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FeverZhouYunTheAffiliatedHospitalofMedicalCollegeofNingboUniversityEmergencyDepartmentObjectiveDefinitionPathophysiology
PathogenesisEtiologyandclassificationClinicalmanifestationDefinitionDefinitionoffever:AtemperatureabovethenormalrangeNormalbodytemperature36-37℃(setpoint)Circadianvariation:<1℃:36.3-37.2℃
RectalT0.5℃>OralT0.5℃>AxillaryTFeverPyrogensElevatedset-pointMaintaininganabnormallyelevatedTemperatureBMR(basalmetabolicrate)increasesT=Elevatedset-pointBMR10%=T0.6oCHyperthermia
FeverduetoadisturbanceofthermalregulatorycontrolExcessiveheatproduction(e.g.statusepilepticus,hyperthyroidism)Decreaseddissipationofheat(e.g.extensiveskindisease)
Lossofregulation(e.g.injuryofthehypothalamicregulatorycenter)HyperthermiaExcessiveheatproductionTDecreaseddissipationLossofregulationPathophysiology
Heatproduction
ShiveringBasalmetabolicrate
↑
Heatisproducted
bytissuesAbsorbedfromtheenvironment↑
Dermalvasoconstriction↑
HeatlossThevolumeofbloodflowingtoskin’ssurface↑Vaporization(sweating)
↑TransfertheheattothesurroundingmediumDermalvasodilation↑
PathophysiologyRegulatedbythecentralnervoussystemThebodytemperatureisundercontrolofthePreopticareaoftheanteriorhypothalamus370C390CHeatProductionHeatLossHeatProductionHeatLossShiveringMetabolicactivityvasoconstrictionSweatingVasodilationSet-pointcoolingelevatingPathophysiologyHypothalamicthermostatInherentSetPoint:37oCLowest:4a.m;Peak:8~10p.mFeverfollowthispatternFactorsaffectbodytemperatureExerciseMenstrualcycleEnvironmentaltemperaturePathogenesisoffeverWhatwillmakethehypothalamuschangethesetpoint?Pyrogens
SubstancesthatcancausefeverEitherexogenousorendogenous
ExogenousPyrogensFromoutsidethehostMostofthemarewithhighmoleculeweightCouldnotpenetrateblood-brainbarrierStimulatingmonocytesandmacrophagestoinducetheformationofendogenouspyrogenExogenousPyrogensMajorityaremicroorganism,theirproductsortoxinsGram-:
Endotoxin(lipopolysaccaride,LPS)Gram+:
Lipoteichoicacid Peptidoglycan ExotoxinsandenterotoxinsExogenousPyrogensOthersSteroidhormonemetabolitesAntigen-antibodycomplexEndogenousPyrogensInresponsetoinvasivestimuli:ExogenouspyrogenChemicalagents(amphotericinandotherdrug)Producedbycellsofimmunesystemofthehost(macrophages,lymphocytes)Proteinsdesignated‘monokines’and‘lymphokines’CytokinesEndogenousPyrogensCytokinesIL(interleukin)TNF(tumornecrosisfactors)IFN(interferon)Phagocytesandlymphocytes:majorsourceofpyrogeniccytokinesItmayalsoreleasedthroughautonomousproductionandsecretionPathogenesisoffeverBacteriaprovokereleaseofIL-1ViralproteinsstimulateIFNCombinedproductionofseveralcytokinescausefeverEtiologyandclassificationInfectivefeverNon-infectivefeverInfectivefeverMetabolitesfromorganismcausefeverMostcommoncausesoffever(50%~60%)Bacteriapyrogens:Commoncauseofinfectivefever(43%)Viralpyrogens:(6%)Non-infectivefeverAbsorptionofnecroticsubstancesInjuryIschemicnecrosisCellnecrosisAllergy
Antibiotics(penicillin-based)EndocrineandmetabolicdisturbancesHyperthyroidismDehydrationNon-infectivefeverDecreasedeliminationofheatfromskinHeartfailureExtensivedermatitisAntigenantibodyreactionRheumaticfeverSerumdiseaseConnectivetissuediseaseNon-infectivefeverDysfunctionofcentralheatregulationPhysical:heatstrokeChemical:barbituratepoisoningMechanical:cerebralhemorrhageDysfunctionofvegetativenervoussystemSympatheticoveractivityClinicalmanifestationThegradeoffeverLowgradefever:37.3~38℃Middlegradefever:38~39℃Highgradefever:39.1~41℃Hyperthermiafever:>41℃ClinicalmanifestationClinicalcourseoffeverOnsetSuddenonsetPneumoniaGradualonsetTyphoid
Persistence
VariespatternSubsidence
CrisisLysisCharacteroffeverContinuousFeverT:keptat39℃~40℃constantlyCircadianvariation:<1℃PneumoniaTyphoidfeverCharacteroffeverRemittentFeverT:>39℃
Circadianvariation>2℃RheumaticfeverTuberculosis
SepticaemiaAcuteinfectiousendocarditisCharacteroffeverIntermittentFeverT:suddenrising(fewhours)andsuddendecreasingMalaria
AcutepyelonephritisCharacteroffeverRecurrentFeverT:abruptlyrisingtothepeak,lastingforseveraldays,suddenlydecreasingtothenormalHodgkindiseaseCharacteroffeverUndulantFeverT:Risinggraduallytothepeak(>39℃)decreasinggraduallytothenormal,repeatingforseveraltimesBrucellosisCharacteroffeverIrregularFeverTuberculosisRheumaticfeverBronchopneumoniaFeverpatternasdiagnosticcluesFeverPatternCauseAlternate-dayfeverPlasmodiumvivax,P.Ovalefevereverythirdday
P.MalariaRelapsingfeverdailyfor3~6daysBorreliaspfever-freeintervalratbitefever
forabout1weekContinuous“undulating”Brucellosis,typhoidPeriodicpyrexiaHodgkin’sdisease(Pel-EbsteinPhenomenon)withvariablecyclesAssociatedsymptomsChillsorrigorSepticaemiaAcuteinfectionsCongestionofconjunctivaHemorrhagefeverHerpessimplexHerpesvirus(lobarpneumonia)BleedingtendencyInsevereinfection(hepatitis)Blooddyscrasia(leukemia)AssociatedsymptomsLymphadenopathyLymphomaCancermetastasisEnlargementofliverandspleenHepatitisRashDrugrashMeaslesAssociatedsymptomsArthralgiaGoutRheumaticdis
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