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Week 120 > Fever > Flashcards

Fever Flashcards

1
Q

What is fever?

A

Elevated core temperature often as part of a defensive mechanism against invasion of microorganisms recognised as pathogenic by the host

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2
Q

What % of paediatric admissions are due to fever?

A

30%

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3
Q

How does termperature regulation work?

A

Heat sensitive receptors in skin and within hypothalamus are sensitive to changes inblood temperature

Signal frequency is increased if temperature increases above 37.1, increasing the signal which inhibits sympathetic stimulation causing sweating and vasodilation

Signal frequency is decreased if temperature drops below 37.1, preventing inhibition of the SNS and causing vasoconstriction, piloerection, shivering, behavioural changes.

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4
Q

Effects of a drop in blood temperature?

A

Decreased inhibition of the SNS:

  • piloerection
  • shivering
  • vasoconstriction
  • behavioural changes
  • NA release
  • TSH release
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5
Q

Pathophysiology of fever?

A

Exogenous pyrogen e.g. LPS

Stimulates release of endogenous pyrogens by MACROPHAGES and neutrophils, such as IL-1, IL-6, IFN-Y, TNF-alpha

As well as initiating inflammation, these cross the BBB and cause upregulation of COX2 enzyme which increases PGE2 via the arachidonic acid pathway.

PGE2 acts at the PGER3 in the preoptic area of the hypothalamus raising cAMP and causing sympathetic output.

PGE2 raises the set temperature until PGE2 is no longer present

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6
Q

How do NSAIDs work and how do they cause stomach ulcers?

A

Inhibit COX2 to reduce the inflammatory effects of PGE2 and to reduce the raising of the hypothalamic set temperature

Also inhibit COX1 which reduces basal PGE2 production which usually has a protective effect

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7
Q

What is the primary cytokine to best correlate with fever?

A

IL-6

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8
Q

What cytokine is an endogenous antipyretic factor?

A

IL-10

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9
Q

Which other endogenous antipyretic facotrs are there?

A

glucocorticoids e.g. cortisol

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10
Q

What resets the thermostat?

A

PGE2 (and cAMP)

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11
Q

How does malignancy cause fever?

A

Direct production of TNF-a, IL-1 and IL-6 by the tumour

or

Macrophage production of TNF-a, IL-1, IL-6, in response to the tumour

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12
Q

Describe the APR

A

Endogenous pyrogens are produced by macrophages and neutrophils in response to injury or infection (IL-1, IL-6, IFN-y, TNF-a)

These cause the liver to produce CRP, SAA, fibrinogen, complement factor (up to several hundred times their basal concentration)

CRP = opsonin activation
SAA = attracts leukocytes to site
fibrinogen = coagulation factor aids in trapping microbes in blood clots
CF = complement activation
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13
Q

What is raised ESR and what causes it?

A

Erythrocyte sedimentation rate; RBCs fall faster

Due to rouleaux formation

Due to fibrinogen (acute phase response)

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14
Q

What stimulates leukocytosis, and what is it?

A

IL-1 and TNF-a

First mechanism = release of cells from post-mitotic reserve pool in bone marrow = more immature cells (left shift)

Second = CSFs stimulate proliferation of precursor cells in bone marrow e.g. macrophage CSF

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15
Q

Why is fever potentially good?

A

IL-1 is critical for initation of innate immune system

Its evolutionarily conserved

It interfers with growth and virlence of pathogens (which grow best at normal body temp)

Small temperature elevations enhance immune function

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16
Q

What are the four types of fever and their example causes?

A

Remittent - Endocarditis, typhoid
Intermittent - malaria
Sustained - Pneumonia, UTI
Relapsing - tick-borne

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17
Q

What causes a fever which is always elevated but keeps spiking, and what type of fever is it?

A

Remittent fever

Endocarditis, typhoid fever

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18
Q

What causes a normal temp to keep spiking intermittently, within hours?

A

Intermittent fever

Malaria

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19
Q

Fever is always high, what’s it called and examples?

A

Sustained

UTI, pneumonia

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20
Q

Fever is low for a few days then spikes a while then low a few days

A

Relapsing

Tick borne disease

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21
Q

What are the four phases of fever?

A

Prodromal: “flu-like symptoms”, non specific

Chill: feeling cold, shivering etc as temperature is rising toward new set point e.g. vasoconstriction, piloerection, shivering, goose bumps, behavioural changes, feeling warm and shivering then stops.

Flush: cutaneous vasodilation causes red, warm and dry skin

Defervescence: sweating

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22
Q

What are rigors, and common cause?

A

Shivering to try to increase temperature

UTI

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23
Q

Night sweats common causee

A

Lymphoma, TB

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24
Q

Headache is due to? Red flag for? Also though?

A

Vasodilatation of cerebral vessels

Red flag for meningitis

Also common in non-specific fevers though

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25
Q

Delirium

A

Temporary mental confusion

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26
Q

Who is delirium common in?

A

Children and elderly

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27
Q

Myalgia and athralgia

A

Viruses ++ e.g. flu

Bacteraemia ++ e.g. meningococcal disease

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28
Q

Management of sepsis?

A 
ABCDE 
Oxygen
IV fluids
ABx
Blood cultures
Serial lactates
Hourly fluid output
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29
Q

Four conditions not to give antibiotics in?

A

Acute otitis media
Acute conjunctivitis
Acute URTI
Acute sinusitis

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30
Q

When shoudl you give ABx for sinusitis?

A

Double acute sinusitis - typical bacterial

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31
Q

What is hyperthermia?

A

Raised core temperature without a change in set hypothalamic point

Raised core temperature without sweating

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32
Q

What does hyperthermia look like?

A

Tachycardia / tachypnoea

NO SWEATING

Hypothermia

Collapse/LOC/seizures

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33
Q

Which drugs have no effect in hyperthermia?

A

Antipyretics

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34
Q

What is malignant hyperthermia?

A

Autosomal dominant condition

Triggered by exposure to halogenated anaestetic agents in GA or succinylcholine

Drastic increase in oxidative metabolism of skeletal muscle causing muscle contraction and overwhelms bodys ability to produce O2 and remove CO2 - rapid t increase to 43… fast death

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35
Q

What is drug fever.?

A

Fever coinciding with drug administration and ending when drug is stopped

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36
Q

How do antihistamines and TCAs cause drug fever?

A

Impaired heat dissipation

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37
Q

How does cimetidine cause drug fever?

A

Direct blocking of hypothalamic receptors

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38
Q

How do anticancer drugs cause drug fever?

A

Direct pyrogens

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39
Q

What is neuroleptic malignant syndrome and what might cause it?

A

Rare but life threatening reaction to DA antagonist neuroleptic medications such as haloperidol and chlorpromazine.

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40
Q

How does NMS present?

A

Central dopamine blockae in the hypothalamus leads to increased mucular rigitiy, EPS and hyperthermia

Onset 4-14d after start of therapy

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41
Q

How to treat NMS?

A

Discontinue the drugs

May need to treat complication e.g. ITU

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42
Q

How does thyrotoxicosis cause hyperthermia?

A

Raised T3/T4 = raised BMR

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43
Q

Acute exacerbation of chronic bronchitis?

A

Amoxicillin

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44
Q

Low severity CAP

A

Amoxicillin PO

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45
Q

Moderate severity CAP

A

Amoxicillin PO and clarithroymycin PO

Doxycyline if allergy to one

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46
Q

High severity CAP

A

Benpen + clarithromycin IV or co-amoxiclav + clarithromycin IV

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47
Q

HAP

A

Co-amoxiclav (broadspectrum)
Tazocin (anti-pseudomonal)
Ceftazidime (broad-spectrum ceph)

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48
Q

Gastroenteritis

A

Usually nothing as viral or self-limiting

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49
Q

Campylobacter

A

Clarithromycin if severe or immunocomprimised

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50
Q

Salmonella

A

Ciprofloxacin if severe

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51
Q

Shigellosis

A

Ciprofloxacin if severe

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52
Q

C diff

A

Oral metronidazole / vancomycin

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53
Q

Typhoid

A

cefotaxime

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54
Q

Pre-hospital meningitis tx

A

Benzylpenicillin as soon as possible

Cefotaxime if pen allergic

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55
Q

Hospital meningitis tx

A

After initial dose of benpen/cefotaxime

Cefotaxime up to 50y
Add amoxicillin if >50y

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56
Q

Lower UTI

A

Trimethoprim or nitrofurantoin (quinolone)

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57
Q

Lower UTI in pregnancy

A

Cefalexin

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58
Q

Sepsis

A

Tazocin or timentin (broad-spectrum anti-pseudomonal)

or

Cefuroxime (broad-spectrum cephalosporin)

Add vanc if suspected MRSA

Add metronidazole if suspected GIT origin (anaerobe)

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59
Q

Purulent conjunctivitis

A

Chloramphenicol

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60
Q

Periodontitis

A

Metronidazole

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61
Q

Otitis externa

A

Flucloxacillin

Clari if pen allergic

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62
Q

Otitis media

A

Nothing as usually caused by viruses

If systemically unwell or high risk of complications e.g. immunosuppression, amoxicilin or clarithro

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63
Q

Throat infections

A

Pen V

but URTI usually self limiting

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64
Q

Cellulitis

A

Flucloxacillin

65
Q

Biliary / gut

A

Cefuroxime + metronidazole

66
Q

Malaria

A

Quinine + doxycycline

67
Q

TB

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

68
Q

What is lysozyme?

A

Attaches onto PG layer of gram-positives

69
Q

What is the definition of PUO?

A

> 38.3 for 3 weeks

3 days inpatient
3 outpatient consultations

70
Q

Signs & symptoms of meningitis?

A 
Unwell/drowsy
STIFF NECK
Purpuric haemorrhagic non blanching rash
Bulging fontanelle
Decreased consciousness
Fever
71
Q

Investigations of meningitis?

A

Bloods
BLood cultures
LP
CSF culture

72
Q

Treatment of meningitis in neonate?

A

Gentamicin

73
Q

Viral infections signs and symptoms?

A

Prodromal symptoms

Cough

74
Q

Signs and symptoms of roseola infantum?

A

Sixth disease

High fever > generalised macular rash starting on trunk then face > FEVER SUBSIDES VERY QUICKLY ONCE RASH APPEARS and child becomes better

75
Q

Complications of sixth disease?

A

Febrile convulsions, aseptic meningitis / encephalitis

76
Q

Most common time for sixth disease?

A

9-12m

77
Q

Pathophysiology of 6th disease?

A

HHV-6 infects CD4+ lymphocytes - remains latent

Can affect many organs and CNS early

78
Q

Treatment of 6th disease?

A

SUpportive

Antivirals (ganciclovir) in immunocomprimised

79
Q

Most common cause of seizures in childhood?

A

Febrile convulsions

80
Q

What characterises simple febrile convulsons?

A

Up to 15m
Tonic clonic
Once in 24h
Full recovery in 1h

81
Q

What characterises complex febrile convulsons?

A 
Usually tonic clonic
Above 15m
Partial seizure
More thn 1 in 24h
No full recovery in 1h
82
Q

Risk of recurrence of febrile convulsions?

A

30-50%

83
Q

Initial investigations for febrile convulsions?

A

Rule out meningitis / encepahlitis with LUMBAR PUNCTURE

Glucose (hypoglycaemia = seizures)

Ca/Mg (low = seizures)

If all tests negative… maybe febrile convulsions

84
Q

Symptomatic treatment of febrile convulsions

A

Rectal diazepam if above 5 minutes

Antipyretics

85
Q

S&S Elderly patient with UTI

A 
Dysuria
Haematuria
Lower abdo pain
Fever
CLEAR CHEST
86
Q

Ix Elderly patient with UTI

A

Bloods
Urinalysis
MCU (MC&S)

87
Q

Infective endocarditis S&S

A 
Heart murmur
Night sweats 
Weight loss
Myalgia
Arthralgia
Fever
88
Q

Infective endocarditis investigations

A

Bloods
Cultures
CXR
Echo

89
Q

Sepsis

A 
Rigors
Hypotension
Tachycardia
Headache
Fever
Oliguria
90
Q

Sepsis ix

A 
Bloods
Cultures
CXR
Urinalysis
Sputum
91
Q

Pneumonia ix

A

CXR
Bloods
Sputum
Urine

92
Q

Meningitis signs

A 
Headache
Confusion
NECK STIFFNESS
Non blanching rash
Fever
93
Q

Meningitis ix

A

Bloods

LUMBAR PUNCTURE + CSF culture

94
Q

Most common cause of UTI?

A

E coli and other “coliforms”

Proteus mirabilis

Klebsiella

95
Q

Risk factors for UTI?

A

Elderly because LOW FLOW AND INEFFECTIVE EMPTYING

96
Q

What is a simple UTI versus complicatied?

A 
Simple = just in bladder
COmplicated = tracking up
97
Q

Treatment of simple UTI?

A

3 days trimethoprim

98
Q

Diagnosis of UTI?

A

MSU sample

99
Q

Waht do you do with an existing catheter in a UTI?

A

REPLACE IT

100
Q

Wide-ranging non-focussed line of quiestioning - searhing for a positive response. Gets a comprehensive but time consuming history

A

Inductive

101
Q

Initial differential diagnosis formed from initial info and then specific lines of focussed questioning

A

Hypothetico-deductive

102
Q

Experienced clinical recognises key symptoms and links them quickly

A

Pattern recognition process

103
Q

Pattern recognition process strength and weakness?

A

Fast decision making but mental short cuts may lead to errors

104
Q

Adverse effects of macrolides?

A

N&V
Diarrhoea
Prolonged QT
Increased risk of statin-induced myopathy: withhold statin during treatment

105
Q

Which class would you withhold statins during treatment for?

A

Macrolides

106
Q

Which macrolide is particularly bad for causing diarrhoea?

A

Erythromycin (pro-motility)

107
Q

Aminoglycosides A/Es?

A

Lots - dangerous (narrow window)

  • Nephrotoxicity > renal failure
  • Ototoxicity (irreversible damage to vestibular nerve)
  • NMJ breakdown
  • Headache, fever, dizziness
108
Q

What drugs would you monitor serum levels of and why?

A

Aminoglycosides - narrow therapeutic window (monitor for accumulation)

109
Q

Quinolones A/Es

A

Reduce seizure threshold

Tendon damage

110
Q

Tetracyclines A/Es

A

Irritation of gastric mucosa - take with food but not milk (chelation)

Phototoxicity reactions (like severe sunburn)

DISCOLOURATION OF TEETH AND TEMPORARY GROWTH STUNTING DUE TO INCORPORATION INTO BONES - contraindicated in children and pregnancy/breast feeding

111
Q

Trimethoprim A/Es

A

Rare

Rarely causes depression of haematopoesis

112
Q

Sulfamethoxazole AEs

A

Rare but serious side effects e.g. bone marrow depression

Used rarely e.g. PJP pneumonia and other immunocompromised patients, and toxoplasmosis

113
Q

Toxoplasmosis

A

Sulfamethoxazole

114
Q

Metronidazole A/Es

A 
Metallic taste
Rashes
Disulfram reaction with alcohol
Dark urine
Hepatitis/pancreatitis
115
Q

Glycopeptides A/Es

A 
Red man syndrome if infused too rapidly
Phlebitis if not diluted sufficiently
Nephrotoxicity (elderly++)
Ototoxicity (elderly ++)
Neutropenia after 1w or 25g
116
Q

Monitor serum levels of..

A

Aminoglycosides

Vancomycin (after 3-4 doses; less in renal impairment)

117
Q

Rifampicin A/Es

A

Stain body secretions orange

118
Q

Monitor what during rifampicin tx?

A

LFTs

119
Q

Oxazolidinones A/Es

A

HAEMATOPOETIC DISORDERS e.g. thrombocytopenia, anaemia, leukopaenia, pancytopenia

OPTIC NEUROPATHY (28d +++++)

120
Q

Oxazolidonones monitoring?

A

FBC weekly

121
Q

Oxazolidonones interactions?

A

MAOI so no tyramine rich foods, SSRIs, TCAs

122
Q

Max course length linezolid?

A

28d

123
Q

Penicillins AEs?

A

Few

Hypersensitivity 10%/true = 0.2%

Cholestatic jaundice

124
Q

Which causes cholestatic jaundice?

A

Flucloxacillin

125
Q

One of least toxic penicillins?

A

Benpen (pen G)

126
Q

Cephalosporins A/Es

A

Hypersensitibity (about 10% of those pen allergic)

127
Q

1st gen ceph use?

A

Skin / soft tissue (gram +ve)

128
Q

2nd gen ceph use?

A

G-ve

129
Q

3rd gen

A

G-ve … bad for g +ve
Good CSF for ceftriaxone so meninitis
Ceftazidime for pseudomonas

130
Q

Which bacteria are intracellular?

A

Legionella
Listeria
Chlamydia
Mycobacterium

Lets Live inside Cosy Membranes

131
Q

Which antibiotics pass into mammalian cells?

A

Glycopeptides
Macrolides
Quinolones
Tetracyclines

Quick, There! Get Me in!

132
Q

Which drugs are cautioned in liver diseae?

A

Rifampicin (liver elimination)
Flucoxacillin (toxicity)
Co-amoxiclav (toxicity)

133
Q

Which antibiotics impair CYP enzymes?

A

Macrolides

134
Q

Which drug wouldn’t you use for UTI in renal impairment?

A

Nitrofurantoin

Excretion insufficient to raise level in urinary tract enough

135
Q

Mycoplasma / legionella treatment?

A

Macrolides
Tetracyclines
Quinolones

(Quick, There, Get Me in!)

136
Q

Which antibiotic would you give family planning advice with, to a fertile female?

A

Rifampicin

CYP enzyme induction = OCP level not high enough

137
Q

Which antibiotic is highest linkage to peudomembranous colitis?

A

Clindamycin

138
Q

Which type of antibiotics are most likely to cause c diff?

A

Broad spectrum

e.g. quinolones, 2nd/3rd gen cephs

139
Q

If a patient is on methotrexate with a UTI, which drug would be given / not given?

A

Not trimethoprim as MTX toxicity likely as both reduce folate metabolism: liver toxicity, bone marrow suppression, neutropenia, ifnections

NITROFURANTOIN?

140
Q

Give these on an empty stomach

A

Erythromycin / azithromycin
Penicillins

Note clarithromycin should be with food

141
Q

Which macrolide is OD?

A

Azithromycin

142
Q

Which macrolide causes particularly bad N&V/diarrhoea

A

Erythromycin

  • increased gastric motility (used in gastroparesis)
143
Q

What is the MOA of aminoglycosides?

A

Enter bacterial cell via O2-dependent transport system

Then bind to 30s…

144
Q

Which bacteria is gentamicin NOT active against?

A

Anaerobes

  • no o2-carrier system!
  • hence no use for abscesses, CSF
145
Q

Which is the only currently available oral anti-pseudomonals?

A

Quinolones

  • ciprofloxacin

VERY GOOD BIOAVAILABILITY! Good for serious infections with oral dosing.

146
Q

Which drug class shouldn’t be given with Ca/Al/Mg?

A

Quinolones

147
Q

CYP inhibitor

A

SICKFACES.COM

Sodium Valproate
Isoniazid
Cimetidine
Ketoconazole & fluconazole

Fluoxetine
Alcohol - acute consumption & cigarettes
Cardiac failure and liver failure
Erythromycin & clarithromycin
Sulphonamides
.
Ciprofloxacin
Omeprazole
Metronidazole
148
Q

Acne treatment

A

Tetracyclines

149
Q

PJP w/ AIDS
Toxoplasmosis
Immunocompromised patients

A

Cotrimoxazole

-Rare but serious side effects so rarely used

150
Q

Aspiration pneumonia AB

A

Metronidazole

151
Q

Caution in 1st trimester++ of pregnancy due to mutagenic activity

A

Metronidazole

152
Q

Glycopeptide used once daily

A

Teicoplanin due to long half life - 50h

153
Q

Glycopeptide given intraventricularly

A

Vanc - directly into CSF

154
Q

Elimination of nasal carriage of neisseria meningiditis

A

Rifampicin

155
Q

Not licensed for under18s

A

Linezolid

156
Q

Which unusual bacteria aren’t sensitive to penicillins, and why?

A

Mycoplasma - no cell wall

157
Q

Which drugs are given with aminoglycosides?

A

Penicillins - synergism

158
Q

Cephalosporins names and generations

A

1st gen… A

  • CephALOthin
  • CefAZOlin
  • CefADROxil

2nd gen… F

  • CeFURoxime
  • CeFOXitin
  • CeFAClor *
3rd gen... T
-   CefoTAXIme
-   CefTIZOXIme
-   CefTAZIDIme
Note also the "me"'s
-   CefTRIAXONE

4th gen… EPIc QUEEN of PI&ROME

  • CefEPIme
  • CefQUINOme
  • CefPIROME
159
Q

Which drugs don’t cephs have action against?

A

LAME

Listeria
Atypicals (mycoplasma/chalmydia)
MRSA (except 5th)
Enterococci

Week 120 (3 decks)

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