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Year 3 Academic Weeks > A1- Fever Including the Returning Traveller > Flashcards

A1- Fever Including the Returning Traveller Flashcards

1
Q

What is a fever?

A

Fever is > 38oC (for core temperature; tympanic or rectal)

• Note measurements at different sites • Oral measurement fever is > 37.5oC • Axillary fever is >37.3oC

At other sites, temperatures are lower than the core temperature, so correspondingly defining a fever using these, has lower threshold

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2
Q

WHat is normal temperature range?

A

Most consider 37oC as ‘normal’ but it can vary by a degree or more

  • Core temperature is maintained in a range
  • And has a diurnal variation
  • Peak at 4pm
  • And varies according to age, external environment and co-morbidities
  • Mean core temperature = 36.6 oC
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3
Q

Fever of Unknown Origin

New definition (Durack & Street 1995)

(3 things)

A
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4
Q

There are 4 main groups of aetiologies for FUO

WHat are they?

A
  • Infective 20-30%
  • Inflammatory/autoimmune 20-25%
  • Neoplastic 10-20%
  • Miscellaneous 10-15%
  • Undiagnosed 25-30%
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5
Q

Example causes of through infection?

A
  • Localized pyogenic infection: Abscesses, Endocarditis
  • Systemic bacterial infection eg typhoid
  • Rickettsial infections
  • Coxiella burnettii (Q fever)
  • Mycobacterial (MTB, MAI)
  • Fungal eg cryptococcal, histoplasmosis
  • Viral eg HIV, CMV
  • Parasitic eg malaria, toxoplasmosis
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6
Q

Example causes of Inflammatory disorders that lead to fever?

A
  • Giant cell arteritis
  • Rheumatoid arthritis
  • Systemic Lupus Erythematosis
  • Behcets
  • Polyarteritis nodosa
  • Granulomatosis with polyangitis
  • Other vasculitides
  • Polymyalgia rheumatica
  • Stills disease
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7
Q

Example causes of Neoplasms that lead to fever

A
  • Lymphoma
  • Leukaemia
  • Solid organ tumours: eg Hepatocellular, Renal Cell Carcinoma, Metastatic lesions esp hepatic
  • Sarcoma
  • Atrial myxomas
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8
Q

Miscellaneous causes of fever

A
  • Granulomatous diseases: Inflammatory bowel disease; sarcoidosis
  • Drug induced fever
  • Endocrine: Thyrotoxicosis; phaeochromocytoma
  • Intracerebral: SOL, pontine CVA
  • Metabolic/ inherited eg Familial Mediterranean fever
  • Tissue infarction: eg post MI (Dresslers syndrome), recurrent PE
  • Factitious fever
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9
Q

WHat are some antibiotics that cause fever?

A
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10
Q

What are some antihypertensives that cause fever

A
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11
Q

Other drugs that cause fever?

A
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12
Q

What should you be looking for when somone presents with fever

A
  • Exact onset of fever, duration and accompanying symptoms eg rigors night sweats
  • Other signs or symptoms emerging or disappearing during the course of the illness
  • If none forthcoming check key features of more common and severe aetiologies

Eg. Weight loss is a red flag for malignancy • Drenching night sweats common in haematological malignancies and TB • Unilateral headache or jaw claudication in elderly (giant cell arteritis)

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13
Q

Fever

What to look out for in PMH?

A
  • Malignancy/ chemo; Immunosuppression
  • Conditions may require steroids
  • Prosthetic material
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14
Q

Fever

What to look out for in DH

A
  • Immunosuppressants
  • New drugs incl OTC, herbal, recreational, vaccinations
  • Contraceptives (PE)
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15
Q

Fever

What to look out for in SH?

A
  • Smoking/ alcohol XS; increased risk cancers, cirrhosis
  • Occupation/ hobbies / travel : zoonoses
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16
Q

Fever

What to look out for in FH?

A
  • Hx of cancers
  • Ethnicity; familial fevers
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17
Q

Fever

What to check for in examination?

A

• General • Don’t forget mouth, dentition • Respiratory • Cardiovascular • Look for endocarditis features • Gastrointestinal • Neurological

Check for

• Lymph nodes •Spine and joints •Skin (rashes, ulcers scars, bites pressure areas) • Malignancy areas; breast, prostate) •Implant sites; pacemakers, prosthetic joints, central or peripheral vascular lines, shunts, grafts and meshes

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18
Q

Fever

Examination clues

What do the following symptoms suggest?

A
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19
Q

Baseline Ix for fever

A
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20
Q

Further investigations as guided for fever

A
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21
Q

What imaging can you do for a patient with fever?

A

• CXR • Miliary – disseminated TB • Atelectasis • Raised hemidiphargam >>>hepatic, splenic pancreatic or subphrenic abscess • Pleural effusion • Mediastinal mass (lymphoma TB sarcoid)

• USS

• CT CAP • Mediastinal mass • Dorsal spine spondylitis disc space disease • Abscesses • Retroperitoneal tumours, LNs or haematomas

• MRI spleen LN brain

•PET CT scan

22
Q

treatment for fever?

A
  • Supportive care, until definitive diagnosis made
  • Attempt to NOT give antimicrobial or steroid trials
23
Q

What are some important factors to think about for someone with fever

A
  • Ensure thorough history, examination & baseline panel has been done
  • Return to history & examination regularly
  • Consider non infectious causes early
  • All patients with PUO should have HIV test
  • Do not give empirical antimicrobial or steroid trials
  • Do not perform serology tests if no history of exposure
  • Careful interpretation of some serology results
  • Consider PET CT scanning
24
Q

What is a common health problem in a returning traveller?

A

Diarrhoea

25
Q

What should be covered in a travel history?

A
26
Q

Falciparum malaria

Tyhoid fever

Parathypoid fever

Leptospirosis

Where are these commonly found around the world?

A
27
Q

Where is lyme disease commonly seen?

A

UK/Europe/USA

28
Q

Where is brucella commonly seen?

A

Middle East/ North Africa

29
Q

Where is Chagas’ Disease seen?

A

South America

30
Q

Where is Meliodosis commonly seen?

A

SE Asia/ Australia

31
Q

Where is Phlebotomine sandlfy Toscana virus seen?

A

Italy; Mediterranean

32
Q

Where is Anopheles mosquito Plasmodium falciparum (Malaria) commonly seen?

A

SSA, Asia ,S.America

33
Q

Where is

Aedes aegypti mosquito

Zika Virus

commonly seen?

A

South America - Brazi

34
Q

Where is

Xenopsylla cheopis (fleas)

Yersinia pestis (Plague)

Commonly seen?

A

Madagascar

35
Q

Some fevers are season name some?

A
36
Q

What disease have a short incubation time?

Short <10 days

A

Acute gastroenteritis

Upper respiratory tract infections

Meningitis

Arbovirus infections (dengue, chikungunya, Zika)

Rickettsial/ relapsing fevers

37
Q

What diseases have a medium incubation time?

Medium 10-21 days

A

Protozoal • Malaria (falcip) • Trypanosomiasis rhodesiense • Acute chagas

Viral • HIV; CMV; EBV; VHFs (EVD, Lassa, Marburg, CCHF)

Bacterial • Enteric fever (typhoid/paratyphoid) • Brucellosis • Q fever • Leptospirosis

38
Q

if the returning traveller has a fever from central/west africa <21 days ago it will most likely be?

A

Viral haemorrhagic fever until proven otherwise

39
Q

THese exposure can cause what diseases?

Freshwater swimming-

Caving (Daubenton bat)-

African game park-

Camels-

Refugee camps-

Austrian mountains – hiking -

A

Freshwater swimming- Schistosomiasis

Caving (Daubenton bat)- Bat lyssavirus

African game park- Tick typhus, tryp rhodesiense

Camels- MERS

Refugee camps- Diarrhoeal illnesses, measles

Austrian mountains – hiking - Tick borne encephalitis

40
Q

More exposures that can cause diseases?

What are the possbile causes of fever?

A
41
Q

These physical signs suggests what ?

A
42
Q

Ix for fever

the essentials

A

Malaria film (thick and thin)/ antigen test

FBC

Blood Cultures

UEs/ LFTs

Serum save (for serological testing)

EDTA for PCR

Other cultures (urine/ stool/ sputum)

CXR

43
Q

Vague presentation of malaria can be?

A

(fevers malaise, myalgia headache, diarrhoea, cough, jaundice, confusion

44
Q

Assessment for Malaria?

A

Observations including BM and urine output

Be very worried about:

  • GCS2%
  • Hypoglycaemia
  • Hb<8
  • PH <7.3
  • Haemoglobinuria
  • Spontaneous bleeding/DIC
  • Pulmonary oedema/ARDS
45
Q

Treatment for malaria?

A
46
Q

What do we mean by enteric fever?

A

typhoid/ paratyphoid

47
Q

Enteric fever

is more commonly seen in Asia or Africa

A

Asia

48
Q

What are some importatn features of enteric fever?

A
  • Incub. 1-3 weeks
  • Salmonella typhi/ paratyphi
  • Can present as anything
  • Fever important; with bradycardia
  • Untreated illness typically lasts 4 weeks
  • Early antibiotic treatment reduces morbidity & mortality
49
Q

Describe a timeline of enteric fever from week 1 to week 4

A

1st week – non specific features

2nd week – bacteraemia; • ‘rose spots’ MP 2-3 mm lesions blanch, • classic sustained high temperature plus bradycardia

3rd week – increasing toxicity; • complications (GI hge, perforation, neuro); diarrhoea

4th week - gradual improvement

50
Q

What is Katayama fever?

A

Katayama fever is a manifestation of acute schistosomiasis. Typical features include fever, an urticarial rash, enlarged liver and spleen, and bronchospasm. The precise pathogenesis of Katayama fever is unknown, but it is thought to be an immune complex phenomenon, initiated by eggs laid by maturing schistosomes.

51
Q

Important features of Katayama fever to know?

A
52
Q

What should you be looking for when returning traveller presents with fever

A

Year 3 Academic Weeks (40 decks)

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