Chills [Rigors]
Chills are extreme, involuntary muscle contractions with characteristic paroxysms of violent shivering and teeth chattering. Commonly accompanied by a fever, chills tend to arise suddenly, usually heralding the onset of infection. Certain diseases, such as pneumococcal pneumonia, produce only a single, shaking chill. Other diseases, such as malaria, produce intermittent chills with recurring high fever. Still others produce continuous chills for up to 1 hour, precipitating a high fever. (See Why chills accompany fever.)
Chills can also result from lymphomas, blood transfusion reactions, and certain drugs. Chills without fever occur as a normal response to exposure to cold. (See Rare causes of chills.)
History and physical examination
Ask the patient when the chills began and whether they're continuous or intermittent. Because fever commonly accompanies or follows chills, take his rectal temperature to obtain a baseline reading. Then check his temperature often to monitor fluctuations and to determine his temperature curve. Typically, a localized infection produces a sudden onset of shaking chills, sweats, and high fever. A systemic infection produces intermittent chills with recurring episodes of high fever or continuous chills that may last up to 1 hour and precipitate a high fever.
Ask about related signs and symptoms, such as headache, dysuria, diarrhea, confusion, abdominal pain, cough, sore throat, or nausea. Does the patient have any known allergies, an infection, or a recent history of an infectious disorder? Find out which medications he's taking and whether a drug has improved or worsened his symptoms. Has he received treatment that may predispose him to an infection (such as chemotherapy)? Ask about recent exposure to farm animals, guinea pigs, hamsters, dogs, and such birds as pigeons, parrots, and parakeets. Also ask about recent insect or animal bites, travel to foreign countries, and contact with persons who have an active infection.
Medical causes
Acquired immunodeficiency syndrome (AIDS).
AIDS is a commonly fatal disease that's caused by infection with the human immunodeficiency virus transmitted by blood or semen. The patient usually develops lymphadenopathy and may also experience fatigue, anorexia and weight loss, diarrhea, diaphoresis, skin disorders, and signs of upper respiratory tract infection. Opportunistic infections can cause serious disease in the patient with AIDS.
Anthrax (inhalation).
Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in a cutaneous, inhalation, or GI form.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
Cholangitis.
Charcot's triad — chills with spiking fever, abdominal pain, and jaundice — characterizes a sudden obstruction of the common bile duct. The patient may have associated pruritus, weakness, and fatigue.
Gram-negative bacteremia.
Gram-negative bacteremia causes sudden chills and a fever, nausea, vomiting, diarrhea, and prostration.
Hemolytic anemia
With acute hemolytic anemia, fulminating chills occur with a fever and abdominal pain. The patient rapidly develops jaundice and hepatomegaly; he may develop splenomegaly.
Hepatic abscess.
Hepatic abscess usually arises abruptly, with chills, a fever, nausea, vomiting, diarrhea, anorexia, and severe upper abdominal tenderness and pain that may radiate to the right shoulder.
Infective endocarditis.
Infective endocarditis produces the abrupt onset of intermittent, shaking chills with a fever. Petechiae commonly develop. The patient may also have Janeway lesions on his hands and feet and Osler's nodes on his palms and soles. Associated findings include a murmur, hematuria, eye hemorrhage, Roth's spots, and signs of cardiac failure (dyspnea, peripheral edema).
Influenza.
Initially, influenza causes an abrupt onset of chills, a high fever, malaise, a headache, myalgia, and a nonproductive cough. Some patients may also suddenly develop rhinitis, rhinorrhea, laryngitis, conjunctivitis, hoarseness, and a sore throat. Chills generally subside after the first few days, but an intermittent fever, weakness, and a cough may persist for up to 1 week.
Legionnaires' disease.
Within 12 to 48 hours after the onset of Legionnaires' disease, the patient suddenly develops chills and a high fever. Prodromal signs and symptoms characteristically include malaise, a headache, and possibly diarrhea, anorexia, diffuse myalgia, and general weakness. An initially nonproductive cough progresses to a productive cough with mucoid or mucopurulent sputum and possibly hemoptysis. The patient usually also develops nausea and vomiting, confusion, mild temporary amnesia, pleuritic chest pain, dyspnea, tachypnea, crackles, tachycardia, and flushed and mildly diaphoretic skin.
Malaria.
The paroxysmal cycle of malaria begins with a period of chills lasting 1 to 2 hours. This is followed by a high fever lasting 3 to 4 hours and then 2 to 4 hours of profuse diaphoresis. Paroxysms occur every 48 to 72 hours when caused by Plasmodium malariae and every 40 to 42 hours when caused by P. vivax or P. ovale. With benign malaria, the paroxysms may be interspersed with periods of well-being. The patient also has a headache, muscle pain and, possibly, hepatosplenomegaly.
Pelvic inflammatory disease.
Pelvic inflammatory disease causes chills and fever with, typically, lower abdominal pain and tenderness; profuse, purulent vaginal discharge; or abnormal menstrual bleeding. The patient may also develop nausea and vomiting, an abdominal mass, and dysuria.
Plague
(Yersinia pestis). Plague is one of the most virulent bacterial infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to a human when bitten by an infected flea. Signs and symptoms include a fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pneumonia.
A single shaking chill usually heralds the sudden onset of pneumococcal pneumonia; other pneumonias characteristically cause intermittent chills. With any type of pneumonia, related findings may include a fever, a productive cough with bloody sputum, pleuritic chest pain, dyspnea, tachypnea, and tachycardia. The patient may be cyanotic and diaphoretic, with bronchial breath sounds and crackles, rhonchi, increased tactile fremitus, and grunting respirations. He may also experience achiness, anorexia, fatigue, and a headache.
Puerperal or postabortal sepsis.
Chills and a high fever occur as early as 6 hours or as late as 10 days postpartum or postabortion. The patient may also have a purulent vaginal discharge, an enlarged and tender uterus, abdominal pain, backache and, possibly, nausea, vomiting, and diarrhea.
Pyelonephritis.
With acute pyelonephritis, the patient develops chills, a high fever, and possibly nausea and vomiting over several hours to days. He generally also has anorexia, fatigue, myalgia, flank pain, costovertebral angle (CVA) tenderness, hematuria or cloudy urine, and urinary frequency, urgency, and burning.
Q fever.
Q fever is a rickettsial disease caused by Coxiella burnetii. The primary source of human infection results from exposure to infected animals. Cattle, sheep, and goats are most likely to carry the organism. Human infection results from exposure to contaminated milk, urine, feces, or other fluids from infected animals. Infection may also result from inhalation of contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include 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.
Renal abscess.
Renal abscess initially produces sudden chills and a fever. Later effects include flank pain, CVA tenderness, abdominal muscle spasm, and transient hematuria.
Rocky Mountain spotted fever.
Rocky Mountain spotted fever begins with a sudden onset of chills, a fever, malaise, an excruciating headache, and muscle, bone, and joint pain. Typically, the patient's tongue is covered with a thick white coating that gradually turns brown. After 2 to 6 days of fever and occasional chills, a macular or maculopapular rash appears on the hands and feet and then becomes generalized; after a few days, the rash becomes petechial.
Septic arthritis.
Chills and fever accompany the characteristic red, swollen, and painful joints caused by septic arthritis.
Septic shock.
Initially, septic shock produces chills, a fever and, possibly, nausea, vomiting, and diarrhea. The patient's skin is typically flushed, warm, and dry; his blood pressure is normal or slightly low; and he has tachycardia and tachypnea. As septic shock progresses, the patient's arms and legs become cool and cyanotic, and he develops oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Later, his skin becomes cold and clammy; his pulse, rapid and thready. He further develops severe hypotension, persistent oliguria or anuria, signs of respiratory failure, and coma.
Sinusitis.
With acute sinusitis, chills occur along with a fever, a headache, and pain, tenderness, and swelling over the affected sinuses. Maxillary sinusitis produces pain over the cheeks and upper teeth; ethmoid sinusitis, pain over the eyes; frontal sinusitis, pain over the eyebrows; and sphenoid sinusitis, pain behind the eyes. The primary indicator of sinusitis is nasal discharge, which is commonly bloody for 24 to 48 hours before it gradually becomes purulent.
Snake bite.
Most pit viper bites that result in envenomization cause chills, typically with a fever. Other systemic signs and symptoms include sweating, weakness, dizziness, fainting, hypotension, nausea, vomiting, diarrhea, and thirst. The area around the snake bite may be marked by immediate swelling and tenderness, pain, ecchymoses, petechiae, blebs, bloody discharge, and local necrosis. The patient may have difficulty speaking, blurred vision, and paralysis. He may also show bleeding tendencies and signs of respiratory distress and shock.
Tularemia.
Also known as rabbit fever, tularemia is an infectious disease that's caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. It's typically a rural disease found in wild animals, water, and moist soil. It's transmitted to humans through the bite of an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It's considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the 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 transmitted to humans by fleas, mites, or body louse. Initial signs and symptoms include a headache, myalgia, arthralgia, and malaise followed by an abrupt onset of chills, a fever, nausea, and vomiting. A maculopapular rash may be present in some cases.
Violin spider bite.
The violin spider bite produces chills, a fever, malaise, weakness, nausea, vomiting, and joint pain within 24 to 48 hours. The patient may also develop a rash and delirium.
Other causes
Drugs.
Amphotericin B is a drug associated with chills. Phenytoin is also a common cause of drug-induced fever that can produce chills. I.V. bleomycin and intermittent administration of an oral antipyretic can also cause chills.
I.V. therapy.
Infection at the I.V. insertion site (superficial phlebitis) can cause chills, high fever, and local redness, warmth, induration, and tenderness.
Transfusion reaction.
A hemolytic reaction may cause chills during the transfusion or immediately afterward. A nonhemolytic febrile reaction may also cause chills.
Special considerations
Check the patient's vital signs often, especially if his chills result from a known or suspected infection. Be alert for signs of progressive septic shock, such as hypotension, tachycardia, and tachypnea. If appropriate, obtain samples of blood, sputum, wound drainage, or urine for culture to determine the causative organism. Give the appropriate antibiotic. Radiographic studies may be required.
Because chills are an involuntary response to an increased body temperature set by the hypothalamic thermostat, blankets won't stop a patient's chills or shivering. Despite this, keep his room temperature as even as possible. Provide adequate hydration and nutrients, and give an antipyretic to help control a fever. The irregular use of an antipyretic can trigger compensatory chills.
Pediatric pointers
Infants don't get chills because they have poorly developed shivering mechanisms. In addition, most classic febrile childhood infections, such as measles and mumps, don't typically produce chills. However, older children and teenagers may have chills with mycoplasma pneumonia and acute pyogenic osteomyelitis.
Geriatric pointers
Chills in an elderly patient usually indicate an underlying infection, such as a urinary tract infection, pneumonia (commonly associated with aspiration of gastric contents), diverticulitis, or skin breakdown in pressure areas. Also, consider an ischemic bowel in an elderly patient who comes into your facility with a fever, chills, and abdominal pain.
Pictures
![Chills [Rigors] - 4432.1.jpg](/bookimages/5/4432.1.jpg)
![Chills [Rigors] - 4432.2.jpg](/bookimages/5/4432.2.jpg)
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.
Other Book Chapters Related to Chills
Read excerpts from these other book chapters related to Chills:
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- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Chills
» Next page: Cold injuries (Professional Guide to Diseases (Eighth Edition))
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