Chills [Rigors]

Chills are extreme, involuntary muscle contractions with characteristic paroxysms of violent shivering and teeth chattering. Commonly caused by an increased body temperature set by the hypothalamic thermostat, chills are usually accompanied by fever and tend to arise suddenly, 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 the use of certain drugs. Chills without fever are a normal response to exposure to cold. (See Rare causes of chills, page 174.)

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, whereas 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 any drug has improved or worsened his symptoms. Has he received any 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

This commonly fatal disease is caused by infection with 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 these patients.

Anthrax (inhalation)

This acute infectious disease is 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 agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, 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, causing rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Cholangitis

Charcot’s triad—chills with spiking fever, abdominal pain, and jaundice—characterizes sudden obstruction of the common bile duct. The patient may have associated pruritus, weakness, and fatigue.

Gram-negative bacteremia

This infection causes sudden chills and fever, nausea, vomiting, diarrhea, and prostration.

Hemolytic anemia

In acute hemolytic anemia, fulminating chills occur with fever and abdominal pain. The patient rapidly develops jaundice and hepatomegaly; he may develop splenomegaly.

Hepatic abscess

This infection usually arises abruptly, with chills, fever, nausea, vomiting, diarrhea, anorexia, and severe upper abdominal tenderness and pain that may radiate to the right shoulder.

Hodgkin’s disease

The patient characteristically experiences several days or weeks of fever and chills alternating with periods of no fever and no chills. This disorder commonly produces regional lymphadenopathy that may progress to hepatosplenomegaly. Other findings include diaphoresis, fatigue, and pruritus.

Infective endocarditis

This infection produces abrupt onset of intermittent shaking chills with fever. In addition to petechiae, the patient may have Janeway lesions on his hands and feet and Osler’s nodes on his palms and soles. Associated findings include murmur, hematuria, eye hemorrhage, Roth’s spots, and signs of heart failure (dyspnea, peripheral edema).

Influenza

Initially, this disorder causes an abrupt onset of chills, high fever, malaise, headache, myalgia, and nonproductive cough. Some patients may also suddenly develop rhinitis, rhinorrhea, laryngitis, conjunctivitis, hoarseness, and sore throat. Chills generally subside after the first few days, but intermittent fever, weakness, and cough may persist for up to 1 week.

Legionnaires’ disease

Within 12 to 48 hours after the onset of this disease, the patient suddenly develops chills and a high fever. Prodromal signs and symptoms characteristically include malaise, 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. Most patients also develop nausea and vomiting, confusion, mild temporary amnesia, pleuritic chest pain, dyspnea, tachypnea, crackles, tachycardia, and flushed and mildly diaphoretic skin.

Lung abscess

In addition to chills, a lung abscess causes sweating, pleuritic chest pain, dyspnea, clubbing, weakness, headache, malaise, anorexia, weight loss, and a cough that produces large amounts of purulent, foul-smelling and, possibly, bloody sputum.

Lyme disease

The bite of a tiny deer tick can transmit this infection, which causes a red macule or papule (erythema migrans) to develop at the bite site. It’s accompanied by chills, fever, malaise, fatigue, lymphadenopathy, arthralgia, and rash. If untreated, Lyme disease may cause cranial neuritis with facial palsy, heart blocks, arthritis, and a characteristic sclerotic rash.

Lymphangitis

Acute lymphangitis produces chills and other systemic signs and symptoms, such as fever, malaise, and headache. Its characteristic signs are red streaks radiating from a wound and cellulitis draining toward tender regional lymph nodes.

Lymphogranuloma venereum

This disorder produces chills, fever, lymphadenopathy, headache, anorexia, myalgia, arthralgia, and weight loss. The primary genital lesion is a papule or small erosion that precedes lymphatic involvement and heals spontaneously within a few days.

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 42 to 40 hours when caused by P. vivax or P. ovale. In benign malaria, the paroxysms may be interspersed with periods of well-being. The patient also has a headache, muscle pain, and possibly hepatosplenomegaly.

Miliary tuberculosis

In the acute form of this disease, the patient suffers intermittent chills, high fever, and night sweats. Epididymal or testicular nodules and splenomegaly may also occur.

Monkeypox

Many individuals infected with the monkeypox virus experience chills. Other common initial symptoms of this rare virus include fever, lymphadenopathy, sore throat, dyspnea, muscle aches, and rash. Although monkeypox occurs primarily in central and western Africa, it was confirmed in the United States in 2003 when several humans contracted the virus from infected pet prairie dogs. There is no treatment for this virus; however, given its similarity to smallpox, the smallpox vaccine is used in certain circumstances to protect individuals against monkeypox.

Otitis media

Acute suppurative otitis media produces chills with fever and severe deep, throbbing ear pain. The patient usually displays a mild conductive hearing loss and a bulging, hyperemic tympanic membrane. He may also have dizziness, nausea, and vomiting. When the tympanic membrane ruptures, pus drains externally through the ear canal and the patient feels relief.

Pelvic inflammatory disease

In this infection, chills and fever are typically accompanied by 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

Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, lethal bacterial infections 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 man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when the plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, 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. In any type of pneumonia, related findings may include fever, 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 headache.

Psittacosis

This disease typically begins with the sudden onset of chills, fever, headache, myalgia, epistaxis, and prostration. A dry, hacking cough occurs initially, progressing to pneumonia with a cough that produces small amounts of mucoid, blood-streaked sputum. The patient also experiences tachypnea, fine crackles, photophobia, abdominal distention and tenderness, nausea, vomiting, a faint macular rash and, rarely, chest pain.

Pyelonephritis

In acute pyelonephritis, the patient develops chills, high fever, and possibly nausea and vomiting over several hours to days. He generally also has anorexia, fatigue, myalgia, flank pain, costovertebral angle tenderness, hematuria or cloudy urine, and urinary frequency, urgency, and burning.

Q fever

Q fever is a rickettsial disease caused by Coxiella burnetii, an organism found in cattle, sheep, and goats. Human infection usually results from exposure to contaminated milk, urine, feces, or other fluids from infected animals, but it 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 fever, chills, 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

This abscess initially produces sudden chills and fever. Later effects include flank pain, costovertebral angle tenderness, abdominal muscle spasm, and transient hematuria.

Rocky Mountain spotted fever

This disorder begins suddenly with chills, 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.

Sepsis, puerperal or postabortal

Chills and 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.

Septic arthritis

Chills and fever accompany the characteristic red, swollen, and painful joints caused by this disorder.

Septic shock

Initially, septic shock produces chills, 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 exhibits oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Later, he develops cold and clammy skin, a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, signs of respiratory failure, and coma.

Sinusitis

In acute sinusitis, chills are accompanied by fever, 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 gradually becoming purulent.

Snake bite

Most pit viper bites that result in envenomization cause chills, typically with 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, paralysis, bleeding tendencies, and signs of respiratory distress and shock.

Tularemia

Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhoid fever

This disorder may initially cause sudden chills and a sharply rising fever. More commonly, though, the patient’s body temperature gradually increases for 5 to 7 days with accompanying chilliness or frank chills. Headache, abdominal discomfort, constipation, and demonstrable splenomegaly appear by the end of the first week. A characteristic rash called “rose spots” develops on the upper abdomen and anterior thorax during the second week but lasts only 2 to 3 days. Later, the patient may develop a dry cough, epistaxis, mental dullness or delirium, marked abdominal distention, significant weight loss, profound fatigue, and diarrhea. The heart rate may be unusually slow in relation to the high fever.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial signs and symptoms include headache, myalgia, arthralgia, and malaise followed by an abrupt onset of chills, fever, nausea, and vomiting. A maculopapular rash may be present in some cases.

Violin spider bite

This bite produces chills, 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, or wound drainage for culture tests to determine the causative organism. Give the appropriate antibiotic. Radiographic studies and serum and urine samples may be required.

Because chills are an involuntary response to an increased body temperature, 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 fever. 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 fever, chills, and abdominal pain.

Patient counseling

Advise the patient to measure his temperature with a thermometer when he experiences chills and to document the exact readings and times. This will help reveal patterns that may point to a specific diagnosis.

Pictures

Book Source Details

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

Other Book Chapters Related to Chills

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Chills

• Back to symptom: Chills: Introduction (review 714 causes)
• Next Book Extract About Chills: Cold intolerance (Professional Guide to Signs & Symptoms (Fifth Edition))
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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