Approach to Fever Work Up Fever Cases. Pedro M. Calderon PGY-3. Learning Objectives. Definition of pyrexia, hyperpyrexia hyperthermia Pathophysiology of fever Evaluate best methods to measure temperature Diagnostic and therapeutic approach for fever in select patient populations
Approach to Fever Work Up Fever Cases
Pedro M. Calderon
Definition of pyrexia, hyperpyrexia hyperthermia
Pathophysiology of fever
Evaluate best methods to measure temperature
Diagnostic and therapeutic approach for fever in select patient populations
Review of IDSA guidelines for important select clinical conditions that cause fevers
Journal of Infection and Public Health (2011) 4, 108—124
Tc = Core Temp
55-year-old man with a history of mitral regurgitation seeks care after an episode of transient weakness in his right arm and speech difficulties. He underwent dental scaling 1 month earlier. He notes recent intermittent fevers and weight loss. On cardiac examination, his regurgitation murmur appears to be unchanged. A TTE shows a mobile, 12-mm mitral-valve vegetation and grade 2 (mild) regurgitation. Magnetic resonance imaging of the brain reveals recent ischemic lesions. How should the patient be further evaluated and treated?
N Engl J Med. 2013 Jun 27;368(26):2536.
N Engl J Med 2013; 368:1425-1433
57-year-old man presents with fever, chills, and new lumbar back pain 2 weeks after undergoing a prostate biopsy because of an increased PSA level. His temperature is 39.7°C; he has an enlarged, tender prostate and lumbar spine tenderness. His white-cell count is 9.1, and the CRP level is 3.43 mg/L.
Urine and blood cultures reveal multidrug-resistant, extended-spectrum β-lactamase–producing Escherichia coli susceptible to imipenem. How should he be evaluated and treated?
N Engl J Med 2010;362:1022-9.
N Engl J Med 2010;362:1022-9.
58 year old man is hospitalized because of fever and chills for the last 2 days. He denies productive cough, shortness of breath, headaches, nausea, vomiting, abdominal pain, diarrhea, dysuria, or rash. According to his wife, he has been "acting differently" for the past 24 hours. He was recently diagnosed with AML. His leukemia is currently in remission, and he is receiving maintenance chemotherapy.
He has no known drug allergies. Works at a local grocery and denies use of tobacco, alcohol or illicit drug. His temperature is 39.4 ºC, blood pressure 81/45 mm Hg, pulse is 122/min, and respirations 22/min. SaO2 96% on RA.
A Hickman catheter is present in the left IJ and it shows erythema and induration over the insertion site. Two sets of blood cultures are obtained, one from a peripheral vein and second from the catheter port. 3 liters of normal saline are given IV, this improves patient's hemodynamics. CXR shows infiltrates. UA without evidence of infection.
Ann Intensive Care. 2011;1:22-22.
Lymphoma, especially non-Hodgkin's*
Renal cell carcinoma (20% of cases)
Hepatocellular carcinoma or other tumors metastatic to the liver
Atrial myxomas (30% of cases)
"“There are no shortcuts to any place worth going.”
20-year-old man who had a history of IV drug use and multiple sexual partners initially presented to the ED with a chief complaint of blood per rectum when he passed stool, and chills for the prior few days. His work-up was normal, including a rapid HIV screen, and he was discharged.
He returned 2 weeks later with constipation, fatigue, myalgias, decreased urination, chills, and a productive cough. His physical examination was most remarkable for temp 39.2, HIV antibody test was negative, but his laboratory tests showed an elevation of CK, amylase, and lipase. His blood count showed a normal hematocrit and white blood cell count. HIV viral load was reported as > 1,000,000 copies/mL.
J Emerg Med. 2013 May;44(5):e341-4
N Engl J Med. 1999 Sep 16;341(12):893-900
Giant cell arteritis
Adult still’s disease
“The future belongs to those who believe in the beauty of their dreams.”
47 year old man with HTN, HLP, asthma, admitted to the MICU 5 days ago from ED with acute asthma attack which required intubation in the ED. Initial vitals Temp: 38.7, HR 110, BP 90/42, 95% on the vent with 50% FiO2, RR 20 (above vent). Patient has right radial arterial line, right IJ central line, sites which do not appear erythematous or indurated. Pt also has OG. Chest x-ray with new small left lower lobe infiltrate, ETT 3 cm above carina, Right central line with tip in SVC, no pneumothorax. Labs with CBC 15/12/36/253, 79% neutrophils, 2% eosinophils. RFP within normal limits. Patient is on steroids, but no antibiotics.
How would you work up and manage fever in this patient?
J Intensive Care Med. 2012 Sep-Oct;27(5):290-7.
Disco fever (boogie fever)
"I do not actually remember which one of my parents taught me this, but one of them told me: 'Son, in this world there are stupid people and there are smart people; there are mean people and there are nice people. If you are smart and nice, you will do well in your work and have a lot of friends. If you are smart and mean, you will be successful but not happy. If you are stupid and nice, you will not be successful but at least you will be happy. But if you are stupid and mean, you will not get anywhere in life.' knowing my limitations, I have always aspired to be the nicest person I can ever be."
--Chin-to Fong , MD
University of Rochester