Fevers

Fevers Definition* fever is elevation of the body temperature above

the average normal

- Normal: 36.5- 37.2c (98- 99f )

- Febrile ( Pyrexia ) above 37.2 c ( above 99f )

- Hyperpyrexia above 41.6 c ( above 107f )

- Subnormal below 36.5c ( below 98 f )

- Hypothermia below 35 c ( below 95 f )

Causes of fever

1-Infection .

2-Tissue trauma: crash injuries and fraction of bones.

3-Tissue destruction:myocardial infarction, and hemolytic anemia.

4-Neoplastic diseases.

5-Collagen diseases.

6-Disturbance of heat regulating center in the brain e.g head injury, sun stroke and cerebral hemorrhage.

7-Drug: belladonna, barbiturates

8-Serum sickness and other hypersensitivity states.

Types (Patterns of fever)

1-Contineuos (sustained ) fever: the temperature continues high for days or weeks with difference between morning and evening temperature about 0.5-1 C This type is seen in typhoid fever, pneumonia, meningitis and typhus.

2-Intermittent fever: the temperature falls to normal once or more during the day e.g. abscess, lymphomas and military tuberculosis.

3-Hectic fever: marked daily temperature swings usually associated with rigors & sweats e.g amebic liver abscess and pyogenic abscess.

4- Remittent fever: the temperature is always raised, but shows considerable variation between morning & evening temperature but not return to normal, as in :•Septic conditions - mycoplasma pneumonia•Rheumatic fever - Rheumatoid arthritis•SABE - Falciparum malaria

5-Saddle back ( Camel –backed) fever :

•Biphasic remittent fever.•A continous fever for a few days is followed by a remission and •A second bout of continous fever associated with appearance of rash and terminating by lysis.•Occur in Dengue fever.

6-Relapsing fever:

*Days with fever alternate with days of normal temperature e.g.

brucellosis (undulant fever), spirochetal relapsing fever, Charcot`s intermittent fever in biliary obstruction and malaria.

When a paroxysm of intermittent or relapse fever occurs:

*Daily, the type is quotidian,

*On alternate days, tertian,

*When 2 days intervene between consecutive attacks, quartan.

7-Factitious fevers:

- It is spurious temp. elevation produced by the pt.

-Not associated with organic disease. -Normal ESR. -Failure of pulse rate to rise with temp.

* Causes of Hyper-pyrexia:

1-Thyrotoxic crisis.

2-Status epilepticus.

3-Heat stroke.

4-Encephalitis.

5-Pontine hemorrhage

* Causes of Hypo-thermia:.

1-Shock.

2-Hypothyroidism.

3-Pan-hypopituitarism.

4-Starvation.

5-Old age.

Manifestations of fever1-Physiological response:-tachycardia.- Chills & rigors.- Each 1◦C increase in body temp. --- increase BMR by 8% . --- increase HR by 10 -15 beat/ min.- Respiratory alkalosis followed by metabolic acidosis.2- specific manifestations: -vague sense of warmth.-flushed or headache- Vague aching- Malaise, anorexia and wt loss

Salmonellosis

* Salmonellosis in Egypt present the form of :- 1- Typhoid &paratyphoid.

2-Chronic salmonellosis complicating Schistosoma infection. 3-Salmonella food poisoning (acute gastroenteritis).

Typhoid Fever & Paratyphoid fever

* Causative organism:*Salmonella typhi and salmonella paratyphoid A,B&C. *It is gram-negative motile bacilli.

* Source of infection :.

1-Patient.

2-Carrier (intestinal, gall bladder or unitary carrier).

* Mode of infection : 5F.

1-Food.

2-Flies.

3-Foments.

4-Feces.

5-Fingers.

* Pathology:.

After invasion of the intestinal mucosa, bacilli

first enter the mesenteric lymph glands through

Payer`s patches blood stream (bactermia)

then pass to other organs e.g liver, spleen and

reticule-endothelial system.

Clinical picture:.

IP:1-2 weeks.The disease passes into 4 stages.

[1] First week:.1-Temperature rise by steps (Ladder step manner) till

the temperature reach 39-40C.2-Headache.3-Pulse: is relatively slow.4-Tongue : coated and dry.5-Abdomen is tender and slightly distended.6-Diarrhea or more commonly constipation.7-Spleen is enlarged between the 7th and 10th days, it is

soft and tender.8-Bronchitis and Epistaxis are common.9- Rash in 10% of cases on the abdomen chest and

back as rosy red papules..

[II] Second week:-.1-Fever is high and continuos.2-Headache disappears3-Pulse is still relatively slow.4-Abdominal symptoms increase.5-Spleen is more enlarged.

[III]- Third week:.1-Temperature stars to drop, general condition and abdominal manifestations improve . or:2-Complications may occur.

[IV]- Fourth week :.1-Convalescence begins . or:2-Relapses may occur.

Investigations

1-Blood : Leucopenia with relative lymphocytosis.

2-Blood culture: Positive in the first week and rarely

later.

3-Stool culture: Positive from 2nd week till 4thwk.

4-Urine culture : Positive in 3rd week in 25% cases.

5-Widal agglutintion recation : positive from the 2nd

week on words, with gradual rising titer. It seems

unreliable

* Complications:[I]- General Complications:.

1-Relapses.

2-Typhoid abscesses.

3-Bed sores.

4-Otitis media.

5-Zenker`s degeneration of

muscle.

6-Severe dehydration of muscle.

7-Sever dehydration.

8-Severe mental confusion.

9-Deafness.

[II]- Medical Complications :-

1-Acute bronchitis is common.

2-Typhoid lobar pneumonia: present with the typical symptoms and signs of lobar pneumonia except that rusty sputum is uncommon and the white blood cell count is low.

3-Myocarditis is common particularly in very toxic patients.

4-Typhoid meningitis is rare and must not be confused with meningism, which is common, chloramphenicol diffuse well into the cerebrospinal fluid, so it gives good results.

5-Mild hemolytic anemia is common in the very toxic typhoid patients. It should be treated with prednisone.

6-Peripheral neuritis may occur, it should be treated with large doses of Vitamin B complex, and this Vitamin should be given routinely in typhoid fever as a prophylactic measure.

7-Febrile albuminuria is common, but a true acute typhoid nephritis is rare.

[III]- Surgical Complications:

1-Acute parotitis: is a dangerous complication and pus

should be drained by transverse incision under local

anaesthetic as early as possible.

2-Intestinal perforation: -This is one of the most serious

complications of typhoid fever, it occurs during the third week of

illness but may occur before.

3-Intestinal Hemorrhage: is a lethal complication which

usually occurs 2-3 weeks after the onset of the illness, the

patient may show massive hemorrhage, which is

manifested by shock and very pale conjunctiva, or small

bleeding.

4-Typhoid Cholecystitis : Occur more frequent in female more than male.

5 -Paralytic ileus : may be secondary to perforation or to severe toxemia.6-Intestinal obstruction: may be due to a localized abscess or adhesions.7-Typhoid orchitis.8-Typhoid Arthritis and osteomyelitis.

* Differential Diagnosis. From prolonged fevers.

Treatment1-Prophylactic:-1)- Control of food, milk and water with anti-fly measures.2)Isolation of patients until stool and urine are negative for 3 successive cultures.3)Carriers : Treated by chloramphenicol or Ampicillin with or without cholecystectomy.

4)-Vaccination : by T.A.B. vaccine, 0.5 - 0.75 then 1.0 cc. Is given subcutaneous at one week intervals to childern, contact and during epidemics. Booster doses are given every year as 0.5 cc.

II-Curative:.1)-General lines of treatment:-

a-Rest in bed.b-Well balanced diet.c-Adequate fluid.

2)-Specific treatment:.a-Chloramphenicol 50mg/kg body weight/day is given orally divided into 4 doses given every 6 hours until fever disappear then given ½ the dose for 2 weeks.

b-Amoxycillin a semi-synthetic penicillin resembling ampicillin, in a dose of 100mg/kg given in 4 equal doses and continued for 10 days after fever stop.

c-Ampicillin

is given orally in a dose of 100mg/kg day. The total daily dose is divided into 4 equal parts and given at 6 hourly intervals. Continued for at least 10 days after stop.

d- Quinolone group : ciprofloxacin , ofloxacin twice /day for 10 days.

e-cefotriaxone 2 gm /d for 7 days.

Brucellosis(Malta Fever or Undulant fever)

Classic zoonotic disease of worldwide distribution* Etiology :.*Causative organism.

-Brucella melitensis in sheep.-Brucella abortus in cows.-Brucella suis in pigs.

*Mode of Infection :-1-Drinking milk of infected animals.2-Through skin during dealing with aborted animals, infected milk or infected meat.

* Clinical picture:.1-Incubation period: 1-3 weeks.2-Onset: gradual with malaise & muscular pains.3-Constitutional symptoms: profuse sweating, muscular pain, headache, joint pain and backache.4-Pulse: relative slow.5-Fever: reach 39-40 c. for 1-3 weeks then apyrexia for 10 days then relapse and so on (undulant fever).

6-G.I.T : Nausea, vomiting & constipation.

7-Enlarged spleen is present in almost half

the patients the spleen is tender and firm

and usually mild enlarged.

8-Lymph nodes : in 50% of cases there is

generalized enlargement, especially the

cervical and axillary lymph nodes.

* Investigations:

1-Blood culture : positive in the 1st week.

2-Blood count: Leucopenia with relative lymphocytosis or monocytosis.

3-Agglutination test: Positive from 2nd week titer over 1/100 or rising titer is diagnostic.

4-Complement fixation :To measure IgG antibodies.

5-Radio-immuno assay to determine the levels of specific anti-Brucella IgM, IgG & IgA.6-Brucellin intradermal test : it is delayed hypersensitivity reaction. Positive reaction

denotes past or present infection, it useful in epidemiological study and negative reaction

exclude infection.

•Complications :.1-Bone and joint complications:

(a) Brucella spondylitis : Where bone and discs are invaded causing osteomyelitis with destruction of bone giving picture similar to disc prolapse .

(b) Suppuration of large joint.(c) Osteomyelitis of long bone.2-Cardiovascular complication:Bacterial endocarditis usually

develops on a congenital or acquired valvular lesion.

3-Hepatic complication:.a-Jaundice.b-Liver cell failure.c-Cirrhosis.

4-genito-urinary complications.a-Orchitis.b-Epididymitis.c-Chronic pyeloneonephritis.

5-Nervous complications:.a-Meningitis.b-Encephalitisc-Myelitis.d-Paraplegia.

e-Aphasia.f-Dysarthria.g-Visual disorders.h-Deafness.

Treatment :.1-Rest in bed, well balanced diet.

2-Symptomatic ttt:Antipyretics and analgesics.

3-Tetracycline : 50 mg/kg /day in divided

dose/4 hours for 3 weeks oral or IM.

4-Streptomycin :

a-Streptomycin 1 gm I. M. daily for 3

weeks.

5- Rifampicin 600 mg/12 h for 3 w

CHOLERADefinition :.An acute infectious disease of man caused by vibrio cholera, characterized by severe painless diarrhea, vomiting, muscular cramps, dehydration and collapse.

Clinical picture:.Incubation period: 1-5 days.

1-Stage of diarrhea:.a-Abrupt onset of severe diarrhea where large amount of fluid are painlessly poured out. The stool are clear or consist of opaque white watery fluid with floating mucus resembling rice-

water in appearance . It is odorless or has fish smell.

b-Vomiting starts after the diarrhea, buttery be absent in 20% of cases.

c-Striated muscle cramps and Tetanic spasm may occur.

d-Signs of dehydration appear when the fluid loss corresponds to 6% of the body weigh. The patients has a pinched face, sunken eyes. • He is apathetic, thirsty and speaks in a husky voice .

* The abdomen is soft and not tender with impaired skin elasticity.

2- Stage of collapse* The patients passes into a stage of

circulatory collapse with :-a-Weak pulse.b-Decrease blood pressure.c-Decrease surface temperature.d-Cyanosis .e-Oliguria.

f-Patient is conscious, but may be drowsy and acidotic.

3- Stage of recovery:-The disease is self-limiting, where rapid improvement occurs and consciousness - normal, skin becomes warm and stool less frequent.-In sever cases, anuria and death may occur.

DiagnosisCholera should be suspected in any acute case of dehydrating diarrhea or gastroenteritis occurring in an endemic area.

-The final diagnosis is made up after:

a)-Dark-field microscopy.

b)-Fluorescent antibody technique.

c)-Isolation of vibrios in specific

culture e.g in TCBs agar

(thiosulphate-citrate-bile salts -

sucrose agar).

Treatment:-

1-Treatment of Dehydration & Acidosis:

a)Intravenous route:-

-A liter of isotonic saline + ½liter of 1/6 molar sodium lactate. They repeated if needed in the same ratio 2:1 -Ringer lactate solution (Hartmann`s solution).

-Dacca solution (5-4-1) per liter (5gm NaCl- 4gm NaHCO3 -1gm KCI) per liter.The rate of intravenous infusion is 100ml/min in adults till a strong radial pulse is restored, then decrease to the equal to intestinal fluid loss.

• b) Oral route :• In patients with no vomiting UNICFE packets

my be used NaCl-NaHCO3-KCI-Glucose which contain:

(3- 5gm-2 gm-120gm.)

2-Antimicrobial drugs:-a-Tetracycline 10 mg/kg/ 6 hours for 2-3

days.b-Chloramphenicol 10 mg/kg/6 hours for

2-3 days.c-Doxycycline in a single dose of 300 mg is

effective as tetracycline.(drug of choice except in pregnant women)d-Combination of trimethoprim + sulphamethoxazole (Co-Trimoxazoles) in a dose of 2 tables /12 hours.