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

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

Infectious diseases
Autoimmune disease
Malignancy

Hyperthermia

Heat stroke
Neuroleptic Malignant Synd
drug-induced hyperthermia
serotonin syndrome
malignant hyperthermia
Thyrotoxicosis
Pheochromocytoma
cerebral hemorrhage
status epilepticus
hypothalamic injury

Hyperpyrexia

Most commonly
occurs in patients
with CNS
hemorrhages

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 druginduced 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
Dengue
Chikungunya
Leptospirosis
JEV
SARS
Ebola
Hepatitis A

Within 1-3 weeks

Typhoid fever
Typhus
Leptospirosis
Ebola
CMV
Rabies
Acute HIV

> 3 weeks
Tuberculosis
HIV
CMV
Autoimmune disease
Malignancies

PATHOGENESIS OF FEVER

Heat conservation
Heat production

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TREATING FEVER
Antimicrobial
drugs

Corticosteroids

Anti-cytokines
drugs

Acetaminophen
NSAIDs

Antimicrobial
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

Dengue

Demam dengue (D) dan demam

berdarah D

Cytomegalovirus (CMV)

Anti-CMV IgM Elisa

Anti CMV IgG Elisa

Infeksi - cytomegalovirus

Epstein - Barr

Paul Bunnel

Mononukleosis Infeksiosa

Virus (EBV)

Anti EBV

Hepatitis A s/d E

Virus A s/d E, berbagai

komponen antivirus A s/d E

Hepatitis akut

Coxiella burnetti

IFA

Demam Q

Human Immunodeficiency virus

(HIV)

Anti HIV-Elisa
Anti HIV-Western Blot
PCR

AIDS
AIDS
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

Mantoux, IGRA

TBC pulmonal dan TBC

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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