Patterns of fever 1.

Continuous fever: Body temperature in remains above normal throughout the day and does not fluctuate more than 10C in 24 hours. 2. Intermittent fever: Elevated temperature is present only for some hours of the day and turns to normal for remaining hours. 3. Remittent fever: Body temperature remains above normal throughout the day and fluctuates more than 10C in 24 hours. 4. Relapsing fever: Elevated body temperature that reappears at times for a number of times, during which it takes almost quite a few days for the body temperature to return back to normal. 5. Saddleback or biphasic fevers are those that are constant for several days, spontaneously reduce for 1 or 2 days, and then increase again. Relationship of fever and loss of appetite Loss of appetite and fever could be caused by a simple case of the flu or by something that could be far more complicated. Because the appetite is affected, the problem may be related to an issue in the digestive system like a stomach infection. It could also be unrelated to the stomach as a loss of appetite could be a result of general malaise. Fever occurs when the body begins to fight an infection or illness. LEPTOSPIROSIS Etiology: An infectious disease caused by pathogenic bacteria called leptospires that are transmitted directly or indirectly from animals to humans. It is therefore a zoonosis. Humanto-human transmission occurs only very rarely. Mode of transmission: Leptospires are excreted in the animal urine. Pathogenic leptospires can survive for 3 months or longer in neutral or slightly alkaline water or damp soil. These do not survive in acidic or dry environments. The organisms enter the animals or human hosts through: a) Abrasions of the skin b) Mucosal lining of the eyes, mouth and pharynx Epidemiology: Leptospirosis occurs worldwide but is most common in tropical and subtropical areas with high rainfall. The disease is found mainly wherever humans come into contact with the urine of infected animals or a urine-polluted environment. The number of human cases worldwide is not known precisely. According to currently available reports, incidences range from approximately 0.11 per 100 000 per year in temperate climates to 10100 per 100 000 in the humid tropics. During outbreaks and in high-exposure risk groups, disease incidence may reach over 100 per 100000. Pathomechanism: 1. What happens to the pathogenic leptospires after they have penetrated the human body? After infection, leptospires appear in the blood and invade practically all tissues and organs. They are subsequently cleared from the body by the host's immune response to the infection. However, they may settle in the convoluted tubules of the kidneys and be shed in the urine for a period of a few weeks to several months and occasionally even longer. They

are then cleared from the kidneys and other organs but may persist in the eyes for much longer. 2. What is the nature of the antibody response? Humans react to an infection by leptospires by producing specific anti-Leptospira antibodies. Seroconversion may occur as early as 57 days after the onset of disease but sometimes only after 10 days or longer. IgM class antibodies usually appear somewhat earlier than IgG class antibodies, and generally remain detectable for months or even years but at low titre. Detection of IgG antibodies is more variable. They may sometimes not be detected at all, or be detectable for only relatively short periods of time, but may sometimes persist for several years. The antibodies are directed against: common antigens (so-called genus-specific antigens) that are shared by all leptospires, both pathogenic and saprophytic; serovar-specific and serogroup-specific antigens. Patients with leptospirosis may produce antibodies that react with several serovars. This phenomenon, called cross-reaction, is often observed in the initial phase of the disease. After the acute disease, cross-reactive antibodies gradually disappear as the immune response "matures", usually in the course of weeks or months, while serogroup- and serovar-specific antibodies often persist for years. Thus the genus-specific antibodies usually remain detectable for months, the serovarspecific antibodies for years. Weak cross-reactions may also occur to other groups of microorganisms and will vary with the serological method used. Occasionally patients produce specific antibodies that react with broadly reactive antigens only, and few or no serovar-specific antibodies are detected. Some other patients may produce only serovarspecific antibodies. 3. Is the antibody response protective? It is generally believed that serovar-specific antibodies are protective and that a patient is immune to reinfection with the same serovar as long as the concentration (titre) of specific antibodies is high enough. Antibodies provoked by an infection with a particular serovar do not necessarily protect against infection with other serovars. Clinical Manifestations: The clinical manifestations are highly variable. Dry cough Fever Headache Muscle pain Nausea, vomiting, and diarrhea Shaking chills Typically, the disease presents in four broad clinical categories: i. A mild, influenza-like illness; ii. Weil's syndrome characterized by jaundice, renal failure, haemorrhage and myocarditis with arrhythmias; iii. Meningitis/meningoencephalitis; iv. Pulmonary haemorrhage with respiratory failure.

The diagnosis of leptospirosis should be considered in any patient presenting with an abrupt onset of fever, chills, conjunctival suffusion, headache, myalgia and jaundice. The diagnosis is more difficult when patients present with symptoms of cough, dyspnoea, nausea, vomiting, abdominal pain, diarrhoea, arthralgias and a skin rash. Conjunctival suffusion and muscle tenderness, most notable in the calf and lumbar areas, are the most distinguishing physical findings. Suspicion is further increased if there is a history of occupational or recreational exposure to infected animals or to an environment potentially contaminated with animal urine. Once the possibility of leptospirosis has been considered, appropriate diagnostic tests and clinical management should be instituted. Clinical diagnosis is difficult because of the varied and non-specific presentation. Confusion with other diseases, e.g. dengue and other haemorrhagic fevers, is particularly common in the tropics. Presentations may overlap as infection progresses. The incubation period is usually 514 days, with a range of 230 days. Diagnosis: i. Samples for culture: Blood during 1st week of illnesses Urine during 2nd and 3rd week of illnesses ii. Dark ground microscope-to demonstrate the spirochaetes iii. Serology-The blood is tested for antibodies to the bacteria. Specific IgM leptospiral antibodies(2nd week onwards) iv. Other tests that may be done: Complete blood count (CBC)-Leukocytosis to neutrophilia, an increase in ESR. Creatine kinase Liver enzymes Urinalysis Treatment: Various antimicrobial drugs, including penicillin, ceftriaxone, and tetracyclines, show antileptospiral activity. 1. Penicillin (eg, 1.5 million units every 6 hours intravenously) or 2. Ceftriaxone (1 g daily intravenously) is the drug of choice in severe leptospirosis and is especially effective if started within the first 4 days of illness. JarischHerxheimer reactions may occur. 3. Doxycycline, 100 mg orally twice daily for 7 days, is also effective as therapy if started early, but this agent is most often used in mild to moderate disease. Although therapy for mild disease is controversial, most clinicians treat with oral penicillin, 500 mg four times daily, or doxycycline, 100 mg orally twice daily, for 7 days. 4. Azithromycin is also active, but clinical experience is limited. Prognosis: Without jaundice, the disease is almost never fatal. With jaundice, the mortality rate is 5% for those under age 30 years and 30% for those over age 60 years.

References http://www.indianetzone.com/41/types_common_fever.htm http://www.yogawiz.com/blog/home-remedies/fever-loss-of-appetite-symptoms-remediesflu-cold.html http://www.nlm.nih.gov/medlineplus/ency/article/001376.htm http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Manua ls/GMOManual/clinical/fever.html Stephen J. McPhee et. al, 2009 Current Medical Diagnosis and Treatment, Lange WHO and ILS, Human Leptospirosis Guidance for Diagnosis, Surveillance and Control