A1- Fever Including the Returning Traveller Flashcards
What is a fever?
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
WHat is normal temperature range?
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
Fever of Unknown Origin
New definition (Durack & Street 1995)
(3 things)
There are 4 main groups of aetiologies for FUO
WHat are they?
- Infective 20-30%
- Inflammatory/autoimmune 20-25%
- Neoplastic 10-20%
- Miscellaneous 10-15%
- Undiagnosed 25-30%
Example causes of through infection?
- 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
Example causes of Inflammatory disorders that lead to fever?
- Giant cell arteritis
- Rheumatoid arthritis
- Systemic Lupus Erythematosis
- Behcets
- Polyarteritis nodosa
- Granulomatosis with polyangitis
- Other vasculitides
- Polymyalgia rheumatica
- Stills disease
Example causes of Neoplasms that lead to fever
- Lymphoma
- Leukaemia
- Solid organ tumours: eg Hepatocellular, Renal Cell Carcinoma, Metastatic lesions esp hepatic
- Sarcoma
- Atrial myxomas
Miscellaneous causes of fever
- 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
WHat are some antibiotics that cause fever?
What are some antihypertensives that cause fever
Other drugs that cause fever?
What should you be looking for when somone presents with fever
- 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)
Fever
What to look out for in PMH?
- Malignancy/ chemo; Immunosuppression
- Conditions may require steroids
- Prosthetic material
Fever
What to look out for in DH
- Immunosuppressants
- New drugs incl OTC, herbal, recreational, vaccinations
- Contraceptives (PE)
Fever
What to look out for in SH?
- Smoking/ alcohol XS; increased risk cancers, cirrhosis
- Occupation/ hobbies / travel : zoonoses
Fever
What to look out for in FH?
- Hx of cancers
- Ethnicity; familial fevers
Fever
What to check for in examination?
• 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
Fever
Examination clues
What do the following symptoms suggest?
Baseline Ix for fever
Further investigations as guided for fever
What imaging can you do for a patient with fever?
• 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
treatment for fever?
- Supportive care, until definitive diagnosis made
- Attempt to NOT give antimicrobial or steroid trials
What are some important factors to think about for someone with fever
- 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
What is a common health problem in a returning traveller?
Diarrhoea
What should be covered in a travel history?
Falciparum malaria
Tyhoid fever
Parathypoid fever
Leptospirosis
Where are these commonly found around the world?
Where is lyme disease commonly seen?
UK/Europe/USA
Where is brucella commonly seen?
Middle East/ North Africa
Where is Chagas’ Disease seen?
South America
Where is Meliodosis commonly seen?
SE Asia/ Australia
Where is Phlebotomine sandlfy Toscana virus seen?
Italy; Mediterranean
Where is Anopheles mosquito Plasmodium falciparum (Malaria) commonly seen?
SSA, Asia ,S.America
Where is
Aedes aegypti mosquito
Zika Virus
commonly seen?
South America - Brazi
Where is
Xenopsylla cheopis (fleas)
Yersinia pestis (Plague)
Commonly seen?
Madagascar
Some fevers are season name some?
What disease have a short incubation time?
Short <10 days
Acute gastroenteritis
Upper respiratory tract infections
Meningitis
Arbovirus infections (dengue, chikungunya, Zika)
Rickettsial/ relapsing fevers
What diseases have a medium incubation time?
Medium 10-21 days
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
if the returning traveller has a fever from central/west africa <21 days ago it will most likely be?
Viral haemorrhagic fever until proven otherwise
THese exposure can cause what diseases?
Freshwater swimming-
Caving (Daubenton bat)-
African game park-
Camels-
Refugee camps-
Austrian mountains – hiking -
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
More exposures that can cause diseases?
What are the possbile causes of fever?
These physical signs suggests what ?
Ix for fever
the essentials
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
Vague presentation of malaria can be?
(fevers malaise, myalgia headache, diarrhoea, cough, jaundice, confusion
Assessment for Malaria?
Observations including BM and urine output
Be very worried about:
- GCS2%
- Hypoglycaemia
- Hb<8
- PH <7.3
- Haemoglobinuria
- Spontaneous bleeding/DIC
- Pulmonary oedema/ARDS
Treatment for malaria?
What do we mean by enteric fever?
typhoid/ paratyphoid
Enteric fever
is more commonly seen in Asia or Africa
Asia
What are some importatn features of enteric fever?
- 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
Describe a timeline of enteric fever from week 1 to week 4
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
What is Katayama fever?
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.
Important features of Katayama fever to know?
What should you be looking for when returning traveller presents with fever
