PIT IDI 2015 - SURABAYA

Management of Adult Patients with Fever

Musofa Rusli
Dep/SMF Ilmu Penyakit Dalam Divisi Tropik - Infeksi
FKUA RSUD Dr. Soetomo Surabaya
 TOPICS

oDefinition
oPathophysiology of fever
oManagement of fever
oFever of unknown origin
oDrug fever

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Definition
Fever
o Fever:
q an elevation of body temperature that exceeds the normal daily variation
and occurs in conjunction with an increase in the hypothalamic set point
[e.g., above 37.2C].
q Heat conservation (vasoconstriction) and heat production (shivering, fat
tissue thermogenesis)
q Anatomic variations: rectal > oral > axillar rectal 0.6 oC higher than oral

o Normal daily oral temperature:

q 36.8 + 0.4 oC
q Low levels at 6 AM and higher levels at 4 6 PM
q Thus, 37.2 oC in the morning fever
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Definition
Pyrogens
Pyrogens any substance that causes fever
oEndogenous
qclass of biologically active proteins called cytokines
pyrogenic cytokines
qrelated to activation of TLR
qE.g.: IL-1, IL-6, TNF-, IFN-

oExogenous
qderived from outside the host
qmainly microbes or their products: toxins
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Definition
Elevated body temperature
oHyperthermia:
qAn uncontrolled increase in body temperature that
exceeds the body's ability to lose heat
thermoregulatory center is unchanged
qDoes not involve pyrogenic molecules
qExogenous heat exposure and endogenous heat
production
oHyperpyrexia:
qan extraordinarily high fever (>41.5C)
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 Elevated body temperature
Fever Hyperthermia Hyperpyrexia
Infectious diseases Heat stroke Most commonly
Autoimmune disease Neuroleptic Malignant Synd occurs in patients
Malignancy drug-induced hyperthermia with CNS
serotonin syndrome hemorrhages
malignant hyperthermia
Thyrotoxicosis
Pheochromocytoma
cerebral hemorrhage
status epilepticus
hypothalamic injury

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Definition
Temperature-pulse relationship

oThe temperature-pulse relationship is linear with an

increase in heart rate of 4.4 beats/ minute for each 1C
oTemperature-pulse dissociation (relative bradycardia)
typhoid fever, brucellosis, leptospirosis, some drug-
induced fevers and factitious fever
oFever may not be present during infection in newborns,
the elderly, patients with chronic renal failure, and in
patients taking corticosteroids
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 Pattern of temperature changes

The pattern of temperature changes may occasionally hint at the

diagnosis

Patterns:
o Continuous fever: Temperature remains above normal throughout
the day and does not fluctuate more than 1 C in 24 hours
o Intermittent fever: The temperature elevation is present only for a
certain period, later cycling back to normal
o Remittent fever: Temperature remains above normal throughout
the day and fluctuates more than 1 C in 24 hours
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 Fever Onset

< 1 week Within 1-3 weeks > 3 weeks

Dengue Typhoid fever Tuberculosis
Chikungunya Typhus HIV
Leptospirosis Leptospirosis CMV
JEV Ebola Autoimmune disease
SARS CMV Malignancies
Ebola Rabies
Hepatitis A Acute HIV

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PATHOGENESIS OF FEVER

Heat conservation
Heat production

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 TREATING FEVER

Antimicrobial Acetaminophen
drugs Corticosteroids NSAIDs

Anti-cytokines Antimicrobial
drugs drugs 11
 Treatment of Fever
oAntipyretics:
qAcetaminophen
qNSAIDs side effects !
oCorticosteroids side effects !!!
oCool damp sponges
oSubmersion should be avoided

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Benefit and complication of fever
Benefit:
o fever is associated with release of endogenous pyrogens, which activate the T
cells and thus enhance the host defence mechanism.
o Some febrile diseases have characteristic patterns diagnostic benefit

Complications:
o a state of catabolism detrimental to body
o fluid and electrolyte imbalance - due to sweating and loss of minerals
o high grade fevers can lead to convulsions, brain damage, circulatory overload
and arrhythmia
o increase oxygen consumption COPD, CHD

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 Drug Fever
Definition (Mackowiak & LeMaistre, 1987):
o a disorder characterized by fever coinciding with administration of a drug and
disappearing after the discontinuation of the drug
o no other cause for the fever is evident after a careful physical examination and
laboratory investigation
o usually a diagnosis of exclusion

Important drugs related to drug fever:

o Antimicrobials: beta-lactams, sulfonamides and nitrofurantoin
o Anticonvulsant
o Minocycline
o Allopurinol
o Sympathomimetic drugs: amphetamines, cocaine

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 Fever of Unknown Origin
Definition (Petersdorf & Beeson, 1961):
o Fever higher than 38.3C on several occasions
o Duration of fever for at least three weeks
o Uncertain diagnosis after one week of study in the hospital
o Classic, nosocomial, neutropenic and HIV-associated FUO (Durrack & Street, 1990)

Classicetiology:
o Infections: tuberculosis, infectious mononucleosis
o Malignancies
o Noninfectious inflammatory diseases (eg, vasculitis, systemic lupus erythematosus,
polymyalgia rheumatica)
o Connective tissue diseases (eg, vasculitis, rheumatoid arthritis)
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 Virology Tests
Virus penyebab Jenis Uji Penyakit
Dengue IHA, IgM/ IgG Dengue, NS1 Demam dengue (D) dan demam
Dengue berdarah D
Cytomegalovirus (CMV) Anti-CMV IgM Elisa Infeksi - cytomegalovirus
Anti CMV IgG Elisa
Epstein - Barr Paul Bunnel Mononukleosis Infeksiosa
Virus (EBV) Anti EBV
Hepatitis A s/d E Virus A s/d E, berbagai Hepatitis akut
komponen antivirus A s/d E
Coxiella burnetti IFA Demam Q
Human Immunodeficiency virus Anti HIV-Elisa AIDS
(HIV) Anti HIV-Western Blot AIDS
PCR AIDS
 DAFTAR UJI BAKTERIO-PARASITOLOGIS
Virus penyebab Jenis Uji Penyakit
Salmonella typhi Widal, Thypidot PCR Demam tifoid
S. Paratyphi A/B/C Widal Demam paratifoid
Streptokokkus ASTO Demam reumatik
Mikobakteria Myco Dot TB PAP TBC pulmonal dan TBC
Mantoux, IGRA Ekstrapulmonal
Leptospira spp MAT Leptospirosis
Brucella spp Aglutinasi Brusellosis
Rickettsia spp Well felix Ricketsiosis
Mycoplasma pneum IF Mycoplasmosis
Legionella IF Legionellosis
Toxoplasma gondii Elisa IgG/IgM Tokoplasmosis
Entamoeba histolitica IDT Amubiasis
Filaria spp IFAT Filariasis
Candida spp IHA atau IFAT Candidiasis
Histoplasma capsulatum IDT Histoplasmosis
 Key Points
oHistory taking
oPhysical examination
oImaging
oLaboratory tests:
qCBC, urinalisys, BUN/ SC, SGOT/ SGPT, LED,
[CRP, lactate, procalcitonine]
qBlood/ urine/ body fluid culture
qSerology, antigen-based test
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THANK YOU

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