FEVER (REVIEW) Fever, a change of in the normal regulation of body temperature set point, literally a resetting of the thermostat,

is one of the changes in homeostatic setting that occur during the acute phase response to inflammatory stimuli. In respect of fever, helpful clues come from the type of onset (abrupt or slow), the duration, the pattern of fever, and the febrile curve following institution of specific treatment. Even not absolutely correct, a specific infection tend to associate with the characteristic pattern of fever. The type of febrile patterns traditionally grouped according to the definition listed below. 1. Continous (sustained) fever with slight remission not exceeding 1 degree celcius in remittance. Within this goup fall fevers caused by lobar and gram (-) types of pneumonia, ricketsial diseases, typhoid fever, CNS disorder, tularemia, and falciparum (malignant tertian) malaria. Intermittent (hectic, quotidian) fever with wide fluctuations. Usually normal or low in the morning with peak at 4.00 to 8.00 pm. This group includes fever caused by localized pyrogenic infections and bacterial endocarditis, chills, and leukocytosis are usually present. Malaria may present as quotidian (daily spike), tertian (spike every third day) or quartian (spike every fourth day). A double qoutidian pattern with two daily spikes occurs sufficiently often to be helpful in salmonellosis, miliary tuberculosis, double malarial infections, and gonococcal endocarditis. Tertian and quartan intermittent febrile pattern occur in malaria, these cyclic patterns occur regularly and are consistent with the parasites repetitive cycles of multiplication. Remittent fever, the fluctuation of body temperature is also wide, more than 1 degree celcius. The difference between remittent and intermittent fever is that in the former, the lowest temperature never reach normal body temperature. The fever usually low in the morning and higher in the late evening. This pattern of fever can be found in the first week of typhoid fever. Saddleback (biphasic) fever, with several days of fever, a gap of reduced fever of about 1 day, and then several additional days fever. This tyoe characterized dengue and yellow fever, colorado tick fever, rift valley fever and viral infections such as influenza and poliomyelitis. Intermittent hepatic fever, with sporadic episodes of fever, gaps in which there are distinct reductions in temperature, and recurrence of fever. This is a frequent, reliable pattern in cholangitis, usually associated with cholelithiasis, jaundice, leukocytosis, and toxic signs. Pel-ebstein fever, characterized by weekly or longer period of fever and equally long afebrile periods with repetition of the cycle. It occurs in hodgkins disease. Reversal on the diurnal pattern of fever (typhus inversus) with the highest temperature elevation in the early morning hours rather than during the late afternoon or early evening. Occasionally in tuberculosis, salmonellosis, hepatic abscess, and bacterial endocarditis.

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Jarisch-Herxhelmer reaction with sharply increased elevation of temperature and exacerbation of clinical manifestations, occurs several hours after beginning penicillin treatment.

Benefits of fever A raised body temperature kills many microorganisms and has adverse effects on the growth and replication of others. Higher body temperatures decrease serum level of iron, zinc, and copper, all of which are needed for bacterial replication. The body switches from burning glucose to a metabolism based on lypolisis and proteolysis, thereby depriving bacteria of a food source. Anorexia and somnolence reduce the demand for muscle glucose. Increased temperature also causes lysosomal breakdown and autodestruction of cells, thus preventing viral replication in infected cells.

Fever of Unknown Origin Fever of unknown origin (FUO) was defined in 1961 by Petersdorf and Beeson as the following: 1. a temperature greater than 38.3C (101F) on several occasions. 2. more than 3 weeks' duration of illness 3. failure to reach a diagnosis despite 1 week of inpatient investigation Etiology FUOs are caused by infections (30-40%), neoplasms (20-30%), collagen vascular diseases (10-20%), and numerous miscellaneous diseases (15-20%).

The following conditions are sources of FUO:

Abscesses Tuberculosis Urinary tract infections Endocarditis Hepatobiliary infections Osteomyelitis Rickettsia Chlamydia Systemic bacterial illnesses Spirochetal diseases HIV Acquired immunodeficiency syndrome (AIDS) Herpes viruses Fungal infections Parasitic infections Lymphomas Leukemias Solid tumors Malignant histiocytosis Collagen vascular and autoimmune diseases Sarcoidosis Regional enteritis Granulomatous hepatitis Drug fever Inherited diseases

Diagnosis A comprehensive and meticulous history (i.e. illness of family members, recent visit to the tropics, medication), repeated physical examination (i.e. skin rash, eschar, lymphadenopathy, heart murmur) and a myriad of laboratory tests (serological, blood culture, immunological) are the cornerstone of finding the cause.

Ultrasound may show cholelithiasis, echocardiography may be needed in suspected endocarditis and a CT-scan may show infection or malignancy of internal organs. Invasive techniques (biopsy and laparotomy for pathological and bacteriological examination) may be required before a definite diagnosis is possible Therapy Unless the patient is acutely ill, no therapy should be started before the cause has been found. This is because non-specific therapy rarely is effective and mostly delays diagnosis. After blood cultures are taken this condition is aggressively treated with broad-spectrum antibiotics. Antibiotics are adjusted according to the results of the cultures taken.