- Signs of Severity
- Infectious Causes of Fever According to Localizing Symptoms
- Laboratory and Other Examinations
- Aetiological Treatment
- Symptomatic Treatment
- Prevention of Complications
– Severe tachycardia, tachypnoea, respiratory distress, SpO2 ≤ 90%.– Shock, altered mental status, petechial or purpuric rash, meningeal signs, seizures, heart murmur, severe abdominal pain, dehydration, critically ill appearance1; a bulging fontanel in young children.
– In endemic area, always consider malaria.– If the patient is ill appearing1 and has a persistent fever, consider HIV infection and tuberculosis, according to clinical presentation.
– Children less than 2 months with a temperature higher than or equal to 37.5 °C without a focus:• Urinary dipstick;• Lumbar puncture (LP) if child less than 1 month or if any of the following: meningeal signs, coma, seizures, critically ill appearance1, failure of prior antibiotic therapy, suspicion of staphylococcal infection;• Chest X-Ray (if available) in case of signs of respiratory disease.– Children 2 months to 3 years with a temperature higher than or equal to 38 °C without a focus:•...
– Antibiotherapy according to the cause of fever.– For patients with sickle cell disease, see Sickle cell disease, Chapter 12.– If no source of infection is found, hospitalise and treat the following children with empiric antibiotics:• Children less than 1 month;• Children 1 month to 3 years with WBC ≥ 15000 or ≤ 5000 cells/mm3;• All critically ill appearing1 patients or those with signs of serious illness;For antibiotic doses according to age, see Acute pneumonia, Chapter 2.
– Undress the patient. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of hypothermia).– Antipyretics may increase the patient’s comfort but they do not prevent febrile convulsions. Do not treat for more than 3 days with antipyretics.paracetamol PO Children less than 1 month: 10 mg/kg 3 to 4 times daily (max. 40 mg/kg daily)Children 1 month and over: 15 mg/kg 3 to 4 times daily (max. 60 mg/kg daily)Adults: 1 g 3 to 4 times daily (max. 4 g daily)oribupro...
– Encourage oral hydration. Continue frequent breastfeeding in infants.– Look for signs of dehydration.– Monitor urine output.Notes:– In pregnant or breast-feeding women use paracetamol only.– In case of haemorrhagic fever and dengue: acetylsalicylic acid and ibuprofen are contraindicated; use paracetamol with caution in the presence of hepatic dysfunction.
Apr 11, 2020 · Adults; Age Temperature What to do; 18 years and up: Up to 102 F (38.9 C) taken orally: Rest and drink plenty of fluids. Medication isn't needed. Call the doctor if the fever is accompanied by a severe headache, stiff neck, shortness of breath, or other unusual signs or symptoms.
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Mar 25, 2020 · Treating a fever. Fever is part of your body's defense against infection-causing germs. By itself, fever is usually harmless, though a high fever can be miserable. These steps may help you feel better: Drink plenty of fluids to help cool your body and prevent dehydration. Eat light foods that are easy to digest. Get plenty of rest.
The definition of fever of unknown origin (FUO), as based on a case series of 100 patients,3 calls for a temperature higher than 38.3°C on several occasions; a fever lasting more than three weeks; and a failure to reach a diagnosis despite one week of inpatient investigation. This strict definition prevents common and self-limiting medical conditions from being included as FUO. Some experts have argued for a more comprehensive definition of FUO that takes into account medical advances and changes in disease states, such as the emergence of human immunodeficiency virus (HIV) infection and an increasing number of patients with neutropenia. Others contend that altering the definition would not benefit the evaluation and care of patients with FUO.4
The classic category includes patients who meet the original criteria of FUO, with a new emphasis on the ambulatory evaluation of these previously healthy patients.6 The revised criteria require an evaluation of at least three days in the hospital, three outpatient visits, or one week of logical and intensive outpatient testing without clarification of the fever's cause.5 The most common causes of classic FUO are infection, malignancy, and collagen vascular disease.
HIV-associated FUO is defined as recurrent fevers over a four-week period in an outpatient or for three days in a hospitalized patient with HIV infection.5 Although acute HIV infection remains an important cause of classic FUO, the virus also makes patients susceptible to opportunistic infections. The differential diagnosis of FUO in patients who are HIV positive includes infectious etiologies such as Mycobacterium avium-intracellulare complex, Pneumocystis carinii pneumonia, and cytomegalovirus. Geographic considerations are especially important in determining the etiology of FUO in patients with HIV. For example, a patient with HIV who lives in the southwest United States is more susceptible to coccidioidomycosis. In patients with HIV infection, non-infectious causes of FUO are less common and include lymphomas, Kaposi's sarcoma, and drug-induced fever.9,10 The differential diagnosis of FUO generally is broken into four major subgroups: infections, malignancies, autoimmune conditions, and miscellaneous (Table 2). Several factors may limit the applicability of research literature on FUO to everyday medical practice. These factors include the geographic location of cases, the type of institution reporting results (e.g., community hospital, university hospital, ambulatory clinic), and the specific subpopulations of patients with FUO who were studied. Despite these limiting factors, infection remains the most common cause of FUO in study reports.3,11,12 Rheumatoid arthritis and rheumatic fever are inflammatory diseases that used to be commonly associated with FUO, but with advances in serologic testing, these conditions usually are diagnosed more promptly. At this time, adult Still's disease and temporal arteritis have become the most common autoimmune sources of FUO because they remain difficult to diagnose even with the help of laboratory testing. The initial approach to the patient presenting with fever should include a comprehensive history, physical examination, and appropriate laboratory testing. As the underlying process develops, the history and physical assessment should be repeated. The first step should be to confirm a history of fever and document the fever pattern. Classic fever patterns such as intermittent, relapsing sustained, and temperature-pulse disparity may prove to be useful but rarely are diagnostic.20 In taking a history from a patient with FUO, particular attention should be given to recent travel, exposure to pets and other animals, the work environment, and recent contact with persons exhibiting similar symptoms. In patients returning from areas where tuberculosis and malaria are common, the index of suspicion for these diseases should be elevated. In patients who have had contact with pets or other animals, diseases common to animal handlers must be suspected. Diagnostic clues often are not readily apparent on physical examination; repeated examination may be essential. Careful attention to the skin, mucous membranes, and lymphatic system, as well as abdominal palpation for masses or organomegaly, is important. The physician's choice of imaging should be guided by findings from a thorough history and physical examination21 (e.g., a cardiac murmur in the presence of negative blood cultures should be investigated with a transthoracic echocardiogram or, if needed, transesophageal echocardiogram) rather than strictly following the stepwise approach outlined in Figure 1. Also, Duke's clinical criteria include two major and six minor criteria that help determine the likelihood of endocarditis.22 [Evidence level A, validated clinical decision tool] A cost-effective individualized approach is essential to the evaluation of these patients, and without a thoughtful and focused investigation, inappropriate tests might be performed. The preliminary evaluation helps in the formulation of a differential diagnosis and guides further studies that are more invasive or expensive. These preliminary investigations should include a complete blood count, liver function test, erythrocyte sedimentation rate, urinalysis, and basic cultures. Simple clues found during initial testing often will guide the clinician toward one of the major subgroups of FUO. The decision to obtain further diagnostic studies should be based on abnormalities found in the initial laboratory work-up and not represent a haphazard use of costly or invasive modalities. Skin testing for tuberculosis with purified protein derivative (PPD) is an inexpensive screening tool that should be used in all patients with FUO who do not have a known positive PPD reaction. However, a positive PPD reaction alone does not prove the presence of active tuberculosis. A chest radiograph also should be obtained in all patients to screen for possible infection, collagen vascular disease, or malignancy. If this initial assessment does not disclose the source of fever, more specific investigatory techniques, such as serology, sonography, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine scanning should be conducted, based on clinical suspicion. Abdominal sonography, pelvic sonography, or CT scanning should be performed early in the diagnostic process to rule out such common causes of FUO as intra-abdominal abscess or malignancy, depending on the primary evaluation.17 This testing, including directed biopsies, has greatly reduced the need for more invasive operative studies.23 MRI should be reserved for clarifying conditions found through the use of other techniques or when the diagnosis remains obscure. The use of radionucleotide scanning, such as gallium 67, technetium Tc 99m, or indium-labeled leukocytes, is warranted for detecting inflammatory conditions and neoplastic lesions that often are underdiagnosed by CT scans; however, these tests tend not to detect collagen vascular disease and other miscellaneous conditions24 (Table 4). Endoscopic procedures may be helpful in the diagnosis of disorders such as inflammatory bowel disease and sarcoidosis. The newest diagnostic technique in the evaluation of the patient with FUO is positron emission tomography (PET). This modality appears to have a very high negative predictive value in ruling out inflammatory causes of fever. However, because of its limited availability it is too early to determine if PET scans will prove to be a useful diagnostic tool in the evaluation of these patients.25,26 More invasive testing, such as lumbar puncture or biopsy of bone marrow, liver, or lymph nodes, should be performed only when clinical suspicion shows that these tests are indicated or when the source of the fever remains unidentified after extensive evaluation. When the definitive diagnosis remains elusive and the complexity of the case increases, an infectious disease, rheumatology, or oncology consultation may be helpful.
Of the many infectious diseases that are associated with FUO, tuberculosis (especially in extrapulmonary sites) and abdominal or pelvic abscesses are the most common.13 Intraabdominal abscesses are associated with perforated hollow viscera (as occurs in appendicitis), diverticulitis, malignancy, and trauma. Other common infections that should be considered as the source of FUO include subacute bacterial endocarditis, sinusitis, osteomyelitis, and dental abscess.11,13 As the duration of fever increases, the likelihood of an infectious etiology decreases. Malignancy and factitious fever are more common diagnostic considerations in patients with prolonged FUO.14 Because of a substantial increase in the elderly population, as well as advances in the diagnosis and treatment of diseases common in this population, malignancy has become a common etiologic consideration in elderly patients. Malignancies that sometimes are difficult to diagnose, such as chronic leukemias, lymphomas, renal cell carcinomas, and metastatic cancers, often are found in patients with FUO.12
Many unrelated pathologic conditions can present as FUO, with drug-induced fever being the most common.11,14 This condition is part of a hypersensitivity reaction to specific drugs such as diuretics, pain medications, antiarrhythmic agents, antiseizure drugs, sedatives, certain antibiotics, antihistamines, barbiturates, cephalosporins, salicylates, and sulfonamides (Table 3). Complications from cirrhosis and hepatitis (alcoholic, granulomatous, or lupoid) are also potential causes of FUO.12,13 Deep venous thrombosis, although a rare cause of FUO, must be considered in relevant patients, and venous Doppler studies should be obtained.17 Factitious fever has been associated with patients who have some medical training or experience and a fever persisting longer than six months.18 Failure to reach a definitive diagnosis in patients presenting with FUO is not uncommon; 20 percent of cases remain undiagnosed. Even if an extensive investigation does not identify a cause for FUO, these patients generally have a favorable outcome.19
The family history should be carefully scrutinized for hereditary causes of fever, such as familial Mediterranean fever. The medical history also must be examined for conditions such as lymphoma, rheumatic fever, or a previous abdominal disorder (e.g., inflammatory bowel disease), the reactivation of which might account for the fever. Finally, drug-induced fever must be considered in patients who are taking medications.19
1. Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2000 summary. Adv Data. 2002;328:132....
- Alan R. Roth, Gina M. Basello
However, it is important to also identify and treat the underlying cause of the fever. 1,3,4 Nonprescription antipyretics and nonpharmacological measures are often used in the management and treatment of fever.
Antibiotic therapy is the only effective treatment for typhoid fever.
Dec 19, 2018 · One randomized clinical trial (RCT), performed at medical wards of 2 teaching hospitals in the United Kingdom, found no evidence that RT-PCR testing for influenza influenced antibiotic prescribing or clinical outcome in adult patients; however, few study patients with RT-PCR–confirmed influenza were prescribed antiviral treatment .
Jun 20, 2016 · How and when you should treat a fever is generally determined by your age. If left untreated, fever can lead to serious complications in young children, older adults, and people with compromised ...
2 days ago · “Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”(Institute of Medicine, 1990) Issued by third-party organizations, and not NCCIH, these guidelines define the role ...