Diseases » Leptospirosis » Causes

Causes of Leptospirosis

Leptospirosis Causes: Book Excerpts

• Differential Diagnosis - Fever
• Differential Diagnosis - Rash with Fever
• Differential Diagnosis - Jaundice
• Differential Diagnosis - Fever – Acute
• Differential Diagnosis - Fever – Cyclic
• Differential Diagnosis - Fever – Recurrent
• Differential Diagnosis - Fever – Unknown Origin
• Differential Diagnosis - Jaundice in Infants – Direct
• Differential Diagnosis - Jaundice in Infants – Indirect
• Medical causes - Fever
• Medical causes - Jaundice
• Causes and incidence - Colorado tick fever
• 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 - Fever [Pyrexia]
• Medical causes - Jaundice [Icterus]
• Differential Overview - Fever of Unknown Origin
• Differential Overview - Jaundice
• Causes - Rheumatic fever and rheumatic heart disease
• Medical causes - Fever
• Medical causes - Fever
• Medical causes - Jaundice
• Principal Causes of Acute Fever - Fever
• Principal Causes of Unconjugated Hyperbilirubinemia - Jaundice
• Medical causes - Fever [Pyrexia]
• Medical causes - Jaundice [Icterus]
• I. Differential Diagnosis - Fever - Case 11-1 18-Month-Old Girl
• I. Differential Diagnosis - Fever - Case 11-4 7-Month-Old Girl
• I. Differential Diagnosis - Jaundice - Case 15-1 14-Day-Old Boy
• I. Differential Diagnosis - Jaundice - Case 15-3 2-Month-Old Boy
• I. Differential Diagnosis - Jaundice - Case 15-4 6-Week-Old Girl
• I. Differential Diagnosis - Jaundice - Case 15-6 5-Week-Old Girl
• Fever and Petechiae - pathophysiology - Fever and Petechiae
• Jaundice - etiology - Jaundice
• Patient Afebrile within the First 3 to 5 Days of Treatment, Etiology Found - Fever and Neutropenia
• Epidemiology and Etiology - Outpatient Evaluation of Fever

What causes Leptospirosis?

Causes: Leptospirosis: Bacteria often caught indirectly from animal urine.
Occurs through direct or indirect transmission from a mammalian host. Indirect transmission via contact with Leptospira contaminated water or soil, is thought to be responsible for most cases. (Source: excerpt from Leptospirosis: DBMD)
Article excerpts about the causes of Leptospirosis:

Leptospirosis (General): DBMD (Excerpt)

Outbreaks of leptospirosis are usually caused by exposure to water contaminated with the urine of infected animals. Many different kinds of animals carry the bacterium; they may become sick but sometimes have no symptoms. Leptospira organisms have been found in cattle, pigs, horses, dogs, rodents, and wild animals. Humans become infected through contact with water, food, or soil containing urine from these infected animals. This may happen by swallowing contaminated food or water or through skin contact, especially with mucosal surfaces, such as the eyes or nose, or with broken skin. The disease is not known to be spread from person to person. (Source: excerpt from Leptospirosis (General): DBMD)

Leptospirosis and Your Pet: DBMD (Excerpt)

The bacteria are spread through the urine of infected animals, which can get into water or soil and can survive there for weeks to months. Humans and animals can become infected through contact with this contaminated urine (or other body fluids, except saliva), water, or soil. The bacteria can enter the body through skin or mucous membranes (eyes, nose, or mouth), especially if the skin is broken from a cut or scratch. Drinking contaminated water can also cause infection. Infected wild and domestic animals may continue to excrete the bacteria into the environment continuously or every once in a while for a few months up to several years.

If your pet has become infected, it most likely came into contact with leptospires in the environment or infected animals. Your pet may have been drinking, swimming, or walking through contaminated water. Because of increased building and development into areas that were previously rural, pets may be exposed to more wildlife, such as raccoons, skunks, squirrels, opossums, or deer that are infected with leptospirosis. Dogs also may pass the disease to each other, but this happens very rarely. (Source: excerpt from Leptospirosis and Your Pet: DBMD)

Leptospirosis: DBMD (Excerpt)

Leptospires are long, thin motile spirochetes. They may be free-living or associated with animal hosts and survive well in fresh water, soil, and mud in tropical areas. These organisms are antigenically complex, with over 200 known pathogenic serologic variants. Molecular taxonomic studies at CDC and elsewhere have identified 13 named and 4 unnamed species of pathogenic leptospires. Although certain geographic regions contain specific leptospiral serovars and species, the serologic characterization of an isolate is not an absolute predictor of its species designation. (Source: excerpt from Leptospirosis: DBMD)

Related information on causes of Leptospirosis:

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

• Risk factors for Leptospirosis
• Contagiousness for Leptospirosis
• Hidden causes of Leptospirosis

Causes of Leptospirosis: Online Medical Books

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

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

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

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

• Viral hepatitis
  –Fatigue, anorexia, fever, nausea, vomiting, dark urine, light-colored (acholic) loose stools, RUQ pain, hepatomegaly, and/or pruritis

• Alcoholic hepatitis
  –Associated with fever, leukocytosis, and AST:ALT ratio >2

• Nonalcoholic steatohepatitis or nonalchoholic fatty liver disease
  –Associated with obesity, diabetes, hyperlipidemia and medications

• Cholecystitis
  –RUQ pain, fever, leukocytosis
  –Female, fertile, fat, forty
  –Murphy's sign: Pain upon palpation of the
  gallbladder while taking a deep breath

• Drugs and toxins
  –Acetaminophen, alcohol, estrogens, isoniazid, chlorpromazine, erythromycin, nitrofurantoin, rifampin

• Gilbert's syndrome
  
  –Decreased conjugation of bilirubin, especially with dehydration, fasting, infection

Sepsis

Malignancy (liver, pancreas, gallbladder/common bile duct, metastatic)

• Liver infiltration
  –Amyloidosis, lymphoma, sarcoidosis, tuberculosis

Total parenteral nutrition (usually requires at least 2 weeks of therapy)

Intravascular hemolysis

• Cholangitis
  –Charcot's triad of fever, RUQ pain, and jaundice

Sickle cell disease
–Chronic hemolysis, hepatic dysfunction

• Autoimmune hepatitis
  –May mimic viral hepatitis
  –Females >> males, often 10–30 years old
  –Associated with autoimmune disease
  (e.g., RA, UC, Sjögren's syndrome, thyroiditis)

Intrahepatic cholestasis of pregnancy
–Pruritus in third trimester
–Resolves after delivery

Hereditary cholestatic disorders (e.g., Dubin-Johnson syndrome, Rotor syndrome)

Physiologic jaundice of newborn

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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
  >>

» READ BOOK EXCERPT ONLINE »

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
  >

» READ BOOK EXCERPT ONLINE »

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

» READ BOOK EXCERPT ONLINE »

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

» READ BOOK EXCERPT ONLINE »

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

Jaundice in Infants – Direct: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Bile duct obstruction
  –Biliary atresia: Represents the most frequent cause for liver transplantation in the pediatric patient; prompt diagnosis is crucial, as patient outcome is better if intervention comes before 60 days of life
  –Choledochal cyst
  –Common bile duct gallstone
  –Choledochocele
  –Bile duct stricture
  –Alagille syndrome
  –Caroli disease
  –Congenital hepatic fibrosis

• Neonatal hepatitis
  –Idiopathic hepatitis: Diagnosis of exclusion that should be made only when other causes are excluded; accounts for 60% of patients with neonatal cholestasis
  –Infections: TORCH, hepatitis B, HIV, E. coli, adenovirus, enterovirus, parvovirus B16, tuberculosis, listeriosis, malaria

• Metabolic disorders
  –α-1 antitrypsin deficiency
  –Cystic fibrosis
  –Hypothyroidism
  –Neonatal iron storage disease
  –Amino acids: tyrosinemia
  –Carbohydrates: Galactosemia, fructosemia
  –Lipids: Niemann-Pick, Gaucher, Wolman, cholesterol ester storage disease
  –Mitochondropathies
  –Bile acid synthetic disorders
  –Peroxisomal: Zellweger syndrome
  –Urea cycle defects
• Toxins
  –Total parenteral nutrition
  –Drugs: Trimethaprim-sulfamethoxazole, anticonvulsants
• Miscellaneous
  –Sepsis/hypoperfusion
  –Erythrophagocytic lymphohistiocytosis
  –Extracorporeal membrane oxygenation
  –Trisomy 17, 18, 21
  –Neonatal lupus erythematosus
  –Donohue syndrome
  –Rotor syndrome
  –Dubin-Johnson syndrome
  –Byler disease (PFIC type 1)
  –Cholestasis of North-American Indians
  –Nielsen syndrome

» READ BOOK EXCERPT ONLINE »

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

Jaundice in Infants – Indirect: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Icterus neonatorum (physiologic jaundice)
  –The most common form of indirect jaundice in infants under 14 days of age
  –Caused by increased bilirubin production with transient limited conjugation abilities
• Breast-feeding jaundice
  –Occurs in first week of life in 13% of breast-fed infants
  –Secondary to poor volume intake
• Breast-milk jaundice
  –Occurs in about 2% of breast-fed infants after day 7 of life
  –Secondary to glucuronidase in breast milk
• Hematologic: Hemolysis increases bili load
  –Rh incompatability
  –ABO incompatability
  –Glucose-6-phosphate dehydrogenase (G6PD) deficiency
  –Pyruvate kinase deficiency
  –Hereditary spherocytosis
  –Elliptocytosis
  –Thalassemia
  –Polycythemia
• Extravascular blood
  –Cephalohematoma
  –Trauma
  –Swallowed maternal blood
• Endocrinologic
  –Hypothyroidism
  –Maternal diabetes
• Sepsis
• Metabolic
  –Crigler-Najjar I
  –Crigler-Najjar II (Arias syndrome)
  –Crigler-Najjar III
• Cardiopulmonary
  –Congestive heart failure
  –Patent ductus arteriosus
  –Portal vein thrombosis
• Anatomic
  –Pyloric stenosis
  –Duodenal atresia/stenosis
  –Duodenal web
• Drugs
  –Oxytocin
  –Sulfonamides
  –Ceftriaxone
  –Chuen-Lin
• Lucey-Driscoll syndrome

» READ BOOK EXCERPT ONLINE »

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

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

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

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, a recurrent fever, and chills

Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right upper quadrant discomfort and tenderness, nausea, weight loss, and a slight fever. Examination may reveal irregular, nodular, firm hepatomegaly; ascites; peripheral edema; a bruit heard over the liver; and a right upper quadrant mass.

Withpancreatic cancer,progressive jaundice — possibly with pruritus — may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, a fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right upper quadrant pain, and a high fever with chills.

Cholecystitis

Cholecystitis produces nonobstructive jaundice in about 25% of patients

Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), a fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign and, possibly, abdominal distention and rigidity.

Cholelithiasis

Cholelithiasis commonly causes jaundice and biliary colic

It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes a fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency

Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right upper quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis,fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome

With Dubin-Johnson syndrome, which is a rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40

Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure

Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites are a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hepatic abscess

Multiple abscesses may cause jaundice, but the primary effects are a persistent fever with chills and sweating

Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; an elevated right hemidiaphragm; and ascites.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis

Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgia, myalgia, a headache, anorexia, photophobia, pharyngitis, a cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right upper quadrant pain and tenderness.

Pancreatitis (acute)

Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, the primary symptom of acute pancreatitis is usually severe epigastric pain that commonly radiates to the back

Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include a fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany — the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in the patient with sickle cell anemia

Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen (painful) joints, a fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; a low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice

Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, 3-hydroxy-3-methylglutaryl reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

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

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

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

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.

» READ BOOK EXCERPT ONLINE »

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

Jaundice [Icterus]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Agnogenic myeloid metaplasia

This myeloproliferative disorder of the bone marrow may cause jaundice. Its typical effects, however, are associated with anemia, including fatigue, weakness, anorexia, massive splenomegaly, hepatomegaly, purpura, and bleeding tendencies.

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right-upper-quadrant discomfort and tenderness, nausea, weight loss, and slight fever. Examination may reveal irregular, nodular, firm hepatomegaly, ascites, peripheral edema, a bruit heard over the liver, and a right-upper-quadrant mass.

With pancreatic cancer, progressive jaundice—possibly with pruritus—may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right-upper-quadrant pain, and high fever with chills.

Cholecystitis

This disorder produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign, and, possibly, abdominal distention and rigidity.

Cholelithiasis

This disorder commonly causes jaundice and biliary colic. It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cholestasis

With benign, recurrent intrahepatic cholestasis, the patient experiences prolonged attacks of jaundice (sometimes spaced several years apart) accompanied by pruritus. Other signs and symptoms are similar to those of hepatitis—fatigue, nausea, weight loss, anorexia, pale stools, and right-upper-quadrant pain.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right-upper-quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome

With this rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40. Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Glucose-6-phosphate dehydrogenase deficiency

Acute intravascular hemolysis following ingestion of such drugs as quinine or aspirin causes jaundice, pallor, dyspnea, tachycardia, and malaise. Palpation may reveal splenomegaly and hepatomegaly.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hemolytic anemia (acquired)

This disorder may produce prominent jaundice along with dyspnea, fatigue, pallor, tachycardia, and palpitations. Rapid hemolysis causes chills, fever, irritability, headache, and abdominal pain; severe hemolysis causes signs of shock.

Hepatic abscess

Multiple abscesses may cause jaundice, but the primary effects are persistent fever with chills and sweating. Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; elevated right hemidiaphragm; and ascites.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgias, myalgias, headache, anorexia, photophobia, pharyngitis, cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right-upper-quadrant pain and tenderness.

Leptospirosis

Severe leptospirosis (Weil’s disease) may cause jaundice. This disorder begins suddenly with a frontal headache, severe muscle aches in the thighs and lumbar area, cutaneous hyperesthesia, abdominal pain, nausea, conjunctival suffusion, and vomiting. Chills and a rapidly rising fever follow. Signs and symptoms of meningeal irritation include drowsiness, decreased mentation, stiff neck, and positive Kernig’s and Brudzinski’s signs. Right-upper-quadrant tenderness, hepatomegaly, and jaundice indicate hepatic involvement; proteinuria, pyuria, and hematuria indicate renal involvement. Epistaxis, hematemesis, melena, and hemoptysis may also occur.

Pancreatitis (acute)

Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, this disorder’s primary symptom is usually severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany—the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in patients with this disorder. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, (painful) swollen joints, fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; low-grade fever; and increased weakness, jaundice, and dyspnea.

Zieve syndrome

Caused by alcohol abuse, this relatively rare disorder produces abdominal pain and a sudden onset of severe jaundice. However, spider angiomas, ascites, and other signs of advanced liver disease are absent.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, HMG-CoA reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and phenytoin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» READ BOOK EXCERPT ONLINE »

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

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

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Jaundice: Differential Overview
(Field Guide to Bedside Diagnosis)

Conjugated

❑ Viral hepatitis

❑ Gallstone obstruction

❑ Drugs

❑ Carotinemia

❑ Alcohol-induced hepatitis

❑ Cirrhosis

❑ Pregnancy (cholestatic)

❑ Postoperative

❑ Metastatic cancer

❑ Pancreatic cancer

❑ Ampullary carcinoma

❑ Hepatoma

❑ Sclerosing cholangitis

❑ Primary biliary cirrhosis

❑ Leptospirosis

❑ Hepatic vein obstruction (Budd-Chiari)

❑ Hemochromatosis

Unconjugated

❑ Hemolysis

❑ Gilbert syndrome

❑ Sepsis

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

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.

» READ BOOK EXCERPT ONLINE »

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

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

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or metastases to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right-upper-quadrant discomfort and tenderness, nausea, weight loss, and slight fever. Examination may reveal irregular, nodular, firm hepatomegaly, ascites, peripheral edema, a bruit heard over the liver, and a right-upper-quadrant mass.

With pancreatic cancer, progressive jaundice — possibly with pruritus — may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right-upper-quadrant pain, and high fever with chills. The patient may also report pruritus. Acholic or hypocholic stools may be present.

Cholecystitis

Cholecystitis produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign and, possibly, abdominal distention and rigidity.

Cholelithiasis

Cholelithiasis commonly causes jaundice and biliary colic. It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cholestasis

With benign, recurrent intrahepatic cholestasis, the patient experiences prolonged attacks of jaundice (sometimes spaced several years apart) accompanied by pruritus. Other signs and symptoms are similar to those of hepatitis — fatigue, nausea, weight loss, anorexia, pale stools, and right-upper-quadrant pain.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right-upper-quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Glucose-6-phosphate dehydrogenase deficiency

Acute intravascular hemolysis following ingestion of such drugs as quinine or aspirin causes jaundice, pallor, dyspnea, tachycardia, and malaise. Palpation may reveal splenomegaly and hepatomegaly.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hemolytic anemia (acquired)

Acquired hemolytic anemia may produce prominent jaundice along with dyspnea, fatigue, pallor, tachycardia, and palpitations. Rapid hemolysis causes chills, fever, irritability, headache, and abdominal pain; severe hemolysis causes signs of shock.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgias, myalgias, headache, anorexia, photophobia, pharyngitis, cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right-upper-quadrant pain and tenderness.

Pancreatitis (acute)

Pancreatitis can cause jaundice; however, this disorder’s primary symptom is usually severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany — the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in patients with sickle cell anemia. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen joints (sometimes painful), fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, HMG-CoA reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs. Postoperative jaundice may lead to edema and obstructed bile flow from the administration of halothane or from prolonged surgery resulting in shock, blood loss, or blood transfusion. A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» 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

Jaundice: Principal Causes of Unconjugated Hyperbilirubinemia
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Neonatalonset
   1. Increasedbilirubin production
      1. Physiologic
      2. Hemolytic anemia
         1. Isoimmunization
         2. Red cell enzyme defects
            1. Glucose-6-phosphatedehydrogenase deficiency
            2. Pyruvate kinase deficiency
            3. Other enzyme defects
         3. Red cell membrane defects
            1. Hereditaryspherocytosis
            2. Hereditary elliptocytosis
            3. Hereditary stomatocytosis
            4. Infantile pyknocytosis
         4. Septicemia
      3. Polycythemia
      4. Enclosed hematoma
   2. Decreased bilirubin uptake, storage,or metabolism
      1. Physiologic
      2. Hypoxia and acidosis
      3. Hypoalbuminemia
      4. Increased serum fatty acids
      5. Septicemia
      6. Drugs
      7. Hypothyroidism
      8. Lucey-Driscoll syndrome (transientfamilial neonatal hyperbilirubinemia)
      9. Crigler-Najjar syndrome (types I andII)
   3. Increased enterohepatic circulation
      1. Physiologic
      2. Breast-feeding–related jaundice
      3. Intestinal obstruction
2. Postneonatal onset
   1. Increasedbilirubin production
      1. Hemolytic anemia
      2. Septicemia
   2. Decreased bilirubin uptake, storage,or metabolism
      1. Gilbertsyndrome
      2. Septicemia

» READ BOOK EXCERPT ONLINE »

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

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

Jaundice [Icterus]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Carcinoma.Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, a recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right upper quadrant discomfort and tenderness, nausea, weight loss, and a slight fever. Examination may reveal irregular, nodular, firm hepatomegaly; ascites; peripheral edema; a bruit heard over the liver; and a right upper quadrant mass.

With pancreatic cancer, progressive jaundice—possibly with pruritus—may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, a fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis.Obstruction and infection in the common bile duct cause Charcot's triad: jaundice, right upper quadrant pain, and a high fever with chills.

Cholecystitis.Cholecystitis produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), a fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy's sign and, possibly, abdominal distention and rigidity.

Cholelithiasis.Cholelithiasis commonly causes jaundice and biliary colic. It's characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes a fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cirrhosis.With Laënnec's cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right upper quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren's contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome.With Dubin-Johnson syndrome, which is a rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40. Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Heart failure.Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hepatic abscess.Multiple liver abscesses may cause jaundice, but the primary effects are a persistent fever with chills and sweating. Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; an elevated right hemidiaphragm; and ascites.

Hepatitis.Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgia, myalgia, a headache, anorexia, photophobia, pharyngitis, a cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right upper quadrant pain and tenderness.

Pancreatitis (acute).Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, the primary symptom of acute pancreatitis is severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner's or Cullen's sign. Other findings include a fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, dia-phoretic extremities; paresthesia; and tetany—the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia.Hemolysis produces jaundice in the patient with sickle cell anemia. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen (painful) joints, a fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; a low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs.Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments.Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Fever - Case 11-1: 18-Month-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Fever - Case 11-4: 7-Month-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Jaundice - Case 15-1: 14-Day-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Jaundice - Case 15-3: 2-Month-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Jaundice - Case 15-4: 6-Week-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Jaundice - Case 15-6: 5-Week-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Fever and Petechiae: Fever and Petechiae - pathophysiology
(The 5-Minute Pediatric Consult)

Petechiae may result from several different mechanisms:

• Disruption of vascular integrity—owing to infections, vasculitis, or trauma
• Platelet deficiency or dysfunction—typically thrombocytopenia owing to sepsis, disseminated intravascular coagulation (DIC), ITP, or leukemia
• Factor deficiencies (more likely to manifest as ecchymoses and deep bleeding)

Fever and Petechiae - etiology

Petechiae, when accompanied by fever, most often have an infectious cause. Multiple organisms are associated with fever and petechiae. Less commonly, fever and petechiae may be caused by other entities, such as acute leukemia, ITP, and bacterial endocarditis.

• Bacterial:
  • N. meningitidis
  • S. pneumoniae
  • H. influenzae type B
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Escherichia coli
• Viral:
  • Enterovirus
  • Adenovirus
  • Influenza
  • Parainfluenza
  • Epstein-Barr virus (EBV)
  • Rubella
  • Respiratory syncytial virus
  • Hepatitis viruses
• Rickettsial diseases:
  • Rickettsia rickettsii
  • Ehrlichiosis

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

Jaundice: Jaundice - etiology
(The 5-Minute Pediatric Consult)

The most common causes of pathologic jaundice:

• Newborn period: Biliary atresia, idiopathic neonatal hepatitis, α1-antitrypsin deficiency, infection
• Older child: Autoimmune hepatitis, viral hepatitis, Wilson disease, biliary obstruction

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

Fever and Neutropenia: Patient Afebrile within the First 3 to 5 Days of Treatment, Etiology Found
(Pediatric Infectious Disease)

If a responsible pathogen is isolated, the antibiotics can be changed to give optimal treatment to the specific pathogen. Antibiotic treatment should be continued for a minimum of 7 days; many specialists continue treatment for at least 10 to 14 days if an isolate is recovered in blood culture. Often, antibiotics are continued until there is evidence of bone marrow recovery (i.e., neutrophil count > 500/m3). In cases in which neutropenia is predicted to be prolonged, afebrile patients may have antibiotics stopped and are closely observed.

Patient Afebrile, No Etiology Found

The management of these patients is difficult because no infectious disease process has been documented. Patients who are afebrile and who have an absolute neutrophil count of more than 500/m 3 may have their antibiotics discontinued. In persistently neutropenic children, there has been an effort to divide patients into low-risk and high-risk categories. Children are considered at low risk if they lack ongoing signs of sepsis, chills, hypotension, severe mucositis, and have a neutrophil count of more than 100/m 3. In these children, antibiotics may be stopped when the child is afebrile for about 1 week. A small number of studies have suggested that the antibiotic can be changed to oral cefixime and the child monitored closely. It should be noted that these studies involving the use of oral antibiotics often took place with the patients remaining as inpatients for close monitoring. Children who are labeled at high risk (i.e., those with continued absolute neutropenia or mucositis, or in whom follow-up cannot be guaranteed) are continued on intravenous antibiotics until the resolution of neutropenia.

Continued Fever without Etiology

Patients who continue to have fever without obvious etiology present the most difficult management dilemma. The most important management principal in these patients is continued evaluation with physical examination, blood cultures, and radiographic studies. Because systemic fungal infections can be associated with negative blood cultures and may present with progressive intracranial, sinus, or pulmonary disease, these areas should be closely monitored. Examination of the oropharynx for viral lesions caused by either herpes simplex virus or cytomegalovirus is important. Children with persistent fever and neutropenia are often treated for 2 weeks, with a complete reevaluation at that time. In certain situations, it has been suggested that if the patient remains clinically stable with no evidence of progressive infectious disease, antibiotics may be discontinued under close observation.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Infectious Disease, 2004

Outpatient Evaluation of Fever: Epidemiology and Etiology
(Pediatric Infectious Disease)

More than one half of all women have bacterial genital tract colonization, often with group B streptococcus. About one half of neonates born to colonized women themselves become colonized. Of these colonized infants, about 1% develop invasive disease. Risk factors for invasive neonatal disease include prematurity, maternal fever during delivery, and prolonged rupture of membranes.

There are certain patient populations in which the chance of a serious bacterial infection is high and the physical exam and laboratory evaluations nonspecific enough that a full workup and empiric antibiotics are always indicated. Such a patient is the child in the first month of life.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Infectious Disease, 2004

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