• Procedure
• Take and record the patient’s temperature every 6 to 8 hours
• Study the patterns
• Patterns:
• Continuous (variation < 1o)
• Remittent (variation > 2o over 1 day)
• Intermittent (afebrile periods mixed with fever spikes)
• Quotidian (remittent with daily fever spikes) ex: Plasmodium
• Relapsing (intermittent and cyclic, fever returns every 5-7
days ex: Borrelia sp)
Diagnostic approach to fever
• History of fever/pattern
• Date of onset
• Periodicity
• Accompanying symptoms
» Chills
» Sweating
» Arthralgias
» Myalgias
• Information on travel/exposure to agents or animals
• History personal or family:
• Blood transfusions
• Immunizations
• Thromboembolic disease, valvular disease, tuberculosis
• Cancer
• Repeated physical examinations:
• Skin
• Eyes
• Nail beds
• Heart
• Abdomen
• Lymph nodes
Laboratory evaluation
• Elevated ESR, neutrophilia
• Elevated CPR
• Elevated liver functional tests
• Creatinine, bloodglucose, calcemia
• LDH, coagulation
• Proteinuria, urinary sediment
• Blood cultures
• Serology: Salmonella, Brucella, Yersinia
• Increased immunoglobulins: nuclear antibodies,
rheumatoid factor, cryoglobulin
• TSH
• Tumor markers
Approach algorrhythm
Clinical examination
Laboratory evaluation
Abdominal ultrasound
Chest X-Ray
FUO
• Infections
• Connective tissue disorders
• Neoplasia ( leukemia, lymphoma)
Intermittent fever of infectious origin
• Situations:
1. “channel” fever: gram-negative or gram –positive
bacteremia of urinary, biliary or intestinal origin
2. Infection of implants – orthopedic, vascular,
prosthesis, pace-maker
3. Infectious endocarditis
4. Tuberculosis
5. Persistent infection with Yersinia enterocolitica
6. Malaria
Fever of urinary origin
1. UTI
- Plain X-ray of abdomen
- Intravenous urography
- Cystogram
- Ultrasonography
- Computed tomography
2. Acute nephritic syndrome
- Red blood cell casts
- Antibody titer :ASLO
UTI – localizing urinary tract infection
Method Comments
Clinical Distinct features of pyelonephritis, perinephric abcess,
cystitis, prostatitis, urethritis
Urinalysis Bacterial cast pathognomonic of pyelonephritis: WBC cast
suggests nonspecific tubulointerstitial inflammation; tissue
may indicate papillary necrosis
Endocarditis or pace-maker
Symptoms / signs Laboratory Dg
• Infections
• Connective tissue disorders
• Neoplasia (leukemia, lymphoma)
Connective tissue disorders
• Systemic lupus eritematosus
• Rheumatoid arthritis
• Polymiositis
• Arthritis associated to spondylitis: ankylosis spondylitis
• Juvenile arthritis
Symptoms / signs Laboratory Dg
• Infections
• Connective tissue disorders
• Neoplasia (leukemia, lymphoma)
Fever in neoplasic disease
• Neoplasia
• Colorectal cancer
• Cancer of pancreas
• Grawitz kidney tumor
• Cancer of the ovary
• Metastasis
• Hemopathies
• Hodgkin
• Non-Hodgkin malignant lymphomas
• Acute leukemias
• myelodysplasia
Clinical case
J.I. , 71 Years [M]
• HT
• Dyslipidemia
3 months ago - progressive weakness
- progressive weight loss (10kg)
- non-productive cough (dry)
- retro-sternal chest pain, more severe with
inspiration
On admission:
- no fever (36.8o C )
- dullness at percussion, abolished breath sounds in left lower
pulmonary lobe
Chest X-ray: Dense consolidation of left lower lobe
Multiple non-homogeneous infiltrates in medium and lower
right lobes
Laboratory test
• Hg (g%) 13,9
• Ht (%) 42,4
• L (mmc) 10.800
Gr = 77%, Lf = 18%
• ESR (mm/1h) 83
• Fibrinogen (g/l) 6,8
Diagnosis
RETICULAR PULMONARY FIBROSIS. BILATERAL BRONCHIECTASIS
COMPLICATED WITH LEFT LOWER LOBE PNEUMONIA
Evolution: complicated
40
T e m p e r a tu r a (g r a d e C )
39
38
37
Zile de s pitalizare
Reconsider diagnosis
• Hemoculture: negative
• CT scan thorax:
Bilateral reticular fibrosis of the 2lower/3rds of
pulmonary parenchima, bronchiectasis.
Extensive consolidation of right lower lobe and
of external 1/3 of middle and lower right lobes
Minimal mediastinal and bilateral tracheo-bronchial
adenopathy
• Bronchofibroscopy/Biopsy:
Broncho-pulmonary “oat cell”carcinoma