more than anyone needs to know about fevers, but negects to mention MSA

[Guest guest]

Since fevers concern us:

FROM: The Department of Medicine, Tufts University School of Medicine,

Boston, Massachusetts and The Medical Index Project, St. Hospital,

Worcester, Massachusetts

Articles selected are in English with-preference given to the more readily

obtainable journals. Initials of authors are omitted as are names of some

multiple authors. Comment after a reference is either the exact title of

the article or, in most instances, a statement of the reason for its

selection.

Because of its simplicity, objectivity, and accuracy, body temperature

measurements are almost invariably included as an important consideration

in the evaluation of a patient.

If the fundamental facts which influence body temperature are well

understood, this measurement is indeed very valuable. Some of the factors

which normally and physiologically influence and vary body temperature are

briefly presented here before going on to a discussion of fever as a

manifestation of disease,

1. NORMAL BODY TEMPERATURE

The commonly accepted value of 98.6 F (37.0 C) orally, and 99.6 F (37.7C)

rectally is only a generally accepted average with a range reported in the

literature of many studies with range from 97.2 to 99. 9 F for oral values.

There is evidence that the morning rectal temperature for normal men varies

from 97.0 to over 99.0 F; and for women, from about 97.0 to 100.0 F or

more. Likewise the relation of oral to rectal temperature has a similar

variable range. The normal morning value for any one individual would be

followed by a diurnal variation with a rise higher than the morning value.

It is well to remember that there is no single normal value for everyone -

nor for that matter even for all males or all females. It is very helpful

if the usual normal range for any individual is known so comparisons can be

made when illness occurs.

A variety of new instruments for measuring body temperature, other than the

standard oral and rectal thermometers have been developed and much research

on temperature of parts of the body, other than oral and rectal has been

recorded. Studies have been made of the temperature of the skin of the

forehead, the nasopharynx, the esophagus, the tympanic membrane, the skin

of infants and the umbilicus of infants. The tympanic membrane provides

temperature levels consistent with those in the esophagus and more

indicative of the influence on the hypothalamic centers than temperatures

recorded in more peripheral portions of the body.

2. PHYSIOLOGICAL VARIATIONS IN NORMAL BODY TEMPERATURE

Digestion of food - rise 0. 5 to 1.0 F

Exercise (Vigorous) - rise to 102-104 F (return to normal within thirty

minutes with rest or shower)

Diurnal Variation - low point early a.m.; peak in late afternoon, early

evening. Variation varies - rarely up to three degrees, usually 1 to 2 F or

may be reversed with changes in work habits.

Menstrual Cycle - rise of 0.5-0.75 F rectally at time of ovulation with

drop back at menstruation. Absent with amenorrhea. (See page 23)

Pregnancy - continuation of above rise for about the first four months of

pregnancy.

Warm Environment -slight increase (0.5 F)

Cold Environment - very slight drop in healthy adults; marked drop in

infants and very old adults.

Emotion - slight temporary rise with emotion

3. INFLUENCE OF AGE

Infants - tend to be much more susceptible to environmental changes than

older children or adults. Easy to lose heat and get hypothermia. May at

times have convulsions rather than a chill with fever rise. Diurnal

variations may not be established until second year. Rise with infection

not as striking as in older children.

Children -temperature response to many ordinary ills (especially infections

or toxic agents). More bizarre and marked than in adults. Exercise

elevation of mild degree common.

Old People -.normal temperature may be subnormal by standards of young

adults. Circulation is feeble. Temperature often does not respond to

infections or toxic agents as for younger people. Therefore, easier to miss

an infection. Easier to get hypothermia on exposure to cold environment

temperatures. Occasionally diurnal variation may be reversed.

4. CONTROL OF NORMAL BODY TEMPERATURE

Normal body temperature range maintained by balance between factors which

increase heat production and increase heat loss:

HEAT PRODUCTION (increased by)

Amount of clothing

Metabolism of food

Diminished skin circulation

Tensioning of muscles

Muscular activity - normal

Warm environment

HEAT LOSS (Increased by)

Radiation (60%) transfer to cooler objects by E. M. waves.

Convection (12-15%) to air. about body and that moving in and out of the

respiratory tract.

Vaporization (20-27%) from skin and respiratory tract even without gross

sweating.

Greatly increased by:

Exercise (vigorous)

Shivering (chill)

Disease (by producing shaking chill)

Aided and increased by:

Cooler environment

Less clothing

Increased skin circulation

Greatly Increased by

Sweating

Panting

Loss of balance between heat production and heat loss can either raise or

lower body temperature.

5. VARIATIONS OF TEMPERATURE INDIFFERENT PARTS OF BODY

It is important to stress that all parts of the body care not all the same

temperature. In clinical practice, temperatures are commonly recorded

orally, rectally, in the axillae, and more rarely in the groin, and of

recently voided urine. More rarely, or for special studies, temperature can

be recorded far various parts of the skin or other parts of the body (e.g.

, the ear, esophagus, etc.) Oral and rectal temperatures are, in a sense,

" spot " or " local " readings. However, for practical purposes, the oral or

rectal temperatures are used in clinical practice as indicative or

reflective of " body " temperature. The tympanic membrane temperature comes

closer to reflecting the body temperature in the thermoregulating centers

of the brain.

Oral Temperature: This type is most commonly used in practice and, if

correctly taken, may be more indicative of fluctuations of body temperature

than rectal readings. Oral readings of temperature are easily falsely

lowered by mouth breathing, drinking or eating cold substances, and in

shock, are falsely elevated by hot food or drink, chewing (activity of

muscles of mastication), smoking and increased salivary gland activity (as

after a meal or with chewing,)

Rectal Temperature: 0.5-1.0 F higher than oral temperature, but this

relationship is not constant. This reading is used especially in children,

in adults with suspected shock, or where oral reading is not valid for

reasons given above.

Axillary or Groin Temperature: In well nourished persons this

approximates oral temperature; in thin and emaciated subjects, lower than

oral temperature and not reliable.

Urine Temperature: In a fresh urine specimen, collected in vessels

previously warmed to body temperature, the temperature of the urine is very

reliable indicator of body temperature and averages 0.3-0.5 F below rectal

temperature. This method is foolproof for checking on spurious or

malingered body temperature elevations if the collections are properly

made.

Tympanic Membrane: Increasingly, tympanic thermometry is being utilized.

The readings are more consistent than oral or rectal recordings. They are

consistent with esophageal readings which, while valuable, are impractical

to utilize for routine clinical activities. They are only 0.2 C lower than

the esophageal temperature. Tympanic recordings more accurately reflect the

central temperature in man at the thermoregulating centers in the brain

than oral, skin or rectal temperatures. This technique has been especially

helpful for continuous recording of body temperature during surgical

operations while the patient is under anesthesia.

6. CLINICAL THERMOMETRY

The clinical thermometer is an instrument of precision within limits. A

surprising number of recent studies have been concerned with it and its

paper use. Many errors in recording of body temperature result from poor

techniques. These are discussed in the following papers. Likewise not to be

overlooked is the possibility of cross infection from the use of oral

thermometers, or even rectal thermometers and the occasional injury to the

rectum from the latter. Development of new methods of taking the

temperature, recording it, study of temperature taken from unusual sites

(e.g., the ear, the esophagus, the umbilicus, etc.) indicate continued

interest and research of this important procedure of " taking the

temperature " . Studies of body temperatures using the ear technique have

greatly broadened the understanding of body regulation of normal

temperature. It has proven to be a more reliable measure of central body

heat than the use of rectal values.

7. FEVER

Often defined as increase in body temperature over the normal range which

is caused by disease. More exactly, it may be defined as any rise above

normal body temperature due to disease and not from environmental exposure,

pregnancy, emotion, exercise, eating or other such physiological factors.

Mechanism of fever from disease is complex, but by a brief sort of

definition is produced by action of certain substances (probably produced

by disease process from the tissues or WBC of the host) acting on

thermoregulatory centers in the hypothalamus. The normal balance between

the anterior center (concerned with heat dissipation by vasodilation and

sweating related to parasympathetic activity and the posterior center

(concerned with conserving heat by vasoconstriction and shivering and

related to sympathetic activity is upset to produce a positive heat balance

and raise the body temperature above normal.

8. DEFINITION OF TYPES OF FEVER AND FEVER CURVES

In clinical practice, especially for patients admitting to a hospital, the

" body temperature " is recorded 2 or more times a day and plotted on a

temperature chart. This permits a visual recording of the low and high

values for the 24 hours. The type of fever curve produced is another

helpful indicator of diagnosis and prognosis, along with the history,

physical examination and laboratory data, or specialized studies. The

following definitions of types of fever or fever curves will be helpful as

background knowledge.

Pyrexia - synonymous with fever.

Habitual Pyrexia - (or fever) average temperature elevated minimally and

constantly over normal range in a person otherwise healthy. This has also

been called habitual hyperthermia but this term is a poor one since

hyperthermia more commonly refers to excessively high body temperature.

Diurnal Variation - daily rhythmic change in body temperature, varying 1-2

F with lowest point in early a.m. and peak in afternoon or evening. Diurnal

variation may be evident even when patient shows a continuous or sustained

temperature.

Chill - uncontrollable muscular shivering (and other physiological

phenomena) which produces a sharp rise in body temperature.

Ague - Synonymous with repeated chills.

Rigor - Synonymous with chill.

Hyperpyrexia or Hyperthermia - means body temperature higher than 105.8 F

Intermittent (or Quotidian) Fever - daily fever peak followed by a fall to

normal temperature level.

Hectic (or Septic) Fever - an intermittent fever with large daily swings in

body temperature, usually accompanied by chills and sweats.

Remittent Fever - significant variations in temperature level or more than

the diurnal variation each day, but no drop to a normal level of

temperature. Some examples are: acute-rheumatic fever, pulmonary

tuberculosis, etc.

Continuous (or Sustained) Fever - fever sustained at a high level in which

daily diurnal variations are no wider than usual for the individual. Some

examples are pneumococcal lobar pneumonia before treatment, rickettsial

diseases, certain types of drug fever, etc.

Spurious (or False) Fever - elevation in the thermometer reading produced

by trickery on part of the patient. Also called Factitious Fever or Fever

of Malingering. (See page 16)

Psychogenic (or Emotional) Fever- elevation in temperature produced by

emotional stimulus. Good examples are: slight elevation of temperature on

the day of admission to hospital with normal temperature thereafter, or

rise in temperature while students are taking complicated or important

examinations). (See page 20)

Catheter Fever - passage of catheter, cystoscope, etc. through infected

urethra is followed by fever in short time due to transitory bacteremia.

More severe forms accompanied by a chill.

Charcot's (Hepatic) Intermittent Fever - is due to cholangitis with

intermittent biliary obstruction due to a ball valve stone often lying in

the Ampulla of Vater. Fever occurs periodically. Bile duct narrowed by

stricture or tumor, or by a polyp may also be a cause.

Osler - s Hopkins Hosp Report 2: 3 1891 (A classic paper)

** Morgenstern - New Eng. J. Med. 261: 36, 1949 ( " Jean- Charcot and

Charcot's fever " ) (interesting historical data and translation of the

original report by Charcot)

Pel-Ebstein Type of Fever - rare type seen in Hodgkins disease, somewhat

comparable type may be seen in Brucellosis (Undulant Fever). In a sense, it

is a form of relapsing fever but with longer febrile and afebrile periods

and slower rises and falls in the fever curve. Also known as Murchison's

Fever from a description published in 1870.

Thirst Fever - a type of fever curve seen in dehydrated infants in very

warm climates characterized by marked elevation in the morning with return

to normal by the evening.

Shaker - Brit. Med. J. 1: 586, 1966 ( " Thirst fever, with a characteristic

temperature pattern in infants in Kuwait " )

Quartan Fever - in the quartan type of malaria, the chill and fever occur

every third day. It is a form of relapsing fever curve. The regularity of

this fever, pattern may suggest the diagnosis.

Syndrome of the Monday Night Chill and Fever - see Metal Fume Fever

9. DOUBLE QUOTIDIAN FEVER CURVE

(Two steeple-like rises and falls in twenty-four hours). Seen primarily in:

Kola-Azar Juvenile

Rheumatoid Arthritis

Gonococcal Endocarditis

Adult Onset Juvenile Rheumatoid

Meningococcal Endocarditis

Arthritis

Miliary Tuberculosis

Rarely in other infections

10. RELAPSING TYPE FEVER CURVE<

Short febrile periods of variable duration (usually with sharp rise and

fall in temperature) are interspersed by periods of one of more days of

normal temperature. When seen in the United States, a relapsing type of

fever curve should suggest:

Malaria

Chronic Meningococcal Septicemia

Rat-bite Fever

Charcot's (Hepatic) Intermittent Fever

Relapsing Fever - Tick borne due to Borrelia duttoni

Elsewhere in the world a few other causes exist for this type of fever

curve. It should not be confused with the following:

Saddle-Back Fever (Biphasic Temperatue Curve)

Undulant Type Fever (e.g. Hodgkins Disease, Brucellosis)

Septic Fever (Daily fever swings with sweats)

Intermittent or Quotidian Fever (Daily fever swings)

11. " SADDLE BACK " FEVER OR BIPHASIC TYPE OF FEVER CURVE

A form of relapsing fever curve limited to two febrile episodes of one or

more days each separated by a period free of fever for a short period.

Recurrence or progression of clinical features occur with the second

febrile episode. It has been noted in dengue fever, Colorado tick fever,

lymphocytic-choriomeningitis, yellow fever, poliomyelitis, and certain

other virus diseases.

12. HECTIC FEVER WITH REVERSED DIURNAL GRADIENT ( " TYPHUS INVERSUS " )

In this type of hectic fever curve, there is reversal of the normal diurnal

pattern so that the highest temperature peak occurs in the early a.m. hours

and the lowest in the evening hours. This type of fever curve suggests

tuberculosis (especially of the miliary type) salmonella bacteremia and

rarely other causes.

13. METAL FUME FEVER (Occasionally Presenting As " Syndrome of Monday Night

Chill and Fever " )

Due to inhalation of zinc oxide fumes. Zinc has a low melting point and

volatilizes at 500 C. On exposure for the first time, one gets a mild

headache, malaise and muscle aches, anorexia and mild cough. Later in the

day, frequently after work, there may be a chill, fever and sweats.

Continued exposure produces immunity which is lost when individual does not

work over a weekend or holiday. Episodes recur on first day back to work.

Occasionally, may get a bizarre clinical picture of chills and fever each

Monday night after leaving work in individuals who don't work on Saturday

and Sunday and lose their immunity over the weekend. " Monday diseases " have

been recognized by industry for many years. Fumes of certain other metals

may do this.

14. MEDICAL (or CLINICAL) THERMOGRAPHY

Thermography is a technique by which infrared radiation from the skin of

the human body can be recorded via a special camera and device which

converts infrared radiation via electronics to visible light which can be

photographically recorded as a " thermograph " . Warmer areas and colder areas

can be recognized by a different shade from white to black; techniques

exist also for color thermograms. It records areas of increased or

decreased skin temperature. Heat production from the skin is increased in

areas of increased vascularity or metabolism (i.e inflammation, malignancy,

etc), diminished over areas of benign processes (i.e. scar tissue),

vascular obstructions, etc.). A surprising number of conditions can be

detected or suspected. Much interest has centered on, its use to detect

breast cancer and other breast diseases, placental localization, certain

orthopedic conditions, peripheral vascular disease, other types of cancer,

as an aid in skin grafts, carotid artery disease, skin disease and other.

In recent years, its use is increasingly being more refined.

15. COMPLICATIONS OF FEVER

Fever, aside from the disease producing it, and in fact even if produced by

mechanical means (as in fever therapy), may produce certain complications

which are reversible when temperature returns towards normal. The most

important of these are:

1. Febrile albuminuria

2. Delirium - the threshold at which it occurs varies greatly, more readily

produced in infants, the aged, alcoholics.

3. Convulsions - most - common in infants under age 2

4. Herpes Simplex (especially when temperature rises sharply)

5. Headache (related to dilatation of certain cerebral arteries as a result

of the fever, also certain specific types of infections are likely to cause

this symptom)

In a sense, chill or rigor (with sharp rise in body temperature, and sweats

with rapid drop in body temperature may also be considered as a

complication of fever. They may be dangerous in debilitated persons. Fever

may contribute to causing anemia, and influence certain liver function

tests. Fever increases the body metabolic rate and has significant effects

on cardiac and pulmonary function.

16. DIAGNOSTIC SIGNIFICANCE OF FEVER

To most physicians, fever is considered a valuable clue of some abnormal

state of body function or disease process.

Diagnosis is not a problem in most instances of an acute illness with fever

and becomes apparent as a rule from a routine workup, results of

specialized studies, course of the disease process, and response to therapy

In the following sections, major emphasis will be on unexplained fevers of

some duration (one or two weeks or longer), unusual causes of fever of

shorter duration, or diagnostic evaluation of certain clinical syndromes

involving fever. It is, of course, impossible to present data in an outline

of this type on every condition which can produce fever.

17. DIAGNOSTIC APPROACH TO PERSISTENT FEVER OF UNKNOWN OR OBSCURE ETIOLOGY:

F.U.O.

A not uncommon clinical problem in hospital practice is evaluation of a

patient who has had a persistent and unexplained fever for two or more

weeks. Before undertaking a detailed diagnostic workup, the following two

possibilities should be checked upon first; namely, the possibility that

the fever is (a) factitious or ( from reaction to a drug.

(a) Factitious (Spurious) (False) (Fraudulent) Fever

Failure to consider this possibility as an explanation of an obscure fever

has proved embarrassing to many physicians. It can easily be ruled out

first without directly mentioning it by the simple procedure of personally

taking the temperature with your own thermometer. If in doubt, a rectal

reading should be used to check on elevated oral reading, and a multiple

reading (oral, rectal, and even axillary taken simultaneously). A valid and

reliable check is the temperature of urine voided into a previously warmed

to normal body temperature urinal.

Simulation of a fever by thermometer trickery is not too unusual and should

be suspected, according to sdorf and , when (1) the pulse

reading fails to rise with high temperature peaks (2) lack of a

characteristic daily diurnal curve (3) lack of chills & sweats with

sharp rises and falls in temperature (4) exceptionally high readings; i.e.

over 106 F.

A variety of tricks have been used to simulate " fever " and even a rectal

temperature reading can be falsely distorted.

( Drug Fever

If a patient with persistent unexplained fever has been on medication

therapy, one must consider that the rise in body temperature may be due to

an adverse effect of the medication. Before going on with a diagnostic

study, it is well to withdraw all medication for 24 to 48 hours and note

whether fever diminishes. Drugs causing fever are particularly puzzling

when given to control an infectious process with fever in that the onset of

the drug fever may blend into the cessation of the infectious fever in a

way that might indicate the infection is not under control. Some

medications produce fever only after a latent interval, some after

persistent use, and some from very small doses in susceptible persons. In a

sense, serum sickness might be considered as a form of this type of fever.

Some drugs may produce fever by diminishing heat loss from skin (cessation

of sweating). Some may act centrally. A wide variety of substances which

ordinarily do not produce fever, may rarely do so in susceptible persons.

Presence of a rash, eosinophilia, a continuous fever curve, etc. may

occasionally be noted as helpful in diagnosis.

Some general references, as well as comments on some special syndromes, are

given in the following sections.

(A) Drug Fever - General

A wide variety of drugs may rarely cause a febrile reaction. Some

representative examples are described in the following papers. Many others

are recorded in the literature. Medications can produce a fever by several

mechanisms such as the pharmacologic action of the drug itself; the patient

may react immunologically to the medication; tissue reaction as a result of

a local reaction - when given intramuscularly or subcutaneously (i.e.

sterile abscess); pyrogens or bacterial organisms may be introduced at the

time of injection plus other possible methods, In unsensitized persons,

sometimes, drug fever appears after a number of days. Once sensitized, the

onset is more rapid with a chill and fever plus systemic reaction. The

fever curve maybe of the continuous type.

18. SUDDEN FEVER IN BED PATIENT UNDER OBSERVATION WHO WAS PREVIOUSLY AFEBRILE

A common clinical situation is a rise in temperature of a bed patient whose

temperature curve had previously, under observation, been normal. When this

situation occurs think first of:

1. Changes in thermometer technique: - changes from oral to rectal

temperature new nurse, new thermometer, failure to " shake " it down, etc.

2. Urinary tract infection

3. Pulmonary infarction

4. Bronchopneumonia

5. Disease of leg veins

6. Common respiratory infection

19. MISCELLANEOUS CAUSES OF FEVER OF NON-INFECTIOUS ORIGIN

Fever is often considered as synonymous with, or suggestive of, infection.

It is well to emphasize size, by the list which follows, how frequently

fever may be of non-infectious origin.

1. Lesions CNS; experimental punctures; hemorrhage, especially in lateral

ventricles; tumors.

2. Drugs (a wide variety - see references)

3. Dehydration

4. Deficiency diseases

5. Injections - foreign protein

6. Artificial (therapeutic) produced by physical apparatus.

7. Hyperthyroidism; (thyroid storm)

8. Coronary occlusion with myocardial infarct

9. Dissecting aneurysm

10. Malignant tumors

11. Cardiac decompensation

12. Pernicious anemic

13. Skin diseases (preventing heat loss; i.e. icthyosis, scleroderma,

exfoliative dermatitis, etc.)

14. Blood dyscrasias (leukemia, Hodgkins disease, etc.)

15. Free hemorrhage in any body cavity (pleura, peritoneum, etc.)

16. Gout (metabolic disease)

17. Diabetic acidosis

18. Serum sickness

19. Variations during menstrual cycle

20. Habitual pyrexia

21. Exercise

22. Hot climate

23. Wyatt Syndrome (icthyosis, effort syndrome and fever)

24. Gastrointestinal bleeding

25. Infarction any organ (lung, spleen, etc.)

26. Periodic disease

27. Riley-Day Syndrome

28. Sympathectomy

29. Angiitis etc.

The preceding list is by no means complete, but collected merely to show

how broad the diagnostic possibilities are for explaining fever on a basis

other than an infectious disease.

20. PSYCHOGENIC FEVER

It appears well documented that fever may be produced by an emotional and

possibly an hysterical mechanism. The slight elevation of temperature

commonly seen during the first day of a hospital admission is an example.

Apparently many types of psychic stimuli can do it. Fever has been reported

in some cases of neurocirculatory asthenia.

21. HYPERTHERMIA (HYPERPYREXIA)

Fever with temperature above 105.8 F (41 C) has been designated as

" hyperthermic fever " Irreversible damage occurs when temperature reaches

115.0 F and often at a lower level. Prompt treatment is indicated when

temperature of the body goes over 105.0 F. Temperature of 106.0 F or over

are so unusual that they are strongly diagnostic in a special sense and

suggest (1) thermometer trickery (2) occasional occurrence with fever

therapy (3) heat stroke (4) intravenous pyrogen reaction (5) rarely in less

than five percent of a variety of severe infections (6) malignant

hyperthermia during anesthesia, and (7) occasionally in miscellaneous

conditions, especially those which damage the cerebral centers controlling

temperature regulation, or with disorders of metabolism.

Heat pyrexia, sunstroke, heatstroke, thermal fever, etc. are all terms

meaning the same condition. Cessation of sweating in a warm environment,

especially in those with old age, alcoholism or chronic illness is the

precipitating factor. The clinical picture includes a marked elevation of

body temperature (106- 110 F); hot, dry and flushed skin, strong pulse,

coma and possibly convulsions. Petechiae may be noted. Terminally there may

be a shock-like state and pulmonary edema. Prompt therapy to lower the body

temperature is important.

In recent years, there have been many reports of a clinical syndrome

characterized by a rapid and marked rise in body temperature while

undergoing general anesthesia for a surgical procedure. Possible triggering

agents and metabolic causes have been extensively studied. Some patients

have a hereditary predisposition; other instances appear to be sporadic.

Those under age 20 are more likely to have a hereditary predisposition and

manifest muscle hypertonicity while the non-rigid cases are likely to be

sporadic and over the age of 20. Detection of the early rise of temperature

and prompt treatment are helped by the newer forms of recording body

temperature (e.g. ear). (See page 2) Of importance here is the high body

temperature which occurs - well over 106 F - and fitting into the range of

hyperthermia. Values over 110 F. have been reported.

22. SEVERE HYPERMETABOLISM WITH PRIMARY ABNORMALITY OF SKELTAL MUSCLE

MITOCHONDRIA (LUFT'S SYNDROME)

This is an interesting disease entity characterized clinically by extreme

hypermetabolism manifested by heat intolerance, greatly increased basal

metabolism and persistent fever varying up to 38.5 C with occasional

temperature peaks to 41 C. Pathophysiologically the disorder is

characterized by a skeletal muscle mitochondrial abnormality.

23. SYNDROME OF PREMENSTRUAL FEVER

In women, before the menopause, there is a correlation of the basal body

temperature with ovulation; the temperature rising slightly with ovulation

and persisting until menstruation. Occasionally in disease, fever is

noticed only during this premenstrual period or a previous low febrile

curve shows a noticeably higher febrile level during this period. This is

obviously most likely to be noted when a febrile disorder lasts through one

or more menstrual cycles.

24. SYNDROME OF FEVER WITH GASTROINTESTINAL BLEEDING

Fever occurs in the majority of patients with G.I. bleeding irrespective of

the cause of the bleeding. According to Schiff it usually appears within

twenty-four hours, lasts days to a week or more, and may reach a maximum of

103 F.

A number of unusual disorders have been described which recur cyclically.

In some of these fever is a prominent feature which along with other

clinical manifestations presents as " periodic fever " . Some of these

clinical conditions are well established and others more rare.

26. DIFFERENTIAL DIAGNOSIS OF PERSISTENT FEVER

An enormous literature exists which is concerned with the problem of

diagnosis of persistent and perplexing fevers, especially those which

persist for two or three weeks. Febrile illness which falls into this

pattern (eg. fever of unknown origin - F. U. O.; pyrexia of unknown origin

- P.U.O.; unexplained fever, etc.) have been extensively studied.

27. UNTOWARD EFFECTS OF THERAPEUTIC HYPERTHERMIA

Fever therapy, whether produced by injection of protein substances, or by

physical means is not without danger. A number of complications have been

described. These complications may at times occur with fever due to disease

and are therefore worth knowing about, even though artificial fever therapy

is no longer used in any appreciable extent.

POINTS TO REMEMBER ABOUT CHILLS (Based on Data from s; Altschule &

Freedberg, DuBois, Beeson, etc.)

Chief Signs -Shivering and " Goose Flesh "

Chief Symptoms - Feeling of being cold and general discomfort

In infants and small children, general convulsion with or without coma may

occur at the onset of an acute infection or in conditions that would cause

a rigor to an adult.

In health, comfortable feeling of warmth, depends not upon the temperature

of deeper structures, but upon stimulations of cutaneous sense organs

(corpuscles of Ruffini) by warm blood coursing thru superficial vessels.

Chill mechanism causes spasm of these vessels and exclusion from them of

warm blood from deeper regions.

There is a rough parallelism between body weight and duration of chills.

The lighter the body weight the longer the chill for a comparable rise in

temperature. The longer the chill the greater the final elevation of

temperature for comparable body weights.

A genuine chill may go on for hours without conscious recognition of

effort. Voluntary tremor, on the other hand, rapidly leads to fatigue.

Shivering of chill occurs in a sympathectomized extremity; in the paralyzed

side in hemiplegic, but not as vigorously as in the normal side, but not in

an extremity paralyzed by poliomyelitis.

Prolonged holding of breath may make a chill more readily controllable

voluntarily. If a chill is about to occur, taking deep breaths may bring it

on sooner.

Rectal and body temperature continues to rise for some time (?minutes to

several hours) after termination of the muscular shivering of a chill.

Therefore, when patients have a chill, standing order for a nurse should be

determination of rectal temperature every half hour until peak is reached.

The peak will often be missed if temperature is only taken right after

cessation of a chill.

Oral and axillary temperatures during a chill may be misleadingly low. Due

to chatter of teeth oral thermometry is difficult and possibly dangerous.

Rectal temperatures are always indicated.

Blood cultures are more apt to be positive before or during rather than

after a chill. WBC drops with a chill, It may be misleading to do a blood

count during or shortly after a chill; often will find low value for the WBC.

1.There is a normal variation in body temperature 0.5 to 2.0 F during a

24-hour period; the highest temperature usually occurs in the early

afternoon, while the lowest usually occurs during sleep in the early morning.

2. In hot weather the body temperature may be elevated 1 F, and of course

in victims of heat stroke, it may be considerably higher; digestion,

exercise, and dehydration, especially in children, may also elevate body

temperature.

3. Persistent low-grade fever in patients past middle age is almost always

significant. Young women usually displaying neurotic characteristics and

having an oral temperature of 99.0 to 100. 5 F regularly or intermittently

for years as a rule ultimately prove to have so-called habitual hyperthermia.

4. The possibility of factitious fever is suggested by absence of

tachycardia, lack of sweating after defervescence, and failure of the

temperature curve to observe the expected diurnal variation.

5. Almost half of all fevers of obscure origin (body temperature above 101

F for longer than 3 weeks) ultimately prove to be due to infections.

6. Tuberculosis is to be suspected in cases of fever of obscure origin,

especially in Negroes, diabetics, and patients receiving corticosteroids.

7. A history that a patient had a furuncle several weeks before the onset

of a febrile illness suggests the possibility of perinephritic or renal

cortical abscess.

8. Charcot's intermittent hepatic fever may occur unassociated with

jaundice or colic, so that to rule out this possibility, investigation of

the biliary tract is indicated in fever of obscure origin. A history of

previous cholecystectomy in a patient with intermittent fever especially

warrants exclusion of Charcot's fever.

9. Fever following urinary instrumentation or a urologic surgical procedure

suggests urinary tract, infection, bacteremia, and vertebral osteomyelitis

or disk-space infection due to gram-negative enteric bacilli. In disk-space

infection fever may precede symptoms, and roentgenographic changes may lag

behind clinical signs by several weeks.

10. Persistent fever following dental extraction and not due to local

causes suggests bacterial endocarditis. However, at least 3 mycotic

diseases appear to have followed dental extractions; actinomycosis,

nocardiosis, and cryptococcosis.

11. In patients having fever of obscure origin splenomegaly suggests

infection (endocarditis, brucellosis, typhoid), lymphoma, and, acute

leukemia; if hepatosplenomegaly is present one also considers cirrhosis, if

hepatomegaly without splenomegaly is present one considers cholangitis,

metastatic malignancy, and liver abscess.

12. In patients having fever, a nonvenereal local lesion, and regional

lymphadenopathy, one's considerations should include cat scratch fever,

rickettsial pox, tuberculosis, anthrax, and tularemia.

13. In the diagnosis of bacteremic shock in patients having conditions

characterized by " primary " fever (cirrhosis, acute leukemia, lymphoma) or

fever due to local infection (malignant disease, prostatism, cholangitis),

a sphygmomanometer may be more helpful than a thermometer.

14. Fever may reflect trauma, as in crushing injuries of the limbs or

trunk, extensive operations, and direct injury to the brain (neurogenic

fever).

15. Extensive skin disease may disallow heat loss from the body surface,

resulting in fever. Congenital absence of sweat glands, ichthyosis, and

eczematoid dermatitis are among such causes. One should always exclude

staphylococcal superinfection, including bacteremia.

16. Hematopoietic causes of fever include acute leukemia, aplasia of the

marrow, agranulocytosis, pernicious anemia, and hemolytic crises. In cases,

characterized by hemolytic crises one should consider also cholangitis

associated with cholelithiasis.

17. Possible causes of elevated temperature (usually 0. 0.5 to 1.5 F) in

patients having congestive heart failure include impaired heat dissipation

because of diminished cardiac output, decreased cutaneous blood flow, the

insulating effect of edema, and increased heat production secondary to the

increased muscular activity associated with dyspnea. However, one should

exclude phenomena concerned with be type of head disease present

(myocardial infarction, bacterial endocarditis, rheumatic fever),

thrombo-embolic disease, and urinary tract infection.

18. Elevations in temperature are associated with various metabolic states

including that of ovulation, the postovulatory phase of the menstrual

cycle, the final month of pregnancy, and labor; gout; thyrotoxicosis;

urinary-tract infections associated with urinary calculi as in

hyperparathyroidism, hyperuricemia, and cystinuria; and abnormal

etiocholanolone metabolism.

19. Types of malignant disease most likely to be associated with fever are

lymphoma, hypernephroma, tumors of the liver (primary and metastatic),

biliary tree and pancreas, pulmonary neoplasms, and gastric and intestinal

carcinomas.

20. In patients having cirrhosis, fever, in addition to being a primary

manifestation of the cirrhosis, may be due to malignant transformation,

tuberculosis, and bacteremia due to gram negative enteric bacilli.

21. Causes of fever in victims of lymphoma, in addition to that which is

" primary " and due to the lymphoma per se, include bacteremia, especially

that due to gram-negative enteric bacilli; cryptococcosis; and

urinary-tract infection, especially when retroperitoneal involvement causes

ureteral compression.

22. Three diseases which may be manifested by " primary " fever and also in

which bacteremia is of increased incidence are cirrhosis, acute leukemia

and lymphoma.

23. Febrile states in which the causative agent may be visible on smears of

the peripheral blood include spirillary rat-bite fever (Spirillum minus),

relapsing fever (Spirochaeta recurrentis), leptospirosis, malaria, and

certain bacteremias (staphylococcal, streptococcal, meningococcal, anthrax,

plague).

24. Febrile states of nonbacterial origin which may be characterized by

eosinophilia include parasitism (trichinosis, echinococcal disease), drug

fever, and periarteritis nodosa.

25. Infections that may cause fever and hemolytic anemia include

streptococcal infections, clostridial infections, malaria, splenic

brucellosis, and bartonellosis.

26. Not uncommon infectious diseases causing fever and thrombopenia include

splenic brucellosis, infectious mononucleosis, and Pseudomonas bacteremia.

27. Although most patients having fever of obscure origin appear to have

had blood smears examined for malarial parasites, one should recall that it

is most unusual for malaria to recur after a symptom-free interval of 1 or

more years.

28. Febrile states in which one should rule out hyperglycemia include

bacteremia due to gram-negative enteric bacilli, recurrent biliary-tract

infection (associated pancreatitis), pedal cellulitis, furunculosis and

recurrent urinary-tract infection.

29. In fever of obscure on-gin a positive brucellar agglutination reaction

does not necessarily indicate brucellosis; other muses include prior use of

Brucella protein nucleate (Brucellergen R), amnestic phenomena, cholera

vaccination, and acute tularemia (cross agglutination).

30. In tularemia there are 3 serologic react ions that may be positive and

cause diagnostic confusion: a rise in heterophile antibody titer, and

nonspecific cross agglutination to Brucella and Proteus organisms, the

latter possibly causing confusion with rickettsial infection.

31. In fever of obscure origin excretory urography may reveal

hypernephroma, pyelonephritis, retroperitoneal lymphoma (causing lateral

deviation of the ureters), idiopathic retroperitoneal fibrosis, and other

types of uropathy such as calculi causing urinary-tract infection.

32. Splenic calcification in a patient having fever suggests tuberculosis,

histoplasmosis, and brucellosis.

33. A splenic focus may be most commonly responsible for recurrent febrile

reaction among patients having " chronic " localized brucellosis.

34. Fever occurs in about 90 percent of patients having " acute " bacteremic

or serologic brucellosis, but in less than 50 per cent of those with

" chronic " localized brucellosis.

35. In fever of obscure origin marrow aspiration may be diagnostic;

possible diagnostic findings include acute leukemia, pernicious anemia,

metastatic malignancy, infectious granulomas (histoplasmosis, tuberculosis,

brucellosis), and aplasia or agranulocytosis.

36. In fever of obscure origin liver biopsy, in addition to revealing

primary hepatic disease (hepatitis, cirrhosis, hepatoma), may be diagnostic

of more diffuse disease, including metastatic malignancy, lymphoma, and

infectious granulomas.

37. In fever of obscure origin biopsy of a lymph node also may reveal

similar diagnostic findings, that is, metastatic malignancy, lymphoma, and

infectious granulomas. Cervical, supraclavicular, or axillary nodes are

most likely to be diagnostically productive.

38. Muscle biopsy in fever of obscure origin may reveal periarteritis

nodosa, dermatomysitis, and trichinosis.

39. Specific bacterial diseases likely to be manifested by fever and

arthritis are brucellosis, gonorrhea, tuberculosis, salmonellosis, and

meningococcemia.

40. Acute febrile bacterial arthritis unassociated with specific diseases

most commonly is due to staphylococci, streptococci, and gram-negative

enteric bacilli, in that order.

41. Three mycoses that may cause intra-abdominal disease are actinomycosis,

South American blastomycosis and histoplasmosis. Three mycoses that may

cause disease of the central nervous system are cryptococcosis,

coccidioidomycosis, and nocardiosis. Three mycoses that may cause

endocarditis are candidiasis, histoplasmosis, and coccidioidomycosis.

42. Nonbacterial infections that may be complicated by orchitis are mumps,

sackie disease, and Q fever.

43. Viral infections causing a so-called biphasic fever curve include

dengue, Colorado tick fever, and sackie and ECHO diseases.

44. Microorganisms causing abortion in animals and responsible for febrile

infections in man, in addition to Brucella organisms, are Leptospira,

Vibrio fetus, and Toxoplasma gondii.

45. Five infections that may be complicated by peripheral gangrene are

pneumococcal bacteremia, meningococcemia, bacterial endocarditis, cholera,

and Rocky Mountain spotted fever.

46. In view of the decreased incidence of tuberculosis, of the febrile

states that may be complicated by amyloidosis one considers these

possibilities: osteomyelitis, leprosy, periodic fever, pyelonephritis, and

bronchiectasis.

47. Persistent fever following cardiac operations raises the question of

complicating endocarditis, which most commonly is due to Staphylococcus

aureus, Pseudomonas, and Candida.

48. Fever continuing after apparent control of bacteremia suggests

uncontrolled underlying infection (pyelonephritis) or conditions causing

primary fever (lymphoma), metastatic suppuration endocarditis, phlebitis,

and drug fever.

49. In bacterial meningitis persistent fever despite adequate antibacterial

therapy raises the question of drug fever, subdural effusion, and

superinfection; in superinfection Pseudomonas organisms may be introduced

via a contaminated needle of the time of spinal tap.

50. The 5 microbial species most likely to cause superinfection

complicating tetracycline therapy are Staphylococcus aureus, Streptococcus

pyogens, Candida, Pseudomonas, and enterococci.

aletta mes, vancouver, bc canada

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Site: http://www.aletta.0catch.com

[Guest guest]

Greetings Aletta!

Haven't read the whole thing, let alone memorize it! But it's a good

reference article. Even knowing it's out there can make it easier to find.

Thanks!

Regards,

=jbf=

B. Fisher