three days of
investigation, where at least two days have been allowed for cultures to incubate.