DEFINITION: What is a fever? FEVER refers to an elevation in body temperature.

Technically, any body temperature above the normal oral measurement of 98.6 F (37 C) or the normal rectal temperature of 99 F (37.2 C) is considered to be elevated. Fever is not considered medically significant until body temperature is above 100.4 F (38 C). Also, the body's defense mechanisms seem to work more efficiently at a higher temperature. Fever is just one part of an illness, many times no more important than the presence of other symptoms such as cough, sore throat, fatigue, joint pains or aches, chills, nausea, etc. Fever: A complex physiologic response to disease mediated by pyrogenic cytokines and characterized by a rise in core temperature, generation of acute phase reactants, and activation of immune systems. Signs and Symptoms of Fever: A symptom is something the patient reports and feels, while a sign is something other people, including a doctor may detect. For example, a headache may be a symptom while a rash may be a sign. Feeling cold when nobody else does: Shivering Anorexia - lack of appetite Dehydration - preventable if the patient drinks plenty of fluids Depression Hyperalgesia - the individual is much more sensitive to pain Lethargy Problems concentrating Sleepiness Sweating Febrile seizure (children)

There are two types of febrile seizures: Simple febrile seizure - the seizure lasts no longer than 15 minutes (in most cases less than 5 minutes) and does not occur again during a 24-hour period. It typically involves the whole body - a generalized tonic-clonic seizure. Most febrile seizures are of this type. Symptoms - the body becomes stiff and the arms and legs start to twitch, the patient loses consciousness (but the eyes stay open). There may be irregular breathing and the child may urinate and/or defecate. There may also be vomiting. Complex febrile seizure - the seizure lasts longer and comes back more often, and tends not to affect the whole body, but rather only part of the body. This type of seizure is a cause for more concern that simple febrile seizures. In the majority of cases, a child with a febrile seizure does not need treatment. Temperature may be controlled with acetaminophen (paracetamol) or sponging. If an anticonvulsant, such as sodium valproate or clonazepam may be prescribed The manifestations of fever Chills, rigors high fever (bacteraemia) Arthralgia, myalgia, anorexia & fatigue Tachycardia (10bpm/oC) Tachypnea (2.5 breath per min/oC) Grunting, lethargy ECG - QT, AV conduction, SV ectopics Proteinuria (5-10%) Relative Bradycardia Typhoid fever, drug, CNS lesions, factitious fever Relative Tachycardia Hyperthyroidism, myocarditis

What are the causes of fever? An infection - such as strep throat, flu, chickenpox or pneumonia Rheumatoid arthritis Some medications Over-exposure of skin to sunlight (sunburn) Heat stroke - may be caused either by exposure to high temperatures (nonexertional heat stroke) or prolonged strenuous exercise. Silicosis - a type of lung disease caused by long-term exposure to silica dust. Amphetamine abuse Alcohol withdrawal

How is fever diagnosed? Diagnosing a fever is straightforward - the patient's temperature is taken, if the reading is high, he/she has a fever. It is important to take the person's temperature when they are at rest, because physical activity can warm us up. A person is said to have a fever if: The temperature in the mouth is over 37.7C (99.9F) The temperature in the rectum (anus) is over 37.5-38.3C (100-101F) The temperature under the arm or ear is over 37.2C (99F)

As a fever is a sign rather than a disease, when the doctor has confirmed there is an elevated body temperature, certain diagnostic tests may be ordered, depending on what other signs and symptoms exist, these may include blood tests, urine tests, x-rays and other imaging scans.

How to prevent fever? Hygiene - fevers are commonly caused by bacterial/viral infections. Good hygiene practices help reduces the risk of developing an infection. This includes handwashing before and after meals, and after going to the toilet. A person with fever caused by an infection should have as little contact as possible with other people, to prevent the infection from spreading. Whoever is caring for the patient should regularly wash their hands with warm soap and water. Other terms are used to describe fever or fever types: Prolonged: fever lasting longer than about 10-14 days Constant: Also termed continuous; usually low grade and does not change by much (by about 1 degree F over 24 hours) Chronic: Fever that lasts longer than three to four days; some researchers consider intermittent fevers that recur over months to years as "chronic" fevers Intermittent: Fevers that either varies from normal to fever levels during a single day or may occur one day and recur in about one to three days Remittent: Fevers that come and go at regular intervals

When to call or see the doctor A fever has many possible causes. Most commonly, a fever is part of a viral infection that will go away on its own. However, there are some reasons to be concerned or worried about a fever; do not hesitate to call or see a doctor for any high fevers. Call the doctor if any of these conditions exists. o o o If the temperature is 103 F (39.4 C) or greater If the fever lasts more than seven days If the fever symptoms get worse

Call the doctor or consider going to an emergency center immediately if any of the following symptoms occur with the fever. o o o o o o o o o o o o o Confusion or excessive sleepiness Stiff neck Severe headache Sore throat, especially with difficulty swallowing or if the person is drooling Rash Chest pain Trouble breathing Repeated vomiting Abdominal pain Blood in stool Pain with urination Leg swelling Red, hot, or swollen area of skin

People with serious medical illnesses, such as cancer or HIV, may not show some or any of these warning signs. Mild symptoms with fever in this patient population should be discussed with the doctor to prevent them progressing into more serious infections or other conditions.

When to go to the hospital Certain illnesses that occur with a fever can be life-threatening. Under these conditions, the person should go immediately to a hospital's emergency department. Meningitis is life-threatening and highly contagious if caused by certain bacteria. If a person has the combination of a fever, severe headache, and stiff neck, he or she should be taken to the emergency department immediately. A person with difficulty breathing or chest pain and a fever should go immediately to the emergency department or call for emergency medical transport. If a person has a fever and blood in the stool, urine, or mucus, he or she should seek emergency medical help. A person who has a fever and is very agitated or confused with no obvious reason should be transported to the emergency department. Any person whose immune system is weakened (for example, people with cancer or AIDS) should call their doctor or go to the emergency department immediately if a fever develops. (See special medical conditions.) Hyperthermia is an emergency. Call for emergency medical transport if a person has a temperature greater than 104 F (40 C), is confused, or is not responding.

Exams and Tests A doctor will ask many questions in an effort to find the source of the fever: When the fever started What other symptoms occurred The person's immunization status Any recent travel Any exposures to sick people at work or at home Any medications taken or illicit drug use Exposure to animals Sexual history Recent surgeries Any underlying medical illnesses Allergies

Examples of diagnostic tests that may be ordered are a blood test to measure the infection count (white blood cells), strep throat culture, sputum sample, blood culture, urine analysis, urine culture, stool sample, spinal tap (lumbar puncture), X-ray films or CT scan, liver tests thyroid function tests.

Based on the results of these tests, the physician usually will be able to find the cause of the fever. More specific tests may be done if needed if the tests do not suggest a cause for the fevers. FUOs are challenging, and often specialists need to be involved to help determine what further diagnostic testing may be needed (for example, endoscopy, PET scanning, echocardiography, or radionucleotide studies). Medical Treatment The treatment of a fever depends on its cause. In most cases, except in hyperthermia, acetaminophen or ibuprofen can be given to lower the temperature. Fluids may be given by mouth or IV to prevent dehydration, if necessary. Viral illnesses usually resolve without medical treatment. However, medications to help with specific symptoms can be given. These may include medications to lower fever, help with congestion, soothe a sore throat, or control a runny nose. Viruses that cause vomiting and diarrhea may require IV fluids and medications to slow down the diarrhea and stop nausea. A few viral illnesses can be treated with antiviral medications. Herpes and theinfluenza virus are examples. Bacterial illnesses require a specific antibiotic that depends on the type of bacteria found or where it is located in the body. The physician will determine whether the person is admitted to the hospital or sent home. This decision is based on the illness and the person's overall health status. Most fungal infections can be treated with an antifungal medication. Drug-induced fever is eliminated when the medication is stopped. A blood clot requires admission to the hospital and blood-thinner medications. Any person with an illness that inhibits the immune system will be evaluated closely and usually admitted to the hospital. Environmental heat exposure requires aggressive cooling in the emergency department. The person's clothes will be removed, a cooling fan and cool mist will be used, and his or her vital signs will be monitored closely. Hyperthermic people will be admitted to the hospital. There are 3 principal groups of fever encountered in paediatric practice: Group Fever with localizing signs Fever without localizing signs Pyrexia of unknown origin Commonest cause URTI Viral infection, UTI, bacteraemia, meningitis Infection, autoimmune disease Usual duration < 2 weeks < 2 weeks > 2 weeks

Pattern Continuous

Characteristics Persistent elevation with max. fluctuation of 0.4oC. Absent of normal diurnal variation Temperature returns to normal each day, usually in morning, peaks in afternoon

Diseases Typhoid fever, pneumococcal pneumonia, bacteraemia, malignant falciparum malaria

Intermittent

Hectic or septic fever Double quotidian fever Relapsing or periodic fever

Large difference between peak and nadir 2 peaks within 24h

Malaria, pyogenic infections (septicaemia), bacterial endocarditis, abscess,rhuematioid arthritis, lymphoma Pyogenic abscess, bacterial endocarditis, toxic shock syndrome, Kawasaki disease Kala azar, gonococcal arthritis/endocarditis, miliary TB, RA, drug (CBZ) Tertian or quartan malaria, brucellosis, spirochetes (tick/louse-borne relapsing fever)

Fever interrupted by one to several days of normal temperature

TREATMENT: The following fever-reducing medications may be used at home: Acetaminophen (Tylenol and others) can be used to lower a fever. The recommended pediatric dose can be suggested by the child's health-care provider. Adults without liver disease or other health problems can take 1,000 mg (two "extra strength" tablets) every four to six hours or as directed by your physician. Ibuprofen (Motrin/Advil) can also be used to break a fever in patients over 6 months of age. Discuss the best dose with your doctor. For adults, 400-600 mg (two to three 200 mg tablets) can be used every six hours. Aspirin should not be used for fever in children or adolescents. Aspirin use in children and adolescents during a viral illness (especially chickenpox and influenza, or flu) has been associated with Reye syndrome. Reye syndrome is a dangerous illness which causes prolonged vomiting, confusion, and even coma and liver failure. NSAIDs (non-steroidal anti-inflammatory drugs) such as Tylenol (paracetamol) or ibuprofen can help bring a fever down. However, a mild fever may be helping combat the source of the infection (bacterium/virus) - it may not be ideal to bring it down. If the fever has been caused by a bacterial infection the doctor may prescribe an antibiotic. Fluid intake - the patient with a fever should consume plenty of fluids to prevent dehydration.

Pathophysiology of Fever Fever is a response to various inciting agents, such as viruses or pathogenic bacteria. The hypothalamic thermoregulatory centre located in the preoptic region regulates the febrile response. The generation of fever involves the following steps: 1. Numerous substances from outside the body, exogenous pyrogens, initiate the fever cycle. Endotoxin of Gram-negative bacteria, with their pyrogenic component lipopolysaccharide, is the most potent exogenous pyrogen. Fever is also a common finding in children without obvious evidence of infection, as a result of hypersensitivity reaction, autoimmune diseases and malignancies. 2. The exogenous pyrogen stimulates monocytes, polymorphonuclear leukocytes and other phagocytic bone marrow-derived cells of the reticuloendothelial system to release endogenous pyrogens, collectively termed interleukins. 3. Interleukin-1 accts on the hypothalamic thermoregulatory centre via mediators (of which prostaglandins PGE2 is the most important) to raise the thermostatic set point. Usually the thermoregulatory centre is set at approximately 37C. During a febrile response, the thermoregulatory centre is set to maintain a higher level of body temperature. This elevated temperature is maintained by increased heat production, especially through increased muscle activity, such as shivering; by increased heat conservation, especially through peripheral vasoconstriction; by decreased sweating; and by behavioural measures, such as covering oneself with blankets in response to chills even though the body temperature is elevated. 4. IL-1 also activates T-lymphocytes to produce various factors (such as TNF and IL-2 that are vital for immune response.