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Fevers
Fevers Definition* fever is elevation of the body temperature above
the average normal
- Normal: 36.5- 37.2c (98- 99f )
- Febrile ( Pyrexia ) above 37.2 c ( above 99f )
- Hyperpyrexia above 41.6 c ( above 107f )
- Subnormal below 36.5c ( below 98 f )
- Hypothermia below 35 c ( below 95 f )
Causes of fever
1-Infection .
2-Tissue trauma: crash injuries and fraction of bones.
3-Tissue destruction:myocardial infarction, and hemolytic anemia.
4-Neoplastic diseases.
5-Collagen diseases.
6-Disturbance of heat regulating center in the brain e.g head injury, sun stroke and cerebral hemorrhage.
7-Drug: belladonna, barbiturates
8-Serum sickness and other hypersensitivity states.
Types (Patterns of fever)
1-Contineuos (sustained ) fever: the temperature continues high for days or weeks with difference between morning and evening temperature about 0.5-1 C This type is seen in typhoid fever, pneumonia, meningitis and typhus.
2-Intermittent fever: the temperature falls to normal once or more during the day e.g. abscess, lymphomas and military tuberculosis.
3-Hectic fever: marked daily temperature swings usually associated with rigors & sweats e.g amebic liver abscess and pyogenic abscess.
4- Remittent fever: the temperature is always raised, but shows considerable variation between morning & evening temperature but not return to normal, as in :•Septic conditions - mycoplasma pneumonia•Rheumatic fever - Rheumatoid arthritis•SABE - Falciparum malaria
5-Saddle back ( Camel –backed) fever :
•Biphasic remittent fever.•A continous fever for a few days is followed by a remission and •A second bout of continous fever associated with appearance of rash and terminating by lysis.•Occur in Dengue fever.
6-Relapsing fever:
*Days with fever alternate with days of normal temperature e.g.
brucellosis (undulant fever), spirochetal relapsing fever, Charcot`s intermittent fever in biliary obstruction and malaria.
When a paroxysm of intermittent or relapse fever occurs:
*Daily, the type is quotidian,
*On alternate days, tertian,
*When 2 days intervene between consecutive attacks, quartan.
7-Factitious fevers:
- It is spurious temp. elevation produced by the pt.
-Not associated with organic disease. -Normal ESR. -Failure of pulse rate to rise with temp.
* Causes of Hyper-pyrexia:
1-Thyrotoxic crisis.
2-Status epilepticus.
3-Heat stroke.
4-Encephalitis.
5-Pontine hemorrhage
* Causes of Hypo-thermia:.
1-Shock.
2-Hypothyroidism.
3-Pan-hypopituitarism.
4-Starvation.
5-Old age.
Manifestations of fever1-Physiological response:-tachycardia.- Chills & rigors.- Each 1◦C increase in body temp. --- increase BMR by 8% . --- increase HR by 10 -15 beat/ min.- Respiratory alkalosis followed by metabolic acidosis.2- specific manifestations: -vague sense of warmth.-flushed or headache- Vague aching- Malaise, anorexia and wt loss
Salmonellosis
* Salmonellosis in Egypt present the form of :- 1- Typhoid ¶typhoid.
2-Chronic salmonellosis complicating Schistosoma infection. 3-Salmonella food poisoning (acute gastroenteritis).
Typhoid Fever & Paratyphoid fever
* Causative organism:*Salmonella typhi and salmonella paratyphoid A,B&C. *It is gram-negative motile bacilli.
* Source of infection :.
1-Patient.
2-Carrier (intestinal, gall bladder or unitary carrier).
* Mode of infection : 5F.
1-Food.
2-Flies.
3-Foments.
4-Feces.
5-Fingers.
* Pathology:.
After invasion of the intestinal mucosa, bacilli
first enter the mesenteric lymph glands through
Payer`s patches blood stream (bactermia)
then pass to other organs e.g liver, spleen and
reticule-endothelial system.
Clinical picture:.
IP:1-2 weeks.The disease passes into 4 stages.
[1] First week:.1-Temperature rise by steps (Ladder step manner) till
the temperature reach 39-40C.2-Headache.3-Pulse: is relatively slow.4-Tongue : coated and dry.5-Abdomen is tender and slightly distended.6-Diarrhea or more commonly constipation.7-Spleen is enlarged between the 7th and 10th days, it is
soft and tender.8-Bronchitis and Epistaxis are common.9- Rash in 10% of cases on the abdomen chest and
back as rosy red papules..
[II] Second week:-.1-Fever is high and continuos.2-Headache disappears3-Pulse is still relatively slow.4-Abdominal symptoms increase.5-Spleen is more enlarged.
[III]- Third week:.1-Temperature stars to drop, general condition and abdominal manifestations improve . or:2-Complications may occur.
[IV]- Fourth week :.1-Convalescence begins . or:2-Relapses may occur.
Investigations
1-Blood : Leucopenia with relative lymphocytosis.
2-Blood culture: Positive in the first week and rarely
later.
3-Stool culture: Positive from 2nd week till 4thwk.
4-Urine culture : Positive in 3rd week in 25% cases.
5-Widal agglutintion recation : positive from the 2nd
week on words, with gradual rising titer. It seems
unreliable
* Complications:[I]- General Complications:.
1-Relapses.
2-Typhoid abscesses.
3-Bed sores.
4-Otitis media.
5-Zenker`s degeneration of
muscle.
6-Severe dehydration of muscle.
7-Sever dehydration.
8-Severe mental confusion.
9-Deafness.
[II]- Medical Complications :-
1-Acute bronchitis is common.
2-Typhoid lobar pneumonia: present with the typical symptoms and signs of lobar pneumonia except that rusty sputum is uncommon and the white blood cell count is low.
3-Myocarditis is common particularly in very toxic patients.
4-Typhoid meningitis is rare and must not be confused with meningism, which is common, chloramphenicol diffuse well into the cerebrospinal fluid, so it gives good results.
5-Mild hemolytic anemia is common in the very toxic typhoid patients. It should be treated with prednisone.
6-Peripheral neuritis may occur, it should be treated with large doses of Vitamin B complex, and this Vitamin should be given routinely in typhoid fever as a prophylactic measure.
7-Febrile albuminuria is common, but a true acute typhoid nephritis is rare.
[III]- Surgical Complications:
1-Acute parotitis: is a dangerous complication and pus
should be drained by transverse incision under local
anaesthetic as early as possible.
2-Intestinal perforation: -This is one of the most serious
complications of typhoid fever, it occurs during the third week of
illness but may occur before.
3-Intestinal Hemorrhage: is a lethal complication which
usually occurs 2-3 weeks after the onset of the illness, the
patient may show massive hemorrhage, which is
manifested by shock and very pale conjunctiva, or small
bleeding.
4-Typhoid Cholecystitis : Occur more frequent in female more than male.
5 -Paralytic ileus : may be secondary to perforation or to severe toxemia.6-Intestinal obstruction: may be due to a localized abscess or adhesions.7-Typhoid orchitis.8-Typhoid Arthritis and osteomyelitis.
* Differential Diagnosis. From prolonged fevers.
Treatment1-Prophylactic:-1)- Control of food, milk and water with anti-fly measures.2)Isolation of patients until stool and urine are negative for 3 successive cultures.3)Carriers : Treated by chloramphenicol or Ampicillin with or without cholecystectomy.
4)-Vaccination : by T.A.B. vaccine, 0.5 - 0.75 then 1.0 cc. Is given subcutaneous at one week intervals to childern, contact and during epidemics. Booster doses are given every year as 0.5 cc.
II-Curative:.1)-General lines of treatment:-
a-Rest in bed.b-Well balanced diet.c-Adequate fluid.
2)-Specific treatment:.a-Chloramphenicol 50mg/kg body weight/day is given orally divided into 4 doses given every 6 hours until fever disappear then given ½ the dose for 2 weeks.
b-Amoxycillin a semi-synthetic penicillin resembling ampicillin, in a dose of 100mg/kg given in 4 equal doses and continued for 10 days after fever stop.
c-Ampicillin
is given orally in a dose of 100mg/kg day. The total daily dose is divided into 4 equal parts and given at 6 hourly intervals. Continued for at least 10 days after stop.
d- Quinolone group : ciprofloxacin , ofloxacin twice /day for 10 days.
e-cefotriaxone 2 gm /d for 7 days.
Brucellosis(Malta Fever or Undulant fever)
Classic zoonotic disease of worldwide distribution* Etiology :.*Causative organism.
-Brucella melitensis in sheep.-Brucella abortus in cows.-Brucella suis in pigs.
*Mode of Infection :-1-Drinking milk of infected animals.2-Through skin during dealing with aborted animals, infected milk or infected meat.
* Clinical picture:.1-Incubation period: 1-3 weeks.2-Onset: gradual with malaise & muscular pains.3-Constitutional symptoms: profuse sweating, muscular pain, headache, joint pain and backache.4-Pulse: relative slow.5-Fever: reach 39-40 c. for 1-3 weeks then apyrexia for 10 days then relapse and so on (undulant fever).
6-G.I.T : Nausea, vomiting & constipation.
7-Enlarged spleen is present in almost half
the patients the spleen is tender and firm
and usually mild enlarged.
8-Lymph nodes : in 50% of cases there is
generalized enlargement, especially the
cervical and axillary lymph nodes.
* Investigations:
1-Blood culture : positive in the 1st week.
2-Blood count: Leucopenia with relative lymphocytosis or monocytosis.
3-Agglutination test: Positive from 2nd week titer over 1/100 or rising titer is diagnostic.
4-Complement fixation :To measure IgG antibodies.
5-Radio-immuno assay to determine the levels of specific anti-Brucella IgM, IgG & IgA.6-Brucellin intradermal test : it is delayed hypersensitivity reaction. Positive reaction
denotes past or present infection, it useful in epidemiological study and negative reaction
exclude infection.
•Complications :.1-Bone and joint complications:
(a) Brucella spondylitis : Where bone and discs are invaded causing osteomyelitis with destruction of bone giving picture similar to disc prolapse .
(b) Suppuration of large joint.(c) Osteomyelitis of long bone.2-Cardiovascular complication:Bacterial endocarditis usually
develops on a congenital or acquired valvular lesion.
3-Hepatic complication:.a-Jaundice.b-Liver cell failure.c-Cirrhosis.
4-genito-urinary complications.a-Orchitis.b-Epididymitis.c-Chronic pyeloneonephritis.
5-Nervous complications:.a-Meningitis.b-Encephalitisc-Myelitis.d-Paraplegia.
e-Aphasia.f-Dysarthria.g-Visual disorders.h-Deafness.
Treatment :.1-Rest in bed, well balanced diet.
2-Symptomatic ttt:Antipyretics and analgesics.
3-Tetracycline : 50 mg/kg /day in divided
dose/4 hours for 3 weeks oral or IM.
4-Streptomycin :
a-Streptomycin 1 gm I. M. daily for 3
weeks.
5- Rifampicin 600 mg/12 h for 3 w
CHOLERADefinition :.An acute infectious disease of man caused by vibrio cholera, characterized by severe painless diarrhea, vomiting, muscular cramps, dehydration and collapse.
Clinical picture:.Incubation period: 1-5 days.
1-Stage of diarrhea:.a-Abrupt onset of severe diarrhea where large amount of fluid are painlessly poured out. The stool are clear or consist of opaque white watery fluid with floating mucus resembling rice-
water in appearance . It is odorless or has fish smell.
b-Vomiting starts after the diarrhea, buttery be absent in 20% of cases.
c-Striated muscle cramps and Tetanic spasm may occur.
d-Signs of dehydration appear when the fluid loss corresponds to 6% of the body weigh. The patients has a pinched face, sunken eyes. • He is apathetic, thirsty and speaks in a husky voice .
* The abdomen is soft and not tender with impaired skin elasticity.
2- Stage of collapse* The patients passes into a stage of
circulatory collapse with :-a-Weak pulse.b-Decrease blood pressure.c-Decrease surface temperature.d-Cyanosis .e-Oliguria.
f-Patient is conscious, but may be drowsy and acidotic.
3- Stage of recovery:-The disease is self-limiting, where rapid improvement occurs and consciousness - normal, skin becomes warm and stool less frequent.-In sever cases, anuria and death may occur.
DiagnosisCholera should be suspected in any acute case of dehydrating diarrhea or gastroenteritis occurring in an endemic area.
-The final diagnosis is made up after:
a)-Dark-field microscopy.
b)-Fluorescent antibody technique.
c)-Isolation of vibrios in specific
culture e.g in TCBs agar
(thiosulphate-citrate-bile salts -
sucrose agar).
Treatment:-
1-Treatment of Dehydration & Acidosis:
a)Intravenous route:-
-A liter of isotonic saline + ½liter of 1/6 molar sodium lactate. They repeated if needed in the same ratio 2:1 -Ringer lactate solution (Hartmann`s solution).
-Dacca solution (5-4-1) per liter (5gm NaCl- 4gm NaHCO3 -1gm KCI) per liter.The rate of intravenous infusion is 100ml/min in adults till a strong radial pulse is restored, then decrease to the equal to intestinal fluid loss.
• b) Oral route :• In patients with no vomiting UNICFE packets
my be used NaCl-NaHCO3-KCI-Glucose which contain:
(3- 5gm-2 gm-120gm.)
2-Antimicrobial drugs:-a-Tetracycline 10 mg/kg/ 6 hours for 2-3
days.b-Chloramphenicol 10 mg/kg/6 hours for
2-3 days.c-Doxycycline in a single dose of 300 mg is
effective as tetracycline.(drug of choice except in pregnant women)d-Combination of trimethoprim + sulphamethoxazole (Co-Trimoxazoles) in a dose of 2 tables /12 hours.