Fever

Description of Acute Febrile Illness

1. Acute Febrile Illness Dr. S. Aswini Kumar. MD Professor of Medicine Medical College Hospital Thiruvananthapuram

2. Acute febrile illness should be approached with consideration and caution: Definition: Temperature >38.5 O C For >2 consecutive days Complete recovery is the rule in >99% of these patients Life threatening in 1% as a result of complications Clinical Examination + Routine, Screening And Special tests Detailed history with occupation and contact required 2

3. Viral Fever can be suspected from following history: High grade continuous or remittent fever without chills Nonspecific headache which corresponds with increase in temperature Generalized aches and pains without real arthralgia or arthritis Running nose, sneezing & nasal block characteristic of influenza Dry cough with Minimal white mucoid sputum 3

4. One must check for the vital signs carefully in every patient: Check the pulse rate for tachycardia or relative bradycardia Record blood pressure for evidence of hypotension or shock suggesting sepsis Respiratory rate for any tachypnoea as in bronchopneumonia Record the Temperature and verify in accordance with the pulse rate Check sensorium to exclude Encephalitis, NMS or Cerebral malaria 4

5. Now to proceed with a systematic examination for: Look for evidence of pharyngitis or tonsillitis throat ulcers or abscesses Auscultate the lung fields for any bronchial breathing/ crepitations Palpate the abdomen for hepatosplenomegaly or any renal mass Auscultate the heart for any tachycardia , murmur or gallop Look for meningeal signs focal deficits, increased ICT and plantar reflex 5

6. Routine tests to exclude other causes of fever are: Urine examination under the microscope for any Urinary Deposits Blood TC DC ESR for any leucocytosis , lymphocytosis , neutropenia or high ESR Peripheral Smear for any atypical lymphocytes, abnormal cells or parasites Platelet Count for any thrombocytopenia or thrombocytosis Chest X-Ray PA For any Homogenous or Non-homogenous shadows 6

7. General measures to be taken in uncomplicated Viral Fever: Easily digestible diet kanji or oats or even plain rice and vegetables Plenty of fluids boiled and cooled, tender coconut or kanji water Antipyretic drugs – acetaminophen , mefenemic acid Complete bed rest is advised in every patient till the fever subsides Hospitalization? very sick patient, any complications 7

8. If the temperature is more than 40 C, it should be managed by: Tepid sponging of whole body with luke warm water but not tap/well/ice water Only if there is chills consider covering with a blanket Drinking plenty of water is mandatory to ensure good urine output Good ventilation to the room should be provided Small breeze of air, cold compresses or Internal cooling 8

9. Antibiotic therapy is indicated only in certain circumstances: Secondary Infection of upper respiratory tract like pharyngitis Community acquired or hospital acquired bacterial pneumonia Diabetics and patients on chemotherapy or radiation HIV other types of immuno-compromized patients Old Patient with immobility , incontinence institutionalization 9

10. Life threatening complications may occur in viral fever: Viral M yocarditis if tachycardia or hypotension Viral Bronchopneumonia if tachypnoea or rales Viral Meningoencephalitis if alterated sensorium Viral Gastroenteritis if profuse watery diarrhea Thrombocytopenia <40,000 + bleeding <20,000 – bleeding 10

11. Weil’s disease is likely to occur in the following circumstances: Exposure to rat’s urine via abraded lower limbs Sewer Work or working in a paddy field Swimming in ponds or even a swimming pool or rafting Flooded water contaminated with drainage water - Anybody can get it Contamination of drinking water with rat’s urine 11

12. Diagnosis of Weil’s Disease can be suspected if there is: Mild to moderate Jaundice which is rapidly progressing Rapid decline in quantity of urine or not passing urine Subconjunctival Hemmorrahge is classical Hepato -renal Involvement - often requiring dialysis Sever muscle pain and Muscle tenderness up on pressure 12

13. Investigations to arrive at a diagnosis of Weil’s disease are: Urine examination shows protinuria and RBC casts Mild to moderate thrombocytopenia is common Blood routine will shows PMN leucocytosis Weil’s Antibody ? IgM or Rapid ELISA PCR in 1 st week Abnormal renal function – high blood urea and creatinine 13

14. Important complications of Weil’s disease are: Acute onset Hemorrhagic Pneumonia Acute Renal Failure develops rapidly over 1-2 days Aseptic Meningitis is common but usually non-fatal Bilateral Iridocyclitis - a non-fatal complication , which may lead to blindness Weil’s Myocarditis with tachycardia and hypotension 14

15. Fatal outcome of these complications of Weil’s disease are: Acute Respiratory Distress Syndrome with dyspnea Progressive azotemia resulting from acute renal shut down Cerebral edema is another fatal complication Internal bleeding - Transfusion of fresh blood or packed cells Arrhythmia cardiogenic shock and acute heart failure 15

16. Crystalline penicillin is the drug of choice in Weil’s disease because: It is a leptospiral disease due to L. Icterohemorrhagiae The organism is universally sensitive to penicillin Practically no side effects including anapylaxis seen Weil’s disease Earlier the trt the better Or Erythromycin Or Amoxycillin Doxycyclin No drug resistance so far to penicillin in Weil’s disease 16

17. Infective hepatitis as differential diagnosis of Weil’s Disease Loss of appetite especially to fried foods Aversion to cigarettes in smokers as a surprise Gradually progressive jaundice over one or two weeks High SGPT levels when compared to SGOT levels Viral markers HAV HBV HCV 17

18. Septicemia is the other possibility in acute febrile illness with jaundice: Source of sepsis can be very subtle like the IV cannula Signs of inflammation – redness, swelling and tenderness Multi-organ dysfunction – kidney heart and lungs Evidence of Septic shock - hypotension and cold extremities Severe Sepsis - Dysfunction of organs distant from Site of infection 18

19. Management of Sepsis has following essential components: Drotrecogin Alfa Activated Protein C 24 µg/kg per hour IV infusion Sequence of events SIRS, Sepsis and severe sepsis Admission to the medical intensive care mandatory Antibiotic Cocktail covering gram + ve , - ve and anaerobic In best of centers the Mortality rate is 5-15 % 19

20. Dengue fever can be suspected from the following symptoms: High grade fever lasting for more than 2 days in duration Severe bone and joint pains of upper and lower limbs Retro-orbital pain - Pain behind the eyes is considered diagnostic Mosquito bite especially during morning hours Epidemic in the community - seasonal febrile emergency 20

21. Dengue Hemorrhagic fever is identified by the detection of: Classical dengue fever history some times a biphasic illness Positive tourniquet test – simple done any where Bleeding tendencies- purpura , petechiae , echymosis Thrombocytopenia Platelet count <1,00,000 Increased Capillary Permeability resulting in Polyserositis 21

22. Steps in Tourniquet test for diagnosing Dengue fever are: A BP apparatus is used for this purpose which is tied around the upper arm Mercury column is elevated to between systole diastole Wait for 5 minutes keeping the blood pressure elevated Count the number of petechiae one inch square marked More than20 Petechiae highly suggestive of but how ever not diagnostic of Dengue 22

23. 2 nd infection with another serotype is dangerous because: The dengue Virus has 4 Serotypes, which do not have cross resistance Transmission is by Aedes Egypti mosquito which feed the virus and injects it Homologous Antibodies are formed against the dengue I viruses and neutralizes them Hetrologous Antibodies against Dengue I remain and form non- neuralizing complexes Dengue 2 virus-HAB complexes enter monocytes and replicate rapidly 23

24. Diagnosis of Chikungunya Fever can be considered if: Severe arthralgia involving the peripheral small and large joints symmetrically Desquamating rash all over the trunk and limbs but sparing the palms and soles Severe and prolonged functional disability lasting for months or even years Elevated SGOT and CRP levels are suggestive IgM levels are elevated; Virus isolation facilities are not available 24

25. Treatment of Chikungunya Fever consists of the following: No specific treatment is available for Chikungunya There is no vaccine currently available for chikungunya Anti-inflammatory agent to combat the arthritis Aspirin, ibuprofen, naproxen and other NSAIDs Chloroquine /HCQS/ Salazopyrine found to be useful Or if necessary Steroids 25

26. The Novel H1N1 Influenza virus infection in 2009: Virus were detected in April 2009 in San Diego, US This created a new pandemic as well as a panic No longer called as Swine flu as swine is not involved The novel virus has a structure of Hemagglutinin 1 and neuraminidase 1 26 The human and swine strain of Influenza is mixed in the swine

27. Diagnosis of H1N1 Fever can be considered if patient is having: The symptoms are the same as that of any severe flu It rapidly spread in the community as there was no resistance The government started screening travellers in the airports Throat swabs were taken and sent to specified labs The confirmation of diagnosis was done by R- PCR technique in Rajeev Gandhi Institute 27

28. Treatment of of H1N1 Fever can be ver y simple in uncomplicated : The patient should rest at home isolated from others Shall be admitted to an intensive isolation facility if breathless Artificial ventilator support needed in selected case Tamiflu should be started in all category B patients New vaccines have been produced but not currently available in India 28

29. Prevention of H1N1 Influenza Fever is considered more important Washing hands every time after seeing a patient Or ideally alcohol based hand washes should be used Wearing a mask effectively prevents transmission Patients also should be taught the same principles If you develop fever to stay at home till all the fever and symptoms have subsided 29

30. Lobar Pneumonia is recognized by the symptom triad and CXR High grade remittent fever, cough productive of sputum Laterally placed catching type of pleuritic pain Rusty Sputum or mild degree of frank hemoptysis Characteristic Air Bronchogram inside homogenous opacity Clarithromycin Or Azithromycin Or Levofloxacin 30

31. Acute Malaria is possible if patient has travelled outside Kerala: Intermittent high grade fever with chills and rigor Anemia jaundice and Moderate splenomegaly Peripheral smear –parasites with blue cytoplasm, red nucleus Rapid Malaria test – Highly sensitive and specific test Artesunate 50mg 4 TAB ODX3D + Metakelfen 3TAB Day 1 31

32. Acute Meningitis as a cause for Acute Febrile Illness: Bacterial or Viral origin can not be distinguished clinically Classical triad of symptoms of Meningitis Lumbar Puncture is done under asceptic caution after CT Meningitic Dose Ceftriaxone 2gm IV BID 10-14 days Signs of meningitis – neck stiffness, Kerning’s, Brudzinski 32

33. Diagnosis of Enteric Fever can be suspected from following: Step ladder fever manifest if the initial fever pattern is not altered by antibiotics Abdominal pain, diarrhoea vomiting and malena are characteristic of enteric Splenomegaly is usually mild to moderate along with mild hepatomegaly Single positive Widal Test is not diagnostic of enteric in endemic areas Blood/ Clot Culture for Salmonella Typhi if + ve is Proof of diagnosis 33

34. Urinary Tract Infection is managed in the following lines: Urinary Deposits will show pus cells and bacteria along with presence of albumin Urine Culture and sensitivity test should be done with mid-stream specimen Ciprofloxacin started and after C & S results changed to Sensitive Antibiotics Patients should be motivated to drink several liters of water every day Urinary Alkalinization Potassium citrate 2 tbs twice daily 34

35. Diagnosis of Brucellosis can be suspected from following: Contact with Animals like in farming or handling animal meat Drinking unpasteurized or raw milk gives a definite risk of developing Brucellosis Cervical lymphadenopathy & hepatosplenomegaly is highly suggestive Brucella Antibody Test is diagnostic otherwise demonstration in FNAC Streptomycin + Tetracycline In areas endemic for TB Other wise Rifampicin Brucella Antibody Test 35

36. Focal infections require appropriate radiological investigations: CXR is indicated in cases like suspected lung abscess bronchopneumonia Ultrasound Scan is very useful in detecting, liver and splenic abscess or PID Trans Thoracic Echo or better still TEE is helpful in detecting BE vegetations CT of abdomen is better for demonstrating retroperitoneal abscess MRI and MR Spectroscopy Can detect even small sized Brain Abscess & tuberculoma 36

37. Neuroleptic Malignant Syndrome occurs with intake of several drugs: Any drug which acts at the level of The Central Dopaminergic System There can be several autonomic symptoms like dry skin and dilated pupils Bromocryptine 2.5mg orally BD Titrated up to 45mg/D These are mainly the Antipsychotic drugs belonging to neuroleptics Hyperpyrexia is associated with severe extra-pyramidal lead pipe rigidity 37

38. Miscellaneous conditions presenting as Acute Febrile Illness: Scrub Typhus, a tick borne Acute Ricketsial Infection is suggested by an Eschar Temporal Arteritis and other collagen diseases like SLE can also present acutely Skin Infections like cellulitis , abscess and Varicella infections can cause AFI Acute Gout, septic arthritis and Acute Rheumatic fever DD of Acute Febrile Illness Pontine Hemorrhage Malignant Hyperthermia Heat Stroke, Thyroid storm 38

39. Summary: A patient with acute febrile illness should be always received with consideration and caution 90% of these patients will have an uneventful course, with complete resolution of fever The ability of the physician is in identifying those with potentially fatal complications These patients must be admitted to intensive care immediately and well cared for Serial physical examinations and investigations are sometimes more important Unexpected lab results must be cross checked and repeated when necessary Diagnosis should not be postulated too early in the course of the disease Empirical Antibiotic therapy is not to be withheld in life threatening situations 39

40. Thank You For The Patient Listening 40