fever-dd&management

Differential Diagnosis & Management of common Febrile

illnessDr.Praful Chhasatia,md

Fever

• Since antiquity, Fever has been recognized as cardinal manifestation of disease.

• Given importance over other symptoms and demands high therapeutic expectation.

• Persistent and relapsing fevers are amongst the most difficult diagnostic challenges in medicine

Definition of Fever

• A state of elevated core temperature, which is often, but not necessarily, part of defensive response of body to invasion of live or pathogenic matter.

• Pyrogen endogenous,or exogenous,iduced.

Definition of Hyperthermia

• Unregulated rise in body temp.• Uncontrolled heat production, inadequate

heat dissipation, defective thermoregulation• Not pyrogen related.• No response to antipyratics.

Normal Temperature

• 37°C(98.6°F) is defined as normal• There are various differences among workers• Diurnal variation exist .• Morning Temp.< Evening Temp.• Female have higher Temp. ,and rises further

during menstruation• Hyperpyrexia > 105°F

Measurments

• Shell: axillary, oral• Core: rectal , Tympanic membrane• Instruments: Mercury in glass, Electronics,

Antipyresis

• Physical: Tepid water sponging, Alcohol sponging, ice packs, cooling blankets, exposure to circulating fan

• Drugs: 1.Corticosteroids. 2.Aspirin & NSAID3.Acetoaminophen (paracetamol)

• Benefits Vs Risk of lowering Temp.

Patterns of Fever

• Hi grade spike intermittent with /without rigor• Low grade • Continuous Hi grade• Recurrent-intermittent • Temperature-pulse dissociation: typhoid

fever, leptospirosis, brucellosis, and drug-induced fever.

• Cyclical: hodgkin’s

Patterns of Fever

• Tertian, quartan: Malaria• Travel related: H1N1 Swine Flu, Bird Flu• Drug Fever• Factitious Fever• Fever in Immunocompromized • PUO

Differential diagnosis of fever and hyperthermia

• Fever—common causes• Infections: bacterial, viral, rickettsial, fungal, parasitic• Autoimmune diseases• Malignant disease, especially renal cell carcinoma, primary or metastatic• liver cancer, leukemia, and lymphoma• Fever—less common causes• Cardiovascular diseases, including myocardial infarction, thrombophlebitis,• and pulmonary embolism• Gastrointestinal diseases, including inflammatory bowel disease,• alcoholic hepatitis, and granulomatous hepatitis• Miscellaneous diseases, including drug fever, sarcoidosis, familial• Mediterranean fever, tissue injury, hematoma, and factitious fever• Hyperthermia• Peripheral thermoregulatory disorders, including heat stroke, malignant hyperthermia of anesthesia, and malignant neuroleptic

Common Febrile illnessFever without Rash Fever with Rash

URTI,Sinusitis,Tonsillitis,Otitis,Pharyngitis

Viral :Infections:Dengue,Flu,Hunta virus,Viral Hepatitis, Measles,Mumps

Chickenpox,Measles,Dengue,Herpes,Mumps

Bacterial:Brucelosis,plague,Leptospirosis Typhus,Enteric Fever,Sec.Syphilis,N.meningitis,gonorrhoea,Leptospirosis,Staphylococcua aures,Strepto(Scarlet Fever)

Respiratory:Pneumonia,Tuberculosis,Diptheria,Measles ,plague

GI: Enteric Fever,Bacillary Desentry,Peritonitis,pancreatitis,Liver Abscess,Hepatitis,Abscess,appendicitis, cholecystitis

CNS:Meningitis,Brain Abscess

Urinary:Gonococci,UTI,Prostatitis

Protozoa: Malaria,Babesosis P.F.malaria

Parasites:Filariasis

Clinical Evaluation

• History• Physical Examination• Investigations• Management

HistoryFever

• O,D,P• Nature of Fever:High grade,Low grade,• Continuous /intermittent• Diurnal variation• Rigors: Present/Absent• Past history of fever

Associated Symptoms• Headache• Vomiting• Diarrhea• Cough• Jaundice• Body ache/arthralgia/myalgia• Abdominal pain• Chest pain• Localized pain• Retro orbital pain• Prostration/toxic

Associated Symptoms

• Altered sensorium• Convulsions• coma• Red Eyes• Dark red/black urine

Associated Symptoms• Urinary symptoms• Breathlessness• Joint pain• Backache• Eruptions• Mouth ulcers/stomatitis• Throat pain• Swelling /Ulcers anywhere• Recent travel• Urticaria

Examinationgeneral

Temprature

Pulse Tachycardia, relative bradicardia,irregular,low volume

Respiration Tachypnoea,shallow,

Sp o2 Optional

BP Hypotension, tourniquet test

Sclera,conjuctiva Jaundice,pallor,suffusion,haemorrhage

Tongue Coating,glossitis,candida,ulcers,cynosis

Throat,mouth Tonsills.pharyngs,diptheria,rash,dental abscess,trysmus

Neck Lymph nodes-type,rigidiry,

Skin Rash,ulcers,abscess,nodules,perspiration

Axilla,groin Lymph nodes,abscess

Examinationgeneral

Nails Pallor,clubbing,cynosis,infarcts,fungus

Higher function altered

ExaminationSystemic

RS RR,Movments of chest,dull/tympanic node, Air entry, plural rub, rales, rhnchi, bronchial breathing

AS Brathing,Distension,peristalsis,Tenderness-quadrant,organomegaly,rigidity,gaurding,lump,dull-tympanic node,

CVS Tachycardia,murmur,pericardial rub

CNS Higher function,Neck rigidity,Kernig’s sign,pupils,

Bones & joint Spine abnormality, tenderness,joint infammation

Investigationsbasic

• Blood: CBC with ESR & Platelet count,PS.SGPT, RBS, S.CREATININE,RDT(pf)

• Urine• X-ray chest• USG: Abdomen,chest

Investigationsspecific & advanced

• Serology:Widal,NS1antigen,IgM,IgG for Lepto,Hunta,TB,Virus,HIV

• Sputum:AFB,Gram st.,C&S,Cytology• Culturs:Blood,urine,pus,aspirates,stool• CT Scan: Abdoman,Brain,Chest+HRCT,Sinus• MRI:Spine.Joints,Brain• Acute phase reactant: CRP,ProCalcitonin

CBC

• Hb: down,up,• RBC:down,Sickle,MP,Fragments• WBC:N,H,D• Platelet:N,H,D,ask for manual count,look for

other cause• ESR:non specific• PS: MP,Parasites,Leucamia,TTP,ITP,RBC

morphology,Platelet,Thin and Thick(3) smear• Auto Cell counter

Urine

• Proteins:Infection,renal,pregnancy• Acetone:DM,dehydration,poor nutrition• Sugar:DM,IV fluid,renal• Pus cells:infection,renal• Organism:bacteria,fungus

X-Ray

• Chest:PA,Portable• Spine:• Sinus:• Abdoman:Supine,Standing

USG

• Look for areas studied.Discuss with sonologist• Always ask for Whole abdoman+Chest• In doubt confirm with CT

Investigationsincrease platelet

Condition Adults, >500,000/μL >1,000,000/μLInfection 22% 31%

Rebound thrombocytosis 19% 3%

Tissue damage (surgery) 18% 14%

Chronic inflammation 13% 9%

Malignancy 6% 14%

Renal disorders 5% <1%

Hemolytic anemia 4% <1%

Post-splenectomy status 2% 19%

Blood loss NS 6%

Primary thrombocythemia 3% 14%

InvestigationDecrease platelet

Immune destruction Autoantibodies: ITP, disease-associated IT (collagen disease, lymphoproliferative disorders)Alloantibodies: post-transfusion purpura, neonatal purpuraDrug-induced IT: quinidine, quinine, sulfonamides, gold, etc.Acute ITP

Infection HIV, hepatitis, cytomegalovirus, Epstein-Barr virus

Nonimmune destruction or platelet removal

Infection (bacterial, viral, malarial)Thrombotic thrombocytopenic purpura/hemolytic-uremic syndromeD.I.C. ,Hemangiomas,Platelet loss (massive bleeding)Platelet redistribution (enlarged spleen)

Congestive splenomegalyOther (non-Hodgkin's lymphoma, Gaucher's disease, etc.)

InvestigationDecrease platelet

DECREASED PLATELET PRODUCTION Myeloproliferative disorders (acute or chronic leukemias, multiple myeloma, myelofibrosis

Lymphoproliferative disorders (non-Hodgkin's lymphoma, CLL)Aplasia or hypoplasia (idiopathic, drug induced, radiation)Ineffective hematopoiesis (myelodysplasia, vitamin B12 or folate deficiency)Myelophthisis (prostate, lung, breast, gastrointestinal cancers)Drugs (chemotherapy, thiazides, alcohol, etc.)Congenital/hereditary disorders

Important corelationMalaria Viral Typhoid Pyogenic

SGPT ↑ ↑ N N

LDH ↑ N N N

CRP N N ↑ ↑

Plt. & atypical Lymphocytes

• Platelet :↓ + Atypical LymphocytesDay 1-2 – Malaria

• Platelet : N Day 1-2 + Atypical Lymphocytes ↓ Day 2-3-4+ Atypical Lymphocytes - Dengue

Indirect evidence of Malaria

• Platelet:↓ Day 1-2• Hb:↓ Day 1-2• Atypical Lymphocytes day 1-2• SGPT:↑• Bilirubin:↑• Band cells & Monocytes:↑• Polychromasia• Cholesterol:↓

Rash• Morbilliform• Macular• Papular• Nodular• Vesicular or bullous• Pustular• Plaques• Purpura, petechiae, ecchymosis• Erythematous

Measles

Mumps

Dengue

Dengue

Secondary Syphilis

Chickenpox-vesicles

Chickenpox -pustules

Herpes zoster ophthalmicus

Petechial and purpuric illnesses

• Purpura fulminans• Viral hemorrhagic fevers• Thrombocytopenia• Vasculitis

ecchymosesSeverely ill patient with ecchymoses and gangrene.

Meningococcus, others

Spenectomized host

Meningococcemia

Severely ill patient with papular purpuric rash, with or without meningitis

Eschar of scrub typhus

Erythema multiformeDrug Rash

Treatment• General• Antipyresis• Hydration• Nutrition• Antiemetics• Antacids• Reassurance• Prevent panic in

epidemics• Family care

• Specific• Antibiotics• Antimalarial• Vaccines• Antibodies serun• Steroids?

Dengue

• Self limited• Symptomatic in majority cases• Close observation• IV fluids

DHF Grade 1-2 iv fluid

DHF Grade 3-4 iv fluid

Dengue-What not to do

• Do not give Aspirin or Brufen for treatment of fever.• Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding.• Avoid giving blood transfusion unless indicated, reduction in haematocrit or severe bleeding.• Avoid giving steroids. They do not show any benefit.• Do not use antibiotics• Do not change the speed of fluid rapidly, i.e. avoid rapidly increasing or rapidly slowing the speed of fluids.• Insertion of nasogastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) is not recommended

since it is hazardous

P.vivex-Chloroquin250mg

P.F.Malaria• Uncomplicated:treat• Complicated:Reference• Tratment:ACT(Artemisinin derivative combined with

long acting antimalarial)(Amodiaquinine,Lumefantrine, Mafloquine,Sulfadixine-pyrimethamine)

• Artemisinin alone? No• Pregnancy:ACT in 2nd & 3rd trimester,Quinine in 1st • Mixed Infection: treat like pf• Clinical Malaria: RDT,PS negative but strong clinical

presentation• Vaccine

Complicated PF

• If not detected early and treated ,in severe pF malaria,sevre meifestations can develop in 12-24 hr,and lead to death

• Platelet factor responsible for immunity storm• P.Knowelsi : Thailand , in Monkey

Complicated PFSevere manifestations

• Impaired conciousness/coma• Convulsions• Renal failure• Jaundice• Anaemia:rapid lowerin of Hb <5 g/dl• ARDS• Hypoglycemia• Metabolic Acidosis(clinical?)• Shock• DIC /bleeding• Haemoglobinuria• Hypothermia• Heavy parasitemia• Pregnancy

Enteric Fever

Pneumonia

• Antibiotics:covering Gram positive and or negative/anaerobs/atypical oraganism

• Analgesics• Cough suppresants• Mucolytics• Close observation

UTI

• Antibiotics:• Quinolons• Aminoglycosides• Septran• Cephalosporins• C & S• USG

Tonsillitis,Pharyngitis,URTI

• Antibiotics: gram positive

Brucelossis

• Doxycycline,quinolons,SM,• 6 weeks

Flu

• Symptomatic• Observe closely• Severe, refer

PRACTICAL PROBLEMS

• DIFFERENTIAL DIAGNOSIS :any fever in endemic area demands for quick identification

• QUICK DETECTION & TRETMENT : Late diagnosis &treatment & inadequate treatment in PF,LEPTO,Dengue,PNEUMONIA ,Enteric,Meningitis.Proves expensive and lethal

• Variable presentation

Gram positive-negative

• What is it• What and when to choose• Same group, differs, individually

Antibiotics case1

• Oral quinolon,IV• 3rd cephalosporin• Cefaparozone+sulbactum+new quinolon• Anti viral• Carbapenum + quinolon• Aminoglycoside+carba+new quinolon• 8 in 48 hr

Antibiotics case 2• 80/male• Circumsion• Aminoglycoside single dose• ARF• Bleeding p/r• Hemicolectomy• Ventilated/VAP/recovered• Rebleed• ARDS• 3 weeks

DHF case 3

• 45/m• Platelet :2000• Ascites,Pl.effusion• Iv Fluid• Platelet count low <15000 for 6 days

Thank You