Diseases » Respiratory infections

Fever

Fever: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Pyrexia

A fever is a common sign that can arise from many disorders. Because these disorders can affect virtually any body system, a fever in the absence of other signs usually has little diagnostic significance. A persistent high fever, though, represents an emergency.

A fever can be classified as low (oral reading of 99° to 100.4° F [37.2° to 38° C]), moderate (100.5° to 104° F [38 ° to 40° C]), or high (above 104° F). A fever greater than 106° F (41.1° C) causes unconsciousness and, if sustained, leads to permanent brain damage.

A fever may also be classified as remittent, intermittent, sustained, relapsing, or undulant.

Remittent fever, the most common type, is characterized by daily temperature fluctuations above the normal range.

Intermittent feveris marked by a daily temperature drop into the normal range and then a rise back to above normal. An intermittent fever that fluctuates widely, typically producing chills and sweating, is called

hectic,or septic, fever. Sustained feverinvolves persistent temperature elevation with little fluctuation.

Relapsing feverconsists of alternating feverish and afebrile periods.

Undulant fever refers to a gradual increase in temperature that stays high for a few days and then decreases gradually.

Further classification involves duration — either brief (less than 3 weeks) or prolonged. Prolonged fevers include fever of unknown origin, a classification used when careful examination fails to detect an underlying cause.

Emergency interventions

If you detect a fever higher than 106° F, take the patient’s other vital signs and determine his level of consciousness (LOC). Administer an antipyretic and begin rapid cooling measures: Apply ice packs to the axillae and groin, give tepid sponge baths, or apply a cooling blanket. These methods may evoke a cooling response; to prevent this, constantly monitor the patient’s rectal temperature.

History and physical examination

If the patient’s fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience other symptoms, such as chills, fatigue, or pain?

Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and the use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

Let the history findings direct your physical examination. Because a fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (SeeHow fever develops.)

Medical causes

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

Special considerations

Regularly monitor the patient’s temperature, and record it on a chart for easy
follow-up of the temperature curve. Provide increased fluid and nutritional intake. When administering a prescribed antipyretic, minimize resultant chills and diaphoresis by following a regular dosage schedule. Promote patient comfort by maintaining a stable room temperature and providing frequent changes of bedding and clothing. For high fevers, initial treatment with a hypothermia blanket. Prepare the patient for laboratory tests, such as complete blood count and cultures of blood, urine, sputum, and wound drainage.

Pediatric pointers

Infants and young children experience higher and more prolonged fevers, more rapid temperature increases, and greater temperature fluctuations than older children and adults.

Keep in mind that seizures commonly accompany an extremely high fever, so take appropriate precautions. Also, instruct parents not to give aspirin to a child with varicella or flulike symptoms because of the risk of precipitating Reye’s syndrome.

Common pediatric causes of fever include varicella, croup syndrome, dehydration, meningitis, mumps, otitis media, pertussis, roseola infantum, rubella, rubeola, and tonsillitis. A fever can also occur as a reaction to immunizations and antibiotics.

Geriatric pointers

Elderly people may have an altered sweating mechanism that predisposes them to heatstroke when exposed to high temperatures; they may also have an impaired thermoregulatory mechanism, making temperature change a much less reliable measure of disease severity.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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