Common Symptoms---Fever and Edema

The First Affiliated Hospital of Liaoning

Medical College
Nephropathy Deparment
Zhou HongLi

Fever
1 Introduction
2 Pathlogeny and sort
3 Occurrence Mechanism
4 Clinical occurrence
5 Patterns of fever
6 FUO

Intruduction
1 normal rang: 36-37
2 higher: late afternoon, evening
maximum 8:00-10:00 pm
lower: morning
minimum 3:00-4:00 am
3measure pathway rectum (higher 0.3-0.5)
mouth
axillia (lower 0.2-0.4)

Pathlogeny and sort

1 Infective fever-------most common cause
bacterial
viral
rickettsial
fungal
parasitic

Pathlogeny and sort

2 Noninfective fever
aseptic necrosis mass absorption : tissue
ischemia and infarction,vascularitis,
subarachnoid hemorrage
antigen-antibody reaction: acute rheumatic
fever, still disease ,serum sickness,
systemic lupus erythematosus
familal fever: congenital familial
mediterranean fever

endocrine disease: endocrine hyperthyroidism

tissue damage:myocardial infarction,
pullmonary infarction
drug reaction and gout
tumor: lymphomas,solid tumors
neuroleptic seizures
psychosocial factitious

Occurrence Mechanism

physiologic temperature elevated----fever

(elevation of hypothalamic set point)

Pathologic temperature elevated-- hyperthermia

( unregulated heat generation, impaired heat
exchange)

Occurrence Mechanism--physiologic
set point (hypothalamus)
regulate

Internal temperature
maintain

cellular function
Deviation >4
cellular dysfunction

Occurrence Mechanism
increased heat production
decreased heat dissipation
failure of regulating system

Set point change

Temperature deviation

fever

exogenous pyrogen (bacterial, viral)

activate
neutrophil, eosinophil, mononuclear
macrophage
release
endogenous pyrogen(interleukin-1(IL-1),TNF,
interferon
hypothalamus Set point
heat production heat dissipation

fever

Occurrence Mechanism
Specific patients:
elderly patients
renal failure patients
high doses of corticosteriods

unable to mount
fever
immunocompromised hosts fever
HIV-infected fever
nosocomial fever
require special consideration

Clinical occurrence
low-grade fever:37.3-38

Grade
(oral reading)

middle-grade fever:38.1-39
high-grade fever:39.1-41
hyperthemia: 41

Clinical occurrence
effervescence heat production ,heat
loss

clinical features

altithermal

(chill,rigor,vasoconstriction)
(reach new set point)

(warm,moist,flushed,tarchycardia)
defervescence (heat production heat loss )
sweat

Patterns of fever

Continuous fever
Remittent fever
Intermittent fever
Undulant fever
Relapsing fever
Episodic fever
Pel-Epstein fever

Continuous fever
temperature: 39-40 ,days or weeks;diurnal
variation 0.5-1.0
disease: typhoid, acute pneumonia

Continuous fever

Remittent fever
temperature 38 , diurnal variation 2
no normal temeratrue
disease: sapraemia,acute rheumatic fever,
acute infectious endocarditis

Remittent

fever

Intermittent fever
suddenly reach climax, continue several
hours, suddenly fall to normal,
intermission 1-several days
disease: malaria, acute pyelonephritis

Intermittent fever

Undulant fever
slowly reach 39 ,slowly return to
normal. (repeate the rhythm)
disease: brucellosis,tumor

Undulant fever

Relapsing fever
suddenly reach 39 , continue several
days, suddenly drop to normal. bout every
5-7days
disease: spirochetes infection

Relapsing fever

Episodic fever
last for days or longer, then without fever
for at least 2 weeks
disease: familial periodic fever

Pel-Epstein fever
continuous or remittent fever bouts
several days
disease: Hodgkin disease

FUOfever of unknown origin

Diagnosis criteria:
the illness last at least 3 weeks;
38.3 repeatedly;
no diagnosis after 1 week hospitalization
Causes:
noninfectious inflammatory disease;
infections;
malignancies (hematologic);
50% unexplained

Edema
Pathophysiology
Clinical

occurrence
Idiopathic edema
Tropical edema
angioedema

Pathophysiology

hydrostatic and oncotic pressure

fluid

fluid

filter
out

interstitial tissues

Keep in balance

V
resorption

equilibrating factors
filtration

resorption

capillary hydrostatic pressure

interstitial fluid colloid osmotic pressure
serum colloid osmotic pressure
interstitial tissues pressure

Filtration > resorption

edema

Factors leading to edema

retention of sodium and water

capillary filtration pressure right heart failure
capillary permeability
acute nephritis
serum colloid osmotic pressure (serum albumin )
lymphatic return disturbance (filariasis)

pitting edema detectable:4.5kg fluid accumulate

identify method :
press thumb into the skin against a bony
surface (anterior tibia, fibula,dorsum of foot,
sacrum) to demonstrate the presence of edema
when the thumb is withdrawn, an indention
persist for a short time.

Site of edema:
walking

patient--feet, ankles
gravity
supine patient--posterior calves, sacrum

both legs and symmetricin the pelvis or

more proximally
arms and head---superior vena cava
limited one extremity-vascular channels, local
inflammation

Brawny edema:
chronic edema of the legs leads to fibrosis
of the subcutaneous tissues and skin, so
they no longer pit on pressure.

Clinical occurrence
Localized edema
cause: local vein or lymphatic return,soft
tissues disturbance or capillary permeability
disease: Inflammation infection
insufficiency of the venous valves
chemical or physical injuries
arteriovenous fistulas

site: above the diaphragm--superior

vena cava obstruction
below the diaphragmjugular
venous press ,portal vein hypertension,
loss of venous tone drugs

Generalized edema:
cardiac edema
renal edema
hepatic edema
nutritional edema (protein losing conditions)
Drug (corticosteroid, NSAID)
Systemic inflammatory response syndrome(SIRS)

Cardic edema
Symptoms:

chest distress, short breath,

dyspnea
Site: lower limbs
Disease right heart failure

renal edema
Symptoms

hematuria proteinuria
Site: eyelid legs
Disease: nephrotic syndrome

hepatic edema
Symptoms:

anorexia, vomitting,liver
function test abnormal
Site: first lower limbs, then spread all over
the body, ascites is most common
Disease cirrhosis, chronic liver disease

Protein losing conditions

Enteropathy
Burns
fistulas

Idiopathic edema

women in 30-50years old without disease,affective

disorders and obesity may coexist
Mechanism :upright posture --capillary leakage
inappropriate chronic diuretic administration
-----peripheral edema

activate

hormones involved in
salt and water retention

Tropical edema

Normal adults
condition:48h after traveled from temperate
climate to tropics or from cool and dry to warm
and humid
resolve quickly in a few days of acclimatization

Angioedema
Site: face,lips,tongue, larynx----life-threatening
Subcutaneous soft-tissue edema ;Erythema is not prominent.

Causes: hereditary absence of C1 esterase

exposure to allergen
angiotensin-converting enzyme inhibitors

1Reasons of infective fever

2Grades of fever.
3Patterns of fever.
4cause of generaliz edema
5How to distinguish cardiac edema from
renal edema?