Diseases » Dengue hemorrhagic fever » Causes

Causes of Dengue hemorrhagic fever

List of causes of Dengue hemorrhagic fever

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Dengue hemorrhagic fever) that could possibly cause Dengue hemorrhagic fever includes:

• Dengue

Dengue hemorrhagic fever Causes: Book Excerpts

• Differential Diagnosis - Fever
• Differential Diagnosis - Purpura
• Differential Diagnosis - Rash with Fever
• Differential Diagnosis - Purpura
• Differential Diagnosis - Fever – Cyclic
• Differential Diagnosis - Fever – Recurrent
• Differential Diagnosis - Fever – Unknown Origin
• Differential Diagnosis - Fever – Acute
• Medical causes - Fever
• Medical causes - Purpura
• Causes and incidence - Allergic purpuras
• Causes and incidence - Colorado tick fever
• Causes and incidence - Idiopathic thrombocytopenic purpura
• Causes and incidence - Lassa fever
• Causes and incidence - Relapsing fever
• Causes and incidence - Rheumatic fever and rheumatic heart disease
• Causes and incidence - Rocky Mountain spotted fever
• Medical causes - Purpura
• Medical causes - Fever [Pyrexia]
• Differential Overview - Purpura/Petechiae/Excessive Bleeding
• Differential Overview - Fever of Unknown Origin
• Causes - Allergic purpura
• Causes - Idiopathic thrombocytopenic purpura
• Causes - Rheumatic fever and rheumatic heart disease
• Medical causes - Fever
• Medical causes - Fever
• Medical causes - Purpura
• Principal Causes of Acute Fever - Fever
• Principal Causes of Purpura and Bleeding - Purpura and Bleeding
• Medical causes - Purpura
• Medical causes - Fever [Pyrexia]

Dengue hemorrhagic fever as a complication of other conditions:

Other conditions that might have Dengue hemorrhagic fever as a complication may, potentially, be an underlying cause of Dengue hemorrhagic fever. Our database lists the following as having Dengue hemorrhagic fever as a complication of that condition:

• Dengue fever

What causes Dengue hemorrhagic fever?

Causes: Dengue hemorrhagic fever: Dengue and dengue hemorrhagic fever (DHF) are caused by one of four closely related, but antigenically distinct, virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4), of the genus Flavivirus. Infection with one of these serotypes does not provide cross-protective immunity, so persons living in a dengue-endemic area can have four dengue infections during their lifetimes. (Source: excerpt from CDC Dengue Fever Home Page: DVBID)

Related information on causes of Dengue hemorrhagic fever:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Dengue hemorrhagic fever may be found in:

• Contagiousness for Dengue hemorrhagic fever
• Hidden causes of Dengue hemorrhagic fever

Causes of Dengue hemorrhagic fever: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Dengue hemorrhagic fever.

Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Infection is the most common cause
  –Viral (e.g., influenza, HIV, hepatitis, herpes simplex encephalitis, mononucleosis, adenovirus)
  –Bacterial (e.g., pneumonia, endocarditis, tuberculosis, meningitis, pyelonephritis, appendicitis, cholecystitis, cellulitis)
  –Lyme disease
  –Malaria
  –Syphilis
  –Tularemia
  –Intra-abdominal abscess

• Malignancy
  –Lymphoma (Hodgkin's and non-Hodgkin's)
  –Lymphoproliferative disorders
  –Renal cell carcinoma
  –Leukemia
  –Hepatocellular carcinoma
• Rheumatologic disorders
  –Temporal arteritis/giant cell arteritis
  –Adult-onset Still's disease
  –Systemic lupus erythematosus
  –Sarcoidosis
  –Rheumatoid arthritis
• Drug fever
  –Often temporally associated with the initiation of a new medicine
  –Often associated with a rash (biopsy reveals leukocytoclastic vasculitis)
  –Eosinophilia is common

• Pulmonary embolism
  –Mild fever is often present
  –Other findings of thromboembolic disease (e.g., leg swelling, dyspnea) may be present

Osteomyelitis

Occult abscess

Malignant hypothermia

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Purpura: Differential Diagnosis
(In a Page: Signs and Symptoms)

Palpable purpura (papules or nodules that are red/purple and do not blanch with pressure)

• Leukocytoclastic Vasculitis
  –A necrotizing vasculitis of small vessels
  –Fever, malaise, fatigue and arthralgias
  –Inciting factors include drugs (e.g., NSAIDs, thaizides, and phenothiazines), infection [bacterial (e.g., RMSF, meningococcemia) or viral (e.g., hepatitis)] or, blood abnormalities (e.g., cryoglobulinemia, cryofibrinogenemia)
  –Vasculitic injury to kidneys, brain, lung, heart, and GI tract may occur

• Collagen vascular diseases
  –Systemic lupus erythematosus, Sjögren's syndrome, rheumatoid arthritis
• Granulomatous vasculitis (e.g., Wegener's, Churg-Strauss syndrome)
• Polyarteritis nodosa
• Internal malignancies
  –Myeloma, lymphoma, or leukemia
• Henoch-Schönlein purpura

• Drugs
  –Aspirin, NSAIDs, warfarin, heparin
• Nonpalpable purpura (flat macules, patches
  similar to ecchymoses; or petechiae that do not blanch with pressure)
• Trauma
• Advancing age (senile purpura)
• Actinic changes
• Chronic stasis
• Coagulopathies (affecting platelet number or function)
  –TTP (pentad of fever, microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, and neurologic signs)
  –ITP
  –Drug-induced thrombocytopenia
  –Bacteremia and many viral diseases

• Scurvy (vitamin C deficiency) can cause hemorrhage and purpura
• TORCH infection can cause congenital purpura (“blueberry muffin baby”)
• Many systemic diseases (e.g., Cushing's and diabetes have associated nonpalpable purpura)

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Source: In a Page: Signs and Symptoms, 2004

Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Viral exanthems
  –Leading cause of fever and rash in childhood
  –Most children present with low-grade fevers, viral prodromal symptoms, and a secondary diffuse exanthem that is usually nonspecific and morbilliform
  –Often last only a few days and requires only supportive management
• Drug reactions
  –Account for a large portion of rashes with associated fever
  –Immune complex disease or serum sickness has been reported with many medications
• Meningococcemia
  –Most common under age 1
  –After a brief prodrome; onset is abrupt with spiking fevers, diffuse purpuric lesions, delirium, and death
  –DIC and purpura fulminans with secondary necrosis of digits and limbs can occur

• Rocky Mountain Spotted Fever
  –A fulminant and deadly rickettsial disease transmitted by a tick bite
  –Only 60% of patients are aware of tick bite
  –Characteristic rash starts acrally on wrists and ankles and spreads toward the trunk
  –Initially, pink macules evolve over 10–24 hours into red papules, then purpuric macules and violaceous patches involving most of the body surface area
  –Necrosis and DIC may occur
• Toxic shock syndrome, Staphylococcus aureus, and streptococcal diseases
  –Most cases due to toxin production
  –Rapid onset of fever, hypotension with generalized skin (palms and soles common) and mucous membrane erythema (“erythroderma” in case definition), and subsequent multiorgan failure
  –Palmar/solar desquamation in 1–3 weeks
  –A morbilliform rash and skin “pain” or hyperesthesia is common
  –Nonsurgical and surgical wounds are often the source of infection in the more common nonmenstrual variant of TSS

• Fifth disease
• Measles
• Rubella
• Parvovirus
• Varicella

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Purpura: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Vasculitis (palpable purpura)
  –HSP: Most common vasculitis, incidence: 0.01%, in 50% follows URI; other triggers are bacterial infection, drugs, vaccines, food, insect bites; lasts 1–2 weeks, age 2–8 (mean 4 years), M > F, IgA-mediated, small vessels
  –Polyarteritis nodosa (PAN), Wegener granulomatosis (WG): Rare in children

• Hematologic
  –ITP: Age 1–5 years; autoantibodies against platelets (platelets destroyed by splenic macrophages); usually 1–6 weeks after viral infection; 70–80% acute self-limited; 10–20% chronic recurrent; <1% associated with intracranial hemorrhage
  –Other causes of thrombocytopenia: Wiscott-Aldrich syndrome, aplastic anemia, leukemia, disseminated intravascular coagulation (DIC), thrombocytopenia absent radius (TAR)

• Coagulation factor deficiencies:
  –Hemophilia A/B (factors VIII/XI): A (1/7,500 male births) four times more common than B; X-linked recessive
  –vWD: Prevalence 1%, autosomal dominant, vW factor deficiency or decreased function
  –Liver disease: Decreased production of coagulation factors
  –Hemorrhagic disease of the newborn: Decreased vitamin K-dependent coagulation factors (II, VII, IX, X)

• Infections
  –Bacterial/rickettsial: Meningococcemia (MC), Group A strep (scarlet fever), Streptococcus viridans/Staphylococcus aureus (endocarditis), Gonococcus (disseminated), Leptospirosis, Rickettsia rickettsii (Rocky Mountain spotted fever), R. prowazekii (epidemic typhus), Ehrlichiosis
  –Viral: Hepatitis B, Dengue hemorrhagic fever, atypical measles

• Drugs: Coumadin, heparin, aspirin, thiazide, corticosteroids, penicillins, sulfonamides
• Others: Trauma/abuse, scurvy (vitamin C deficiency)

>

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Fever – Cyclic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• PFAPA, or Marshall syndrome
  –Periodic fever (usually high, 104°F [40°C]), aphthous stomatitis, pharyngitis, and adenitis
  –Most common diagnosis for true cyclic fever, usually in children <5 years
  –Recurs every 3–4 weeks
• Cyclic neutropenia
  –Periodic fever, average cycle of 21 days
  –Pharyngitis, mouth ulcers, and lymphadenopathy are also noted
  –May not be associated with infection
• Infectious diseases
  –Relapsing fever due to Borrelia recurrentis,
  relapses every 10–14 days
  –EBV may occur at 6–8 week intervals
• Familial Mediterranean fever
  –Brief attacks of fever and serositis
  –Autosomal recessive disease
  –Sephardic Jews, Arabs, Turks, and Armenians commonly affected
  –50% have onset before 10 years of age
  –May occur in regular 7–28-day intervals
  –Amyloidosis is a possible complication
• Hyper-IgD and periodic fever syndrome (HIDS)
  –High fevers, abdominal pain, cervical lymphadenopathy, sometimes diarrhea and arthritis, in early infancy
  –Autosomal recessive, most patients from Western Europe (French, Dutch)
  –Cycles may be regular every 14–28 days
  • TNF-receptor-associated periodic syndrome (TRAPS) or Hibernian fever
    –Fever, myalgias with migratory pattern, conjunctivitis and rash
    –Autosomal dominant
    –first described in Irish/Scottish individuals but other ethnic groups involved
    –Amyloidosis is a possible complication (25% of untreated individuals)
  • Familial cold autoinflammatory syndrome or familial cold urticaria
    –Rash, fever, arthralgia, and conjunctivitis
    –Precipitated by exposure to cold
  • Factitious fever
  >

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Fever – Recurrent: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Repeated viral infections
  –Most common cause of recurrent febrile episodes in childhood
  –Start of day care or change of geographic location may be related
• Urinary tract infection (UTI)
  –May be self-limited but recur especially if underlying anomaly exists
• Epstein-Barr virus (EBV)
  –May present with recurrent febrile episodes due to one initial infection
• Other specific viral syndromes
  –Parvovirus B19
  –CMV
• Immunodeficiency
  –Repeated bacterial infections should lead to investigation of immune status
• Dental abscess (non-dental abscesses typically present with prolonged daily fever)
• Chronic meningococcemia
• Acute rheumatic fever
• Inflammatory bowel disease (IBD)
• Juvenile rheumatoid arthritis (JRA)
• Behçet disease
• Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) or Hibernian Fever
  –Autosomal dominant disease with fever, myalgias with migratory pattern, conjunctivitis and rash
• Familial cold autoinflammatory syndrome or familial cold urticaria
  –Rash, fever, arthralgia, and conjunctivitis
  –Precipitated by exposure to cold
• Muckle-Wells syndrome
  –Similar presentation to familial cold urticaria
  –Symptoms not triggered by cold
• Brucellosis
  –Most prevalent around the Mediterranean and Arabic countries, also present in South America and India
• Yersiniosis
• Typhoid fever
• Rat-bite fever
• Malaria
• Factitious fever

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Fever – Unknown Origin: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infections (40%)
  –Infectious mononucleosis (EBV, CMV)
  –Other systemic viral syndromes (e.g., HIV)
  –UTI (e.g., E. coli)
  –Osteomyelitis (e.g., staphylococcus)
  –Upper and lower respiratory infections (sinusitis, mastoiditis, pneumonia)
  –Cat-scratch disease (Bartonella henselae)
  –Tuberculosis, nontuberculous mycobacterial infections
  –Abscess (abdominal or retroperitoneal)
  –CNS infections
  –Endocarditis (subacute)
  –Salmonellosis
  –Lyme disease (Borrelia burgdorferi)
  –Leptospirosis
  –Congenital syphilis
  –Others: Brucellosis, histoplasmosis, leishmaniasis, yersiniosis, Q fever (Coxiella burnetii), Rocky Mountain spotted fever (Rickettsia rickettsii)

• Autoimmune diseases (15%)
  –Rheumatoid arthritis accounts for 3/4 of FUO due to autoimmune diseases
  –Systemic lupus erythematosus
  –Rheumatic fever
  –Vasculitis (e.g., HSP)
  –Sarcoidosis
• Neoplastic diseases (7%)
  –Leukemia/lymphoma accounts for 80% of
  FUO due to malignancies
  –Neuroblastoma
  –Hepatoma
  –Soft tissue sarcoma
• Inflammatory bowel disease (3%)
• Drugs and nutritional supplements (drug fever)
• Factitious fever
• Munchausen by proxy
• Neurologic disorders
  –Familial dysautonomia
  –Central thermoregulatory disorder
  –Head injury
• Hyperthyroidism
• Anhidrotic ectodermal dysplasia
• Diabetes insipidus
• Kikuchi disease

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Fever – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Viral infections
  –Account for the majority of febrile illnesses (FI) in infancy and childhood
  –Upper respiratory infections (e.g., parainfluenza virus)
  –Lower respiratory infections (e.g., RSV)
  –Non-bacterial gastroenteritis (e.g., rotavirus)
  –Aseptic meningitis (e.g., enterovirus)
• Bacterial infections
  –UTIs account for 1.7% of FI in children 5 years and 7.5% in infants <8 weeks
  –Pneumonia (e.g., group A streptococcus)
  –Bacteremia (2% of FI in all children, highest rates seen in younger infants)
  –Meningitis (0.8% of FI in all children)
  –In febrile neonates, the overall rate of serious bacterial infections (SBI) is ~13%
• Vaccine reaction
  • Collagen vascular diseases
    –Kawasaki disease: 3,000 cases per year in the U.S., rates higher in Asia, 80% of cases occur in children <5 years
    –Henoch-Schönlein purpura: Low-grade fever is present in 50% of cases
    –Juvenile rheumatoid arthritis: Incidence 1/10,000
    –SLE
    –Acute rheumatic fever
  • Malignancy
    –Leukemia: Most common childhood malignancy; early symptoms include fever, fatigue, pallor, anemia, bone pain
    –Lymphoma
    –Solid tumors (neuroblastoma, sarcoma)
  • Inflammatory bowel disease
    –Diarrhea, pain, fever, blood loss
    –Crohn disease, ulcerative colitis
  • Tissue injury (trauma, hematoma, burns)
  • Drug reaction
  • Biologic agents (blood products, gamma-globulin)
  • Endocrinologic disorders
    –Thyrotoxicosis
    –Pheochromocytoma
  • Genetic diseases
    –Familial Mediterranean fever
  • Factitious fever
  >>

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Fever: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anthrax, cutaneous

The patient may experience a fever along with lymphadenopathy, malaise, and a headache. After the bacterium

Bacillus anthracisenters a cut or abrasion on the skin, the infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center

Anthrax, GI

Following the ingestion of contaminated meat from an animal infected with the bacterium

B. anthracis,the patient experiences a fever, a loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis

Anthrax, inhalation

 The initial signs and symptoms of inhalation anthrax are flulike, including a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours

Escherichia coli O157:H7

 A fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

When present, a fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), a fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include a headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome)

Infectious and inflammatory disorders

A fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or

Ebola or

Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. A fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, a fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Listeriosis

Signs and symptoms of listeriosis include a fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include a fever, a headache, nuchal rigidity, and a change in the LOC

Gender cue

Infections during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Neoplasms

Primary neoplasms and metastases can produce a prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with a low-grade fever, pallor, and bleeding tendencies or more abruptly with a high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces an undulant fever or Pel-Ebstein fever, an irregularly relapsing fever

In addition to a fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

Yersinia pestis

The bubonic form of plague(transmitted to man when bitten by infected fleas) causes a fever, chills, and swollen, inflamed, and tender lymph nodes near the bite site. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, a fever, a headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency

Q fever

Q fever is a rickettsial disease that’s caused by the infection of

Coxiella burnetii

It causes a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis

 Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms that include a fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream

Rift Valley fever

Typical signs and symptoms of Rift Valley fever include a fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have been documented in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other signs and symptoms include a headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death

Smallpox (variola major)

Initial signs and symptoms of smallpoxinclude a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection

Thermoregulatory dysfunction

Thermoregulatory dysfunction is marked by a sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C). It occurs in such life-threatening disorders as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia and in lesions of the central nervous system (CNS). A low or moderate fever appears in dehydrated patients

A prolonged high fever commonly produces vomiting, anhidrosis, a decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes, such as dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (a decreased LOC with bradycardia, a widened pulse pressure, and an increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Tularemia, also known as rabbit fever, causes an abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema

Typhus

Typhus is a rickettsial disease in which the patient initially experiences a headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of a fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases

West Nile encephalitis

West Nile encephalitis is a brain infection caused by West Nile virus — a mosquito-borne flavivirus that’s commonly found in Africa, West Asia, and the Middle East and rarely in North America. Mild infection is common; signs and symptoms include a fever, a headache, and body aches, usually with skin rash and swollen lymph glands. More severe infection is marked by a high fever, a headache, neck stiffness, stupor, disorientation, coma, tremors, occasional convulsions, paralysis and, rarely, death

Other causes

Diagnostic tests

Immediate or delayed fever infrequently follows radiographic tests that use contrast medium

Drugs

A fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. A fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. A fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments

Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of a fever and chills

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Purpura: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Autoerythrocyte sensitivity

With autoerythrocyte sensitivity, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, a headache, and chest pain are also common.

Disseminated intravascular coagulation (DIC)

DIC can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs. Or, he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis such as oliguria.

Dysproteinemias

With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and a low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.

Easy bruising syndrome

Easy bruising syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.

Ehlers-Danlos syndrome (EDS)

Besides petechiae, EDS is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.

Idiopathic thrombocytopenic purpura (ITP)

Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.

Leukemia

Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.

Acute leukemias also produce severe prostration and a high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, a headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, a low-grade fever, anorexia, and weight loss.

Myeloproliferative disorders

Myeloproliferative disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of a headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.

Systemic lupus erythematosus (SLE)

SLE is a chronic inflammatory disorder that may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, a fever, anorexia, weight loss, and lymphadenopathy.

Thrombotic thrombocytopenic purpura

Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in thrombotic thrombocytopenic purpura. Most patients have a fever, and some also experience fatigue, weakness, a headache, nausea, abdominal pain, arthralgia, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and an altered level of consciousness. Renal failure may also occur.

Trauma

Traumatic injury can cause local or widespread purpura.

Other causes

Diagnostic tests

Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.

Drugs

The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric and then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.

Surgery and other procedures

Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and the use of plasma expanders such as dextran.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Allergic purpuras: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The most common identifiable cause of allergic purpura is probably an autoimmune reaction directed against vascular walls, triggered by a bacterial infection (particularly streptococcal infection). Typically, upper respiratory tract infection occurs 1 to 3 weeks before the onset of symptoms. Other possible causes include allergic reactions to some drugs and vaccines, to insect bites, and to some foods (such as wheat, eggs, milk, and chocolate).

Allergic purpura affects more males than females and is most prevalent in children ages 3 to 7. The prognosis is more favorable for children than adults.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Colorado tick fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Colorado tick fever is transmitted to humans by a hard-shelled wood tick called Dermacentor andersoni. The adult tick acquires the virus when it bites infected rodents and remains permanently infective.

Incidence is high in Colorado, where up to 15% of people who regularly camp show past exposure. It's much less common in the rest of the United States.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Idiopathic thrombocytopenic purpura: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

ITP may be an autoimmune disorder, because antibodies that reduce the life span of platelets have been found in nearly all patients. The spleen probably helps to remove platelets modified by the antibody. Acute ITP usually follows a viral infection, such as rubella or chickenpox, and can follow immunization with a live virus vaccine. Chronic ITP seldom follows infection and is commonly linked to immunologic disorders such as systemic lupus erythematosus. It’s also linked to drug reactions. ITP frequently occurs in patients who have abused alcohol, heroin, or morphine, and in patients with acquired immunodeficiency syndrome who are exposed to the rubella virus.

Acute ITP usually affects children between ages 2 and 6; chronic ITP mainly affects adults younger than age 50, especially women between ages 20 and 40.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Lassa fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

A chronic infection in rodents, Lassa virus is transmitted to humans by contact with infected rodent urine, feces, and saliva. The virus enters the bloodstream, lymph vessels, and respiratory and digestive tracts. It then multiplies in the cells of the reticuloendothelial system. In the early stages of this illness, when the virus is in the throat, human transmission may occur through inhalation of infected droplets.

As many as 100 cases of Lassa fever occur annually in western Africa; the disease is rare in the United States.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Relapsing fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The body louse (Pediculus humanus corporis) carries louse-borne relapsing fever (B. recurrentis), which typically occurs in epidemics during wars, famines, and mass migrations. Cold weather and crowded living conditions also favor the spread of body lice.

Inoculation takes place when the victim crushes the louse, causing its infected blood or body fluid to soak into the victim's bitten or abraded skin or mucous membranes.

Louse-borne relapsing fever is most common in North and Central Africa, Europe, Asia, and South America. No cases of louse-borne relapsing fever have been reported in the United States since 1900.

Tick-borne relapsing fever, however, is found in the United States and is caused by at least 15 Borrelia species; the three species most commonly identified with tick carriers are B. hermsii (associated with Ornithodoros hermsi), B. turicatae (associated with O. turicata), and B. parkeri (associated with O. parkeri). This form of the disease is most prevalent in Texas and other western states, usually during the summer when ticks and their hosts (chipmunks, goats, squirrels, rabbits, mice, rats, owls, lizards, and prairie dogs) are most active. In the colder weather, outbreaks sometimes afflict people such as campers who sleep in tick-infested cabins.

Because tick bites are virtually painless and most Ornithodoros ticks feed at night but don’t imbed themselves in the victim’s skin, many people are bitten unknowingly.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Rheumatic fever and rheumatic heart disease: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Rheumatic fever appears to be a hypersensitivity reaction to a group A beta-hemolytic streptococcal infection, in which antibodies manufactured to combat streptococci react and produce characteristic lesions at specific tissue sites, especially in the heart and joints. Because very few persons (3%) with streptococcal infections ever contract rheumatic fever, altered host resistance must be involved in its development or recurrence. Although rheumatic fever tends to be familial, this may merely reflect contributing environmental factors. For example, in lower socioeconomic groups, incidence is highest in children between ages 5 and 15, probably as a result of malnutrition and crowded living conditions. This disease strikes generally during cool, damp weather in the winter and early spring. In the United States, it’s most common in the northern states.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Rocky Mountain spotted fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

R. rickettsii is transmitted to a human or small animal by the prolonged bite (4 to 6 hours) of an adult tick — the wood tick (Dermacentor andersoni) in the west and by the dog tick (Dermacentor variabilis) in the east. Occasionally, it's acquired through inhalation (it can occur in laboratory settings where aerosolization of blood and specimens may occur) or through the contact of abraded skin with tick excreta or tissue juices. (This explains why people should'nt crush ticks between their fingers when removing them from other people and animals.) In most tick-infested areas, 1% to 5% of the ticks harbor R. rickettsii.

Endemic throughout the continental United States, RMSF is particularly prevalent in the southeast and southwest. Because RMSF is associated with outdoor activities, such as camping and backpacking, the incidence of this illness is usually higher in the spring and summer. Epidemiologic surveillance reports for RMSF indicate that the incidence is also higher in children ages 5 to 9, men and boys, and whites.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Purpura: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyloidosis

This disorder produces purpura that appears either spontaneously on dependent areas of the skin or following minor trauma, coughing, or straining. The eyelids and mucous membranes are commonly affected.

Autoerythrocyte sensitivity

With this syndrome, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, headache, and chest pain are also common.

Cholesterol emboli

Purpura due to cholesterol emboli are most commonly found in the lower extremities of patient with atherosclerotic vascular disease and usually occur after anticoagulation therapy or an invasive arterial procedure such as angiogram or cardiac catheterization but may occur spontaneously. Associated findings include livedo reticularis, cyanosis, gangrene, nodules and ulceration of the skin.

Dermatoses (pigmented)

This group of disorders, thought to result from chronic stasis, produces benign, chronic purpura, mainly on dependent areas.

Disseminated intravascular coagulation

This disorder can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs, or he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis, such as oliguria.

Dysproteinemias

With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.

Easy bruising syndrome

This syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.

Ehlers-Danlos syndrome (EDS)

Besides petechiae, this syndrome is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.

Fat emboli

Petechiae that occur on the upper body a few days after a major injury are caused by fat emboli.

Idiopathic thrombocytopenic purpura (ITP)

Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.

Leukemia

This disease produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.

Acute leukemias also produce severe prostration and high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, low-grade fever, anorexia, and weight loss.

Liver disease

Liver disease may cause purpura, particularly ecchymoses, and other bleeding tendencies. Associated findings include hepatomegaly, ascites, right-upper-quadrant pain, jaundice, nausea, vomiting, and anorexia.

Lymphomas

T-cell (Hodgkin’s) lymphomas initially may produce erythematous patches with some scaling. These lesions, which may be psoriasiform or parapsoriasiform, then become interspersed with nodules. Pruritus and discomfort are common. Later, tumors and ulcerations form, and nontender lymphadenopathy develops.

B-cell (non-Hodgkin’s) lymphoma may produce a scaling dermatitis with pruritus, which usually begins on the legs and then affects the entire body. Small pink-to-brown nodules and diffuse pigmentation also occur. B-cell lymphomas typically produce painless peripheral lymphadenopathy, usually affecting the cervical nodes first. Other findings in both types of lymphoma include fever, fatigue, malaise, weight loss, and hepatosplenomegaly.

Meningococcemia

Transmitted by droplet inhalation, it’s most common in children and caused by Neisseria meningitidis. Cutaneous and oropharyngeal petechia and purpura are initially discrete but become confluent, developing into hemorrhagic bullae and ulcerations. Fulminant infection results in extensive purpura and ecchymosis with irregular borders (purpura fulminans) most notably on the extremities. These lesions may develop necrotic centers. This disease is usually fatal if not recognized and treated early. Prognosis is poor when purpura or ecchymosis is present at the time of diagnosis. Associated symptoms include spiking fevers, chills, myalgia and arthralgia, and recent upper respiratory tract infection. Rapid progression of symptoms leads to headache, neck stiffness and nuchal rigidity. Septic shock ensues within hours on onset of symptoms with altered mental status and hypotension.

Myeloproliferative disorders

These disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.

Nutritional deficiencies

With vitamin C deficiency (scurvy), the characteristic pattern of purpura is perifollicular petechiae, which coalesce to form ecchymoses, in the “saddle area” of the thighs and buttocks. Additional hemorrhaging occurs in arm and leg muscles (with phlebothrombosis), viscera, joints (with limb and joint pain), and nail beds. Related findings include scaly dermatitis; pallor; tender, swollen, bleeding gums and loosened teeth; dry mouth; and poor wound healing. Nonspecific symptoms include weakness, lethargy, and anorexia. Irritability, depression, insomnia, and hysteria may also develop.

Vitamin K deficiency produces abnormal bleeding tendencies, such as ecchymosis, gum bleeding, epistaxis, hematuria, and GI and intracranial bleeding.

Vitamin B₁₂ deficiency can cause varying degrees of purpura. GI findings include anorexia, nausea, vomiting, weight loss, abdominal discomfort, and jaundice. Dyspnea, peripheral neuropathies, ataxia, glossitis and, occasionally, depression also occur.

Folic acid deficiency also can cause varying degrees of purpura. The patient may be irritable and forgetful and complain of fatigue, weakness, dyspnea, palpitations, nausea, anorexia, headaches, and fainting spells. Additional findings include pallor, slight jaundice, and glossitis.

Rocky Mountain spotted fever

This illness is contracted through the bite of an infected tick and is most common among children between ages 5 and 10. Initial skin lesions are small pink macules that evolve into blatant petechia and palpable purpura. Hemorrhagic macules may develop. The palms and soles are particularly affected. Extensive cutaneous necrosis occurs due to disseminated intravascular coagulation in a small percentage of patients experiencing gangrene of the extremities, necessitating amputation. Associated signs and symptoms include fever, severe headache, generalized myalgia, photophobia, nausea and vomiting. Late in the course of the illness, shock and death may occur.

Septicemia

Thrombocytopenia or the effects of toxins in acute infection can lead to purpura, especially in the form of petechiae. Associated findings include fever, chills, headache, tachycardia, lethargy, diaphoresis, and anorexia. Signs and symptoms specific to the area of infection—for example, cough, wound drainage, and urinary burning—also occur.

Stasis

Chronic stasis usually affects the elderly, producing dusky reddish purpura on the legs after prolonged standing.

Systemic lupus erythematosus

This chronic inflammatory disorder may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.

Thrombotic thrombocytopenic purpura

Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in this disorder. Most patients have fever, and some also experience fatigue, weakness, headache, nausea, abdominal pain, arthralgias, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and altered level
of consciousness. Renal failure may also occur.

Trauma

Traumatic injury can cause local or widespread purpura.

Vasculitis

Palpable purpura is commonly caused by allergic vasculitis (leukocytoclastic vasculitis) of which Henoch-Schönlein purpura is one subtype. Most common in adolescents and children, lesions can be found anywhere on the body but are most prevalent on the lower extremities and buttocks. The purpura tends to be smooth, bordered, and circular in nature. Systemic signs and symptoms include fever, arthralgias, abdominal pain, GI bleeding and nephritis.

Other causes

Diagnostic tests

Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.

Drugs

The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.

Surgery and other procedures

Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and use of plasma expanders such as dextran.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Fever [Pyrexia]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anthrax, cutaneous

In this disorder, the patient may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black necrotic center.

Anthrax, GI

After ingesting contaminated meat from an animal infected with the bacterium Bacillus anthracis, the patient experiences fever, anorexia, nausea, vomiting and, possibly, abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation

This acute infectious disease initially produces flulike signs and symptoms, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours.

Avian influenza

Avian influenza, also known as bird flu, is an infection caused by viruses that originate in the intestines of wild birds but are highly contagious to domesticated birds, such as chickens, turkeys, and geese. Infected poultry and surfaces contaminated with infected bird excretions have recently led to human infections and deaths in several Asian countries. Fever is commonly an initial symptom of these viruses along with other conventional influenza symptoms, such as muscle aches, sore throat, and cough. Individuals infected with the most virulent avian virus, influenza A (H5N1), may develop pneumonia, acute respiratory distress, and other life-threatening complications.

Escherichia Coli O157:H7

Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. Children younger than age 5 and elderly patients may develop hemolytic uremic syndrome, which can ultimately lead to acute renal failure.

Immune complex dysfunction

When present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (in AIDS) or morning stiffness (in rheumatoid arthritis). Other disease-specific findings include headache and vision loss (in temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (in ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (in erythema multiforme); and urethritis with urethral discharge and conjunctivitis (in Reiter’s syndrome).

Infectious and inflammatory disorders

Fever ranges from low (in Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, Ebola virus or Hantavirus pulmonary syndrome). It may be remittent, as in infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in a lung abscess, influenza, or endocarditis; sustained, as in meningitis; or relapsing, as in malaria. Fever may arise abruptly, as in toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Kawasaki syndrome

Fever, typically high and spiking, is the primary characteristic of this acute illness. The diagnosis of Kawasaki syndrome is confirmed when fever persists for 5 or more days (or until administration of I.V. gamma globulin if given before the fifth day) and is accompanied by other clinical signs, including conjunctival injection, erythema, lymphadenopathy, and peripheral extremity swelling. This syndrome occurs worldwide, with the highest incidence in Japan. It primarily affects children under age 5, is more prevalent in boys, and can cause serious heart damage and death without prompt treatment with I.V. gamma globulin.

Listeriosis

Signs and symptoms of this infection include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, it may cause meningitis, whose symptoms include fever, headache, nuchal rigidity, and change in LOC.

Gender Cue: Listeriosis during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Monkeypox

Fever is one of the initial symptoms that occurs in almost all patients infected with this rare viral disease. A papular rash that may be localized or generalized appears within 1 to 3 days after the fever begins. Additional symptoms commonly include sore throat, chills, and lymphadenopathy. There is no treatment for monkeypox, but the disease is rarely fatal in developed countries and usually lasts 2 to 4 weeks.

Neoplasms

Primary neoplasms and metastases can produce prolonged fever of varying elevations. For instance, acute leukemia may manifest insidiously with a low fever, pallor, and bleeding tendencies, or more abruptly with a high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

Besides fever and nocturnal diaphoresis, neoplastic disease commonly causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

Caused by Yersinia pestis, plague is one of the most virulent bacterial infections known. The bubonic form of plague is transmitted to man from the bite of infected fleas and causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. Septicemic plague may deveop as a complication of untreated bubonic or pneumonic plague, and occurs when bacteria enter the bloodstream and multiply. Pneumonic plague manifests as a sudden onset of chills, fever, headache, and myalgia after person-to-person transmission by respiratory droplets. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Q fever

This rickettsial disease caused by Coxiella burnetii causes fever (which may last up to 2 weeks), chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. In severe cases, the patient may develop hepatitis or pneumonia.

Respiratory syncytial virus (RSV)

Fever is one of the initial symptoms of this common illness that affects most children by age 2. Healthy adults and children older than age 3 usually develop a low-grade fever along with other common coldlike symptoms of runny nose, cough, and wheezing. Many children less than age 3 have a high-grade fever that may be accompanied by a severe cough, rapid breathing, and high-pitched expiratory wheezing. Infants with RSV typically exhibit lethargy, poor eating, irritability, and difficulty breathing; severe cases may require hospitalization. To avoid repeated RSV infection, individuals should practice infection-control techniques, such as proper hand-washing and avoiding contact with contaminated surfaces.

Rhabdomyolysis

This disorder results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream. Signs and symptoms include fever, muscle weakness or pain, nausea, vomiting, malaise, and dark urine. Acute renal failure, the most common complication rhabdomyolysis, results from renal structure obstruction and injury during the kidneys’attempt to filter the myoglobin from the bloodstream.

Rift Valley fever

Typical signs and symptoms of this infection include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. SARS may produce only mild symptoms, or it may progress to pneumonia and, in some cases, even respiratory failure and death.

Smallpox (variola major)

i> Initial signs and symptoms of this virus include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 or 9 days, they form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction

Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). A low or moderate fever occurs in dehydrated patients.

Prolonged high fever commonly produces vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes (dry skin and mucous membranes, poor skin turgor) and oliguria in dehydration; mottled cyanosis in malignant hyperthermia; diarrhea in thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) in CNS tumor, trauma, or hemorrhage.

Tularemia

This infectious disease, also known as “rabbit fever,” causes abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus

In this rickettsial disease, the patient initially experiences headache, myalgia, arthralgia, and malaise. These symptoms are followed by an abrupt onset of fever, chills, nausea, vomiting, and—in some cases—a maculopapular rash.

West Nile encephalitis

This brain infection is caused by West Nile virus, a mosquito-borne flavivirus commonly found in Africa, West Asia, and the Middle East and rarely in North America. Most patients have mild signs and symptoms, including fever, headache, body aches, rash, and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors and, occasionally, paralysis or seizures. Death rarely occurs.

Other causes

Diagnostic tests

Immediate or delayed fever infrequently follows radiographic tests that use a contrast medium.

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments

A remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of fever and chills.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Purpura/Petechiae/Excessive Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Purpura

❑Trauma

❑Senile purpura

❑Drugs

❑Vasculitis

❑Vitamin K deficiency

❑Psychogenic purpura

❑Cholesterol emboli

❑Warfarin necrosis

❑Scurvy

❑Thrombotic thrombocytopenic purpura

❑Henoch-Schonlein purpura

❑Amyloidosis

Petechiae

❑Autoimmune thrombocytopenia

❑Bacteremia

❑Hypersplenism

Excessive Bleeding

❑Over-anticoagulation

❑Thrombocytopenia

❑von Willebrand disease

❑Circulating anticoagulant

❑Disseminated intravascular coagulation

❑Hemophilia

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Fever of Unknown Origin: Differential Overview
(Field Guide to Bedside Diagnosis)

Infection

❑ HIV

❑ Tuberculosis

❑ Endocarditis

❑ Osteomyelitis

❑ Malaria

❑ Syphilis

❑ Zoonosis

❑ Typhoid fever

❑ Chronic meningococcemia

Neoplasm

❑ Lymphoma

❑ Liver metastases

❑ Renal cell carcinoma

❑ Atrial myxoma

Collagen-Vascular Disease

❑ Giant cell arteritis

❑ Systemic lupus erythematosus

❑ Vasculitis

❑ Rheumatic fever

❑ Still disease

Other

❑ Drugs

❑ Heat stroke

❑ Factitious

❑ Malignant hyperthermia

❑ Multiple pulmonary emboli

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Source: Field Guide to Bedside Diagnosis, 2007

Allergic purpura: Causes
(Handbook of Diseases)

The most common identifiable cause of allergic purpura is probably an autoimmune reaction directed against vascular walls, triggered by a bacterial infection (particularly streptococcal infection). Typically, an upper respiratory tract infection occurs 1 to 3 weeks before the onset of symptoms. Other possible causes include allergic reactions to some drugs and vaccines, allergic reactions to insect bites, and allergic reactions to some foods (such as wheat, eggs, milk, and chocolate).

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Idiopathic thrombocytopenic purpura: Causes
(Handbook of Diseases)

ITP may be an autoimmune disorder because antibodies that reduce the life span of platelets have been found in nearly all patients. The spleen probably helps to remove platelets modified by the antibody. Acute ITP usually follows a viral infection, such as rubella and chickenpox, and can follow immunization with a live virus vaccine. Chronic ITP seldom follows infection and is commonly linked to immunologic disorders, such as systemic lupus erythematosus or human immunodeficiency virus infection. It’s also linked to drug reactions.

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Source: Handbook of Diseases, 2003

Rheumatic fever and rheumatic heart disease: Causes
(Handbook of Diseases)

Rheumatic fever appears to be a hypersensitivity reaction to a group A beta-hemolytic streptococcal infection, in which antibodies manufactured to combat streptococci react and produce characteristic lesions at specific tissue sites, especially in the heart and joints. About 3% of patients with untreated streptococcal infections develop rheumatic fever.

Although rheumatic fever tends to run in families, this may merely reflect contributing environmental factors. It primarily affects children between ages 6 and 15, usually within 1 to 5 weeks after strep throat or scarlet fever. The disease strikes most often during cool, damp weather in winter and early spring. In the United States, it’s most common in the northern states.

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Source: Handbook of Diseases, 2003

Fever: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Anthrax, cutaneous

The patient may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.

Anthrax, GI

Following the ingestion of contaminated meat from an animal infected with the bacterium Bacillus anthracis, the patient experiences fever, loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation

The initial signs and symptoms of inhalation anthrax are flulike ones, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Escherichia coli O157:H7. Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with E. coli O157:H7. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

When present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome).

Infectious and inflammatory disorders

Fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. Fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Listeriosis

Signs and symptoms of listeriosis include fever, myalgias, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include fever, headache, nuchal rigidity, and change in level of consciousness.

Neoplasms

Primary neoplasms and metastasis can produce prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with low fever, pallor, and bleeding tendencies, or more abruptly with high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

Besides fever and nocturnal diaphoresis, neoplastic disease often causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague (Yersinia pestis)

The bubonic form of plague (transmitted to patient when bitten by infected fleas) causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, fever, headache, and myalgias after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Q fever

Q fever is a rickettsial disease that’s caused by the infection of Coxiella burnetii causes fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis

Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms including fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most frequently reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream.

Rift Valley fever

Typical signs and symptoms of Rift Valley fever include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major)

Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After about 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction

Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). Low or moderate fever appears in dehydrated patients.

Prolonged high fever commonly produces vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes: dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Tularemia, also known as rabbit fever, is an infectious disease that causes abrupt onset of fever, chills, headache, generalized myalgias, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus

With typhus — a rickettsial disease — the patient initially experiences headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases.

West Nile encephalitis

A brain infection caused by West Nile virus, the mosquito-borne flavivirus is commonly found in Africa, West Asia, the Middle East and, rarely, in North America. Mild infection is common; signs and symptoms include fever, headache, and body aches, often with skin rash and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional convulsions, paralysis and, rarely, death.

Other causes

Diagnostic tests

Immediate or delayed fever infrequently follows radiographic tests that use contrast medium.

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Medical treatments

Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce abrupt onset of fever and chills.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Fever: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anthrax, cutaneous

The patient with cutaneous anthrax may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.

Anthrax, GI

Following the ingestion of meat contaminated with the bacterium Bacillus anthracis, the patient experiences fever, loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation

The initial signs and symptoms of inhalation anthrax are flulike, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Escherichia coli 0157:H7

Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating foods contaminated with the bacterial strain Escherichia coli 0157:H7. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

When immune complex dysfunction is present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome).

Infectious and inflammatory disorders

Fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola virus or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. Fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. General systemic complaints include weakness, anorexia, and malaise.

Neoplasms

Primary neoplasms and metastases can produce prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with low fever, pallor, and bleeding tendencies, or more abruptly with high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

In addition to fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

Plague is an infection caused by the bacterium Yersinia pestis. The bubonic form of plague causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, fever, headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Rhabdomyolysis

Rhabdomyolysis produces fever, muscle weakness or pain, nausea, vomiting, malaise, or dark reddish brown urine. Acute renal failure is the most frequently reported complication of the disorder.

Severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is an acute infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox

Initial signs and symptoms of smallpox (also known as variola major) include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After about 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction

Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). Low or moderate fever appears in dehydrated patients.

Prolonged high fever commonly produces vomiting, anhidrosis, decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes: dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Also known as rabbit fever, tularemia is an infectious disease that causes abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

West Nile encephalitis

Mild infection is common from West Nile encephalitis, a mosquito-borne Flavivirus. Signs and symptoms include fever, headache, and body aches, commonly with skin rash and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

CULTURAL CUE:West Nile encephalitis is commonly found in Africa, West Asia, and the Middle East. It rarely occurs in North America.

Other causes

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Purpura: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cholesterol emboli

Purpura caused by cholesterol emboli are most commonly found in the lower extremities of patients with atherosclerotic vascular disease and usually occur after anticoagulation therapy or an invasive arterial procedure, such as angiogram or cardiac catheterization; however, they may occur spontaneously. Associated findings include livedo reticularis, cyanosis, gangrene, nodules, and ulceration of the skin.

Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) can cause varying degrees of purpura, depending on its severity and underlying cause. The patient may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis, such as oliguria.

Dysproteinemias

With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.

Easy bruising syndrome

Easy bruising syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.

Fat emboli

Petechiae that occur on the upper body a few days after a major injury are caused by fat emboli. The patient may experience fever, tachycardia, tachypnea, blood-tinged sputum, cyanosis, anxiety, restlessness, altered level of consciousness, seizures, coma, or rash.

Idiopathic thrombocytopenic purpura

Chronic idiopathic thrombocytopenic purpura (ITP) typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.

Leukemia

Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.

Acute leukemias also produce severe prostration and high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, low-grade fever, anorexia, and weight loss.

Liver disease

Hepatic disease may cause purpura, particularly ecchymoses, and other bleeding tendencies. Associated findings include hepatomegaly, ascites, right-upper-quadrant pain, jaundice, nausea, vomiting, and anorexia.

Meningococcemia

With meningococcemia, cutaneous and oropharyngeal petechia and purpura are initially discrete but become confluent, developing into hemorrhagic bullae and ulcerations. Fulminant infection results in extensive purpura and ecchymosis with irregular borders (purpura fulminans), most notably on the extremities. These lesions may develop necrotic centers. Associated symptoms include spiking fevers, chills, myalgia and arthralgia, and recent upper respiratory tract infection. Rapid progression of symptoms leads to headache, neck stiffness, and nuchal rigidity. Septic shock ensues within hours of onset of symptoms, accompanied by altered mental status and hypotension.

Myeloproliferative disorders

Myeloproliferative disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.

Nutritional deficiencies

With vitamin C deficiency (scurvy), the characteristic pattern of purpura is perifollicular petechiae, which coalesce to form ecchymoses, in the “saddle area” of the thighs and buttocks. Additional hemorrhaging occurs in arm and leg muscles (with phlebothrombosis), viscera, joints (with limb and joint pain), and nail beds. Related findings include scaly dermatitis; pallor; tender, swollen, bleeding gums and loosened teeth; dry mouth; and poor wound healing. Nonspecific symptoms include weakness, lethargy, and anorexia. Irritability, depression, insomnia, and hysteria may also develop.

Vitamin K deficiency produces abnormal bleeding tendencies, such as ecchymosis, gum bleeding, epistaxis, hematuria, and GI and intracranial bleeding.

Vitamin B₁₂ deficiency can cause varying degrees of purpura. GI findings include anorexia, nausea, vomiting, weight loss, abdominal discomfort, and jaundice. Dyspnea, peripheral neuropathies, ataxia, glossitis and, occasionally, depression also occur.

Folic acid deficiency also can cause varying degrees of purpura. The patient may be irritable and forgetful and may complain of fatigue, weakness, dyspnea, palpitations, nausea, anorexia, headaches, and fainting spells. Additional findings include pallor, slight jaundice, and glossitis.

Rocky Mountain spotted fever

The initial skin lesions of Rocky Mountain spotted fever are small pink macules that evolve into blatant petechia and palpable purpura. Hemorrhagic macules may develop. The palms and soles are particularly affected. Extensive cutaneous necrosis occurs in a small percentage of patients experiencing gangrene of the extremities, necessitating amputation. Associated signs and symptoms include fever, severe headache, generalized myalgia, photophobia, nausea, and vomiting. Late in the course of the illness, shock and death may occur.

Septicemia

Thrombocytopenia or the effects of toxins in acute infection can lead to purpura, especially in the form of petechiae. Associated findings include fever, chills, headache, tachycardia, lethargy, diaphoresis, and anorexia. Signs and symptoms specific to the area of infection — for example, cough, wound drainage, and urinary burning — also occur.

Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic inflammatory disorder that may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic “butterfly rash” appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.

Trauma

Traumatic injury can cause local or widespread purpura. Specific signs and symptoms depend on the type and location of the trauma.

Other causes

Diagnostic tests

Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas caused by extravasated blood.

Drugs

The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.

Surgery and other procedures

Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. Such procedures include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and use of plasma expanders such as dextran.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Fever: Principal Causes of Acute Fever
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Commoncauses
   1. Infectious
      1. Respiratorytract
         1. Upperrespiratory tract infection (common cold)
         2. Pharyngitis
         3. Tonsillitis
         4. Otitis media
         5. Herpes gingivostomatitis
         6. Herpangina
         7. Sinusitis
         8. Croup
         9. Bronchiolitis
         10. Bronchitis
         11. Pneumonia (viral, bacterial, Mycoplasma)
         12. Pertussis
      2. Gastrointestinal
         1. Gastroenteritis
         2. Appendicitis
         3. Hepatitis
      3. Genitourinary
         1. Urinary tract infection (includingpyelonephritis)
         2. Sexually transmitted diseases
      4. Musculoskeletal
         1. Septicarthritis
         2. Osteomyelitis
         3. Myositis
      5. Central nervous system
         1. Meningitis(viral, bacterial)
         2. Viral encephalitis
      6. Infections associated with prominentrash
         1. Roseola
         2. Hand-foot-mouth syndrome
         3. Varicella
         4. Erythema infectiosum (parvovirus B19)
         5. Measles
         6. Scarlet fever
         7. Meningococcemia
         8. Rocky mountain spotted fever
      7. Other
         1. Viral illnesses
         2. Septicemia/bacteremia
         3. Infectious mononucleosis
         4. Lymphadenitis
         5. Cellulitis/abscess
         6. Cat scratch disease
         7. Dental abscess
         8. Periorbital cellulitis
         9. Parotitis
   2. Noninfectious
      1. Drug reactions
      2. Vaccine reactions
      3. Trauma
      4. Burns
      5. Kawasaki disease
2. Uncommon causes
   1. Infectious
      1. Respiratorytract
         1. Viral
            1. Hantaviruspulmonary syndrome
         2. Bacterial
            1. Supraglottitis
            2. Bacterial tracheitis
            3. Abscess (peritonsillar, retropharyngeal,lateral pharyngeal)
            4. Tuberculosis
            5. Actinomycosis
            6. Nocardiasis
            7. Legionella
         3. Fungal
            1. Aspergillosis
            2. Blastomycosis
            3. Histoplasmosis
            4. Coccidioidomycosis
         4. Parasitic
            1. Pneumocystis carinii
      2. Gastrointestinal
         1. Amebiasis
         2. Pancreatitis
         3. Cholecystitis
         4. Cholangitis
         5. Peritonitis
         6. Intraabdominal abscess
      3. Genitourinary
         1. Epididymitis
         2. Orchitis
         3. Abscesses (perinephric, tuboovarian)
      4. Cardiac
         1. Acute rheumatic fever
         2. Myocarditis
         3. Pericarditis
         4. Endocarditis
      5. Central nervous system
         1. Brainabscess
      6. Other
         1. Viral
            1. Human immunodeficiency virus
            2. Rabies
         2. Bacterial
            1. Staphylococcal scalded skin syndrome
            2. Toxic shock syndrome
            3. Orbital cellulitis/abscess
            4. Borrelia (relapsing fever)
            5. Brucellosis
            6. Leptospirosis
            7. Plague
            8. Psittacosis (ornithosis)
            9. Rat-bite fever
            10. Syphilis
            11. Tularemia
            12. Tetanus
         3. Fungal
            1. Disseminated histoplasmosis
            2. Nonpulmonary blastomycosis
         4. Parasitic
            1. Malaria
            2. Ascariasis
            3. Toxocariasis (visceral larva migrans,ocular larva migrans)
            4. Toxoplasmosis
            5. Trichinosis
         5. Rickettsial
            1. Endemic typhus (murine)
            2. Epidemic typhus (louse-borne typhus)
            3. Q fever
            4. Rickettsial pox
            5. Ehrlichiosis
   2. Noninfectious
      1. Respiratory
         1. Pulmonary infarction
         2. Pulmonary embolism
      2. Gastrointestinal
         1. Pulmonaryinfarction
         2. Pulmonary embolism
      3. Intestinal obstruction
      4. Inflammatory bowel disease
      5. Cardiac
         1. Postpericardiotomy syndrome
      6. Hematologic
         1. Intravascular hemolysis
         2. Bleeding into a closed space
      7. Endocrine
         1. Thyrotoxicosis
         2. Diabetes insipidus
      8. Central nervous system
         1. Intracranialinjury and hemorrhage
         2. Spinal cord injury
         3. Hypothalamic and brain stem lesions
         4. Status epilepticus
      9. Neoplasia
         1. Leukemia
         2. Lymphoma
         3. Neuroblastoma
         4. Pheochromocytoma
      10. Connective tissue disorders
          1. Juvenilerheumatoid arthritis
          2. Systemic lupus erythematosus
          3. Polyarteritis nodosa
          4. Polymyositis
          5. Dermatomyositis
          6. Mixed connective tissue disease
      11. Poisonings
          1. Atropine
          2. Cocaine
          3. Salicylate
          4. Lysergic acid diethylamide
          5. Hydrocarbons
          6. Organophosphates
          7. Tricyclic antidepressants
          8. Amphetamines
          9. Phenothiazines
      12. Other
          1. Spider bites (black widow, brown recluse)
          2. Stevens-Johnson syndrome
          3. Heat-related illness
          4. Serum sickness
          5. Anhidrotic ectodermal dysplasia
          6. Familial dysautonomia
          7. Sarcoidosis
          8. Familial Mediterranean fever
          9. Factitious fever

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Purpura and Bleeding: Principal Causes of Purpura and Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Lossof vascular integrity
   1. Trauma
   2. Infection
   3. Henoch-Schönlein purpura
   4. Drugs
   5. Langerhans histiocytosis
   6. Ehlers-Danlos syndrome
   7. Vitamin C deficiency
   8. Hereditary hemorrhagic telangiectasia(Osler-Rendu-Weber disease)
2. Thrombocytopenia
   1. Increasedplatelet destruction
      1. Immune-mediated
         1. Neonatal alloimmune thrombocytopenia
         2. Maternal autoimmune thrombocytopenia
         3. Idiopathic thrombocytopenic purpura
         4. Collagen vascular disease
         5. Drug-induced thrombocytopenia
      2. Infection
      3. Hemolytic-uremic syndrome
      4. Thrombotic thrombocytopenic purpura
      5. Wiskott-Aldrich syndrome
   2. Decreased platelet production
      1. Infection
      2. Specific platelet disorders
         1. Congenitalamegakaryocytic thrombocytopenia
         2. Thrombocytopenia–absent radiisyndrome
      3. Bone marrow suppression (generalized)
      4. Bone marrow replacement
      5. Megaloblastic anemia
      6. Platelet sequestration
         1. Hypersplenism
         2. Large hemangiomas
3. Abnormal platelet function
   1. Thrombasthenia(Glanzmann disease)
   2. Giant platelet syndrome (Bernard-Souliersyndrome)
   3. Storage pool deficiency
   4. Drugs
   5. Uremia
4. Coagulation disorders
   1. Factordeficiencies
      1. VonWillebrand disease
      2. Factor VIII deficiency (hemophiliaA)
      3. Factor IX deficiency (hemophilia B,Christmas disease)
      4. Deficiencies of Factors I, II, V, VII,X, XI, and XIII
   2. Vitamin K deficiency
   3. Disseminated intravascular coagulation
   4. Liver disease
   5. Circulating anticoagulants

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Purpura: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Autoerythrocyte sensitivity.With autoerythrocyte sensitivity, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, headache, and chest pain are also common.

Disseminated intravascular coagulation (DIC).DIC can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs. Or, he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis such as oliguria.

Dysproteinemias.With multiple myeloma,petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemiatypically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and a low-grade fever may precede or accompany the purpura, which gradually fades over 1 or 2 weeks. Persistent pigmentation develops after repeated outbreaks.

Ehlers-Danlos syndrome (EDS).Besides petechiae, EDS is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.

Idiopathic thrombocytopenic purpura (ITP).Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.

Leukemia.Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.

Acute leukemias also produce severe prostration and a high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemiasbegin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, a low-grade fever, anorexia, and weight loss.

Myeloproliferative disorders.Myeloproliferativedisorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of a headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.

Systemic lupus erythematosus (SLE).SLE may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder's acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud's phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.

Thrombotic thrombocytopenic purpura.Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in thrombotic thrombocytopenic purpura. Most patients have fever, and some also experience fatigue, weakness, headache, nausea, abdominal pain, arthralgia, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and an altered level of consciousness. Renal failure may also occur.

Trauma.Traumatic injury can cause local or widespread purpura.

Other causes

Diagnostic tests.Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.

Drugs.The anticoagulants heparin and warfarin can produce purpura.

Surgery and other procedures.Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and the use of plasma expanders such as dextran.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Fever [Pyrexia]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anthrax, cutaneous.The patient with cutaneous anthrax may experience a fever along with lymphadenopathy, malaise, and a headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.

Anthrax, GI.Following the ingestion of contaminated meat from an animal infected with the bacterium B. anthracis, the patient experiences a fever, a loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation.The initial signs and symptoms of inhalation anthrax are flulike, including a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Avian influenza.Fever is commonly an initial symptom of avian influenza along with other conventional influenza symptoms, such as muscle aches, sore throat, and cough. Individuals infected with the most virulent avian virus, influenza A (H5N1), may develop pneumonia, acute respiratory distress, and other life-threatening complications.

Escherichia coli O157:H7. A fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction.With immune complex dysfunction, a fever, when present, usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), a fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include a headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter's syndrome).

Infectious and inflammatory disorders.With these disorders fever ranges from low (in patients with Crohn's disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. A fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, a fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every body system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Kawasaki syndrome.Fever, typically high and spiking, is the primary characteristic of this acute illness. The diagnosis of Kawasaki syndrome is confirmed when fever persists for 5 or more days (or until administration of I.V. gamma globulin if given before the fifth day) and is accompanied by other clinical signs, including conjunctival injection, erythema, lymphadenopathy, and peripheral extremity swelling. This syndrome occurs worldwide, with the highest incidence in Japan. It primarily affects children under age 5, is more prevalent in boys, and can cause serious heart damage and death without prompt treatment with I.V. gamma globulin.

Listeriosis.Signs and symptoms of listeriosis include a fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include a fever, a headache, nuchal rigidity, and a change in the LOC.

Monkeypox.Fever is one of the initial symptoms that occurs in almost all patients infected with this rare viral disease. A papular rash that may be localized or generalized appears within 1 to 3 days after the fever begins. Additional symptoms commonly include sore throat, chills, and lymphadenopathy. No treatment is available for monkeypox, but the disease is rarely fatal in developed countries and usually lasts 2 to 4 weeks.

Neoplasms.Primary neoplasms and metastasis can produce a prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with a low-grade fever, pallor, and bleeding tendencies or more abruptly with a high fever, frank bleeding, and prostration. Occasionally, Hodgkin's disease produces an undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

In addition to a fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague (Yersinia pestis).The bubonic form of plague (transmitted to man when bitten by infected fleas) causes a fever, chills, and swollen, inflamed, and tender lymph nodes near the bite site. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, a fever, a headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Q fever.Q fever causes a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Respiratory syncytial virus (RSV).Fever is one of the initial symptoms of this common illness that affects most children by age 2. Healthy adults and children older than age 3 usually develop a low-grade fever along with other common coldlike symptoms of runny nose, cough, and wheezing. Many children younger than age 3 have a high-grade fever that may be accompanied by a severe cough, rapid breathing, and high-pitched expiratory wheezing. Infants with RSV typically exhibit lethargy, poor eating, irritability, and difficulty breathing; severe cases may require hospitalization. To avoid repeated RSV infection, individuals should practice infection-control techniques, such as proper hand-washing and avoiding contact with contaminated surfaces.

Rhabdomyolysis.Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms that include a fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney's attempt to filter myoglobin from the bloodstream.

Rift Valley fever.Typical signs and symptoms of Rift Valley fever include  fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other signs and symptoms include a headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major).Initial signs and symptoms of smallpoxinclude a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction.Thermoregulatory dysfunction is marked by a sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C). It occurs in such life-threatening disorders as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia and in lesions of the central nervous system (CNS). A low or moderate fever appears in dehydrated patients.

A prolonged high fever commonly produces vomiting, anhidrosis, a decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes, such as dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (a decreased LOC with bradycardia, a widened pulse pressure, and an increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia.Tularemia, also known as rabbit fever, causes an abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus.Typhus is a rickettsial disease in which the patient initially experiences a headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of a fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases.

West Nile encephalitis.Signs and symptoms of West Nile encephalitis include fever, headache, and body aches, usually with a skin rash and swollen lymph glands. More severe infection is marked by a high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

Other causes

Diagnostic tests.Immediate or delayed fever uncommonly follows radiographic tests that use contrast medium.

Drugs.A fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. A fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. A fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments.Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of a fever and chills.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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