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

①bacterial

②viral

③rickettsial

④fungal

⑤parasitic

Pathlogeny and sort

2 Noninfective fever

①aseptic necrosis mass absorption : tissue ischemia and infarction,vascularitis, subarachnoid hemorrage

②antigen-antibody reaction: acute rheumatic fever, still disease ,serum sickness, systemic lupus erythematosus

③familal fever: congenital familial mediterranean fever

④endocrine disease: endocrine hyperthyroidism

⑤tissue damage:myocardial infarction, pullmonary infarction

⑥drug reaction and gout

⑦tumor: lymphomas,solid tumors

⑧neuroleptic seizures

⑨psychosocial 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)

Internal temperature

cellular function

regulate

maintain

Deviation >4 ℃

cellular dysfunction

Occurrence Mechanism

increased heat production

decreased heat dissipation

failure of regulating system

Temperature deviation

fever

Set point change

exogenous pyrogen (bacterial, viral)

neutrophil, eosinophil, mononuclear macrophage

activate

endogenous pyrogen(interleukin-1(IL-1),TNF, interferon ）

release

hypothalamus Set point

fever

heat production heat dissipation

Occurrence Mechanism

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

immunocompromised hosts fever HIV-infected fever nosocomial fever

unable to mount fever

require special consideration

Clinical occurrence

Grade

(oral reading)

low-grade fever:37.3-38℃

middle-grade fever:38.1-39℃

high-grade fever:39.1-41℃

hyperthemia: 41℃℃

Clinical occurrence

clinical features

effervescence （ heat production ,heat loss ）

(chill,rigor,vasoconstriction) altithermal (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

①temperature: 39-40 ,days or weeks;diurnal variati℃on 0.5-1.0 ℃

②disease: typhoid, acute pneumonia

Continuous fever

Remittent fever

①temperature ＞ 38 , diurnal variation℃ ＞ 2 ℃ （ no normal temeratrue ）

②disease: sapraemia,acute rheumatic fever,

acute infectious endocarditis

Remittent fever

Intermittent fever

① suddenly reach climax, continue several hours, suddenly fall to normal, intermission 1-several days

②disease: malaria, acute pyelonephritis

Intermittent fever

Undulant fever

①slowly reach ＞ 39 ,℃ slowly return to normal. (repeate the rhythm)

②disease: brucellosis,tumor

Undulant fever

Relapsing fever

①suddenly reach 39 ℃ , continue several days, suddenly drop to normal. bout every 5-7days

②disease: spirochetes infection

Relapsing fever

Episodic fever

①last for days or longer, then without fever for at least 2 weeks

②disease: familial periodic fever

Pel-Epstein fever

①continuous or remittent fever bouts several days

②disease: Hodgkin disease

FUO—fever of unknown origin

Diagnosis criteria:①the illness last at least 3 weeks;

②38.3 ℃ repeatedly;③no diagnosis after 1 week hospitalizationCauses:①noninfectious inflammatory disease;②infections;③malignancies (hematologic);④50% unexplained

Edema

PathophysiologyClinical occurrenceIdiopathic edemaTropical edemaangioedema

Pathophysiology hydrostatic and oncotic pressure

A Vfluid fluid

interstitial tissues

Keep in balance

filter out

resorption

equilibrating factors

capillary hydrostatic pressure

interstitial fluid colloid osmotic pressure

serum colloid osmotic pressure

interstitial tissues pressure

filtration

resorption

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 supine patient--posterior calves, sacrum

both legs and symmetric—in the pelvis or more proximally

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

inflammation

gravity

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 tiss

ues 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 diaphragm—jugular 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 edemaactivate

hormones involved in salt and water retention

Tropical edema

Normal adults condition:48h after traveled from temperate cli

mate 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-threateningSubcutaneous 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?