Fever: Difference between revisions
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** As an adverse reaction to drugs, ''e.g.'' [[antibiotic]]s or [[Sulfonamide (medicine)|sulfa drug]]s. |
** As an adverse reaction to drugs, ''e.g.'' [[antibiotic]]s or [[Sulfonamide (medicine)|sulfa drug]]s. |
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** After drug discontinuation, ''e.g.'' [[heroin]] or [[fentanyl]] withdrawal |
** After drug discontinuation, ''e.g.'' [[heroin]] or [[fentanyl]] withdrawal |
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** Neuroleptic Malignant Syndrome; rare, life-threatening hyperpyrexia caused by antidopaminergic drugs (mostly antipsychotics) |
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* Reaction to incompatible blood products |
* Reaction to incompatible blood products |
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* [[Cancer]]s, most commonly [[kidney cancer]] and [[leukemia]] and [[lymphoma]]s |
* [[Cancer]]s, most commonly [[kidney cancer]] and [[leukemia]] and [[lymphoma]]s |
Revision as of 20:57, 12 November 2009
![]() | It has been suggested that Hyperpyrexia be merged into this article. (Discuss) Proposed since March 2009. |
Fever |
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Fever (also known as pyrexia, from the Greek pyretos meaning fire, or a febrile response, from the Latin word febris, meaning fever, and archaically known as ague) is a frequent medical sign that describes an increase in internal body temperature to levels above normal. Fever is most accurately characterized as a temporary elevation in the body's thermoregulatory set-point, usually by about 1–2 °C (1.8-3.6 °F).
Fever is caused by an elevation in the thermoregulatory set-point, causing typical body temperature (generally and problematically considered to be 37 °C or 98.6 °F) to rise, and effector mechanisms are enacted as a result. A feverish individual has a general feeling of cold despite an increased body temperature, and increases in heart rate, muscle tone and shivering, all of which are caused by the body's attempts to counteract the newly perceived hypothermia and reach the new thermoregulatory set-point.
Fever differs from hyperthermia in that hyperthermia is an increase in body temperature over the body's thermoregulatory set-point, due to excessive heat production or insufficient thermoregulation, or both.
A fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body, be it bacterial or viral.
Measurement and normal variation
When a patient has or is suspected of having a fever, that person's body temperature is measured using a thermometer. At a first glance, fever is present if:[citation needed]
- Temperature in the anus (rectum/rectal) is at or over 37.8 °C (100.0 °F)
- Temperature in the mouth (oral) is at or over 37.5 °C (99.5 °F)
- Temperature under the arm (axillary) is at or over 37.2 °C (99.0 °F)
- Temperature in the ear (otic) is at or over 37.2 °C (99.0 °F)
The common oral measurement of normal human body temperature is 36.8±0.7 °C (98.2±1.3 °F). This means that any oral temperature between 36.1 and 37.5 °C (96.9 and 99.5 °F) is likely to be normal.
However, there are many variations in normal body temperature, and this needs to be considered when measuring for fever. The values given are for an otherwise healthy, non-fasting adult, dressed comfortably, indoors, in a room that is kept at a normal room temperature (22.7 to 24.4 °C or 73 to 76 °F), during the morning, but not shortly after arising from sleep. Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at least the previous fifteen to twenty minutes.
Body temperature normally fluctuates over the day, with the lowest levels around 4 a.m. and the highest around 6 p.m.[1] (assuming the subject follows the prevalent pattern, i.e., sleeping at nighttime and staying awake during daytime). Therefore, an oral temperature of 37.2 °C (99.0 °F) would strictly be a fever in the morning, but not in the afternoon. An oral body temperature reading up to 37.5 °C (99.5 °F) in the early/late afternoon or early/late evening also wouldn't be a fever. Normal body temperature may differ as much as 0.6 °C (1 °F) between individuals or from day to day. In women, temperature differs at various points in the menstrual cycle, and this can be used as part of fertility awareness (although temperature is only one of the variables). Temperature is increased after eating, and psychological factors also influence body temperature.
There are different locations where temperature can be measured, and these differ in temperature variability. Tympanic membrane thermometers measure radiant heat energy from the tympanic membrane (infrared). These may be very convenient, but may also show more variability.
Children develop higher temperatures with activities like playing, but this is not fever because their set-point is normal. Elderly patients may have a decreased ability to generate body heat during a fever, so even a low-grade fever can have serious underlying causes in geriatrics.
Fever is usually accompanied by sickness behavior which consists of lethargy, depression, anorexia, sleepiness, hyperalgesia, and the inability to concentrate.[2][3][4]
Mechanism
![](http://upload.wikimedia.org/wikipedia/commons/thumb/f/f7/Fever-conceptual.svg/400px-Fever-conceptual.svg.png)
Hypothermia: Characterized in the center: Normal body temperature is shown in green, while the hypothermic temperature is shown in blue. As can be seen, hypothermia can be conceptualized as a decrease below the thermoregulatory set-point.
Fever: Characterized on the right: Normal body temperature is shown in green. It reads "New Normal" because the thermoregulatory set-point has risen. This has caused what was the normal body temperature (in blue) to be considered hypothermic.
Temperature is ultimately regulated in the hypothalamus. A trigger of the fever, called a pyrogen, causes a release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus, which generates a systemic response back to the rest of the body, causing heat-creating effects to match a new temperature level.
In many respects, the hypothalamus works like a thermostat.[5] When the set point is raised, the body increases its temperature through both active generation of heat and retaining heat. Vasoconstriction both reduces heat loss through the skin and causes the person to feel cold. The liver produces extra heat. If these measures are insufficient to make the blood temperature in the brain match the new setting in the hypothalamus, then shivering begins, to use muscle movements to produce more heat. When the fever stops, and the hypothalamic setting is set lower, the reverse of these processes (vasodilation, end of shivering and nonshivering heat production) and sweating are used to cool the body to the new, lower setting.
This contrasts with hyperthermia, in which the normal setting remains, and the body overheats through undesirable retention of excess heat or over-production of heat.[5] Hyperthermia is usually the result of an excessively hot environment (heat stroke) or an adverse reaction to drugs. Fever can be differentiated from hyperthermia by the circumstances surrounding it and its response to anti-pyretic medications.
Pyrogens
A pyrogen is a substance that induces fever. These can be either internal (endogenous) or external (exogenous) to the body. The bacterial substance lipopolysaccharide (LPS), present in the cell wall of some bacteria, is an example of an exogenous pyrogen. Pyrogenicity can vary, as in extreme examples some bacterial pyrogens known as superantigens can cause rapid and dangerous fevers. Depyrogenation may be achieved through filtration, distillation, chromatography, or inactivation.
- Endogenous
Cytokines (especially interleukin 1) are a part of the innate immune system, are produced by phagocytic cells, and cause the increase in the thermoregulatory set-point in the hypothalamus. Other examples of endogenous pyrogens are interleukin 6 (IL-6), and tumor necrosis factor-alpha.
These cytokine factors are released into general circulation where they migrate to the circumventricular organs of the brain due to easier absorption caused by the blood-brain barrier's reduced filtration action there. The cytokine factors then bind with endothelial receptors on vessel walls, or interact with local microglial cells. When these cytokine factors bind, the arachidonic acid pathway is then activated.
- Exogenous
One model for the mechanism of fever caused by exogenous pyrogens includes LPS, which is a cell wall component of gram-negative bacteria. An immunological protein called lipopolysaccharide-binding protein (LBP) binds to LPS. The LBP–LPS complex then binds to the CD14 receptor of a nearby macrophage. This binding results in the synthesis and release of various endogenous cytokine factors, such as interleukin 1 (IL-1), interleukin 6 (IL-6), and the tumor necrosis factor-alpha. In other words, exogenous factors cause release of endogenous factors, which, in turn, activate the arachidonic acid pathway.
PGE2 release
PGE2 release comes from the arachidonic acid pathway. This pathway (as it relates to fever), is mediated by the enzymes phospholipase A2 (PLA2), cyclooxygenase-2 (COX-2), and prostaglandin E2 synthase. These enzymes ultimately mediate the synthesis and release of PGE2.
PGE2 is the ultimate mediator of the febrile response. The set-point temperature of the body will remain elevated until PGE2 is no longer present. PGE2 acts on neurons in the preoptic area (POA) through the prostaglandin E receptor 3 (EP3). EP3-expressing neurons in the POA innervate the dorsomedial hypothalamus (DMH), the rostral raphe pallidus nucleus in the medulla oblongata (rRPa) and the paraventricular nucleus (PVN) of the hypothalamus . Fever signals sent to the DMH and rRPa lead to stimulation of the sympathetic output system, which evokes non-shivering thermogenesis to produce body heat and skin vasoconstriction to decrease heat loss from the body surface. It is presumed that the innervation from the POA to the PVN mediates the neuroendocrine effects of fever through the pathway involving pituitary gland and various endocrine organs.
Hypothalamus response
The brain ultimately orchestrates heat effector mechanisms via the autonomic nervous system. These may be:
- Increased heat production by increased muscle tone, shivering and hormones like epinephrine.
- Prevention of heat loss, such as vasoconstriction.
The autonomic nervous system may also activate brown adipose tissue to produce heat (non-exercise-associated thermogenesis, also known as non-shivering thermogenesis), but this seems mostly important for babies. Increased heart rate and vasoconstriction contribute to increased blood pressure in fever.
Types
According to one common rule of thumb[citation needed], fever is generally classified for convenience as:
vagina, or ear (core temp.) |
(oral temp.) |
(axillary temp.) | ||||
low grade | 38-39 | 100.0-102.2 | 37.2-38.2 | 99-100.8 | 36.8-37.8 | 98.4-100.2 |
moderate | 39-40 | 102.2-104.0 | 38.2-39.2 | 100.8-102.6 | 37.8-38.8 | 100.2-102 |
high-grade | 40-41.1 | 104.0-106.0 | 39.2-40.3 | 102.6-104.6 | 38.8-39.9 | 102-104 |
hyperpyrexia | >41.1 | >106.0 | >40.3 | >104.6 | >39.9 | >104 |
The last is a medical emergency because it approaches the upper limit compatible with human life.[citation needed] The ranges differ because normal body temperature differs depending on where it is measured.
Most of the time, fever types can not be used to find the underlying cause. However, there are specific fever patterns that may occasionally hint the diagnosis:
- Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma, being high for one week and low for the next week and so on. However, there is some debate as to whether this pattern truly exists.[6]
- Continuous fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis, or typhus. Typhoid fever may show a specific fever pattern, with a slow stepwise increase and a high plateau.
- Intermittent fever: Elevated temperature is present only for some hours of the day and becomes normal for remaining hours, e.g. malaria, kala-azar, pyaemia, or septicemia. In malaria, there may be a fever with a periodicity of 24 hours (quotidian), 48 hours (tertian fever), or 72 hours (quartan fever, indicating Plasmodium malariae). These patterns may be less clear in travelers.
- Remittant fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g. infective endocarditis.
A neutropenic fever, also called febrile neutropenia, is a fever in the absence of normal immune system function. Because of the lack of infection-fighting neutrophils, a bacterial infection can spread rapidly and this fever is therefore usually considered a medical emergency. This kind of fever is more commonly seen in people receiving immune-suppressing chemotherapy than in apparently healthy people.
Febricula[7] is a mild fever of short duration, of indefinite origin, and without any distinctive pathology.
Causes
Fever is a common symptom of many medical conditions:
- Infectious disease, e.g. influenza, HIV, malaria, infectious mononucleosis, or gastroenteritis
- Various skin inflammations, e.g. boils, pimples, acne, or abscess
- Immunological diseases, e.g. lupus erythematosus, sarcoidosis, inflammatory bowel diseases
- Tissue destruction, which can occur in hemolysis, surgery, infarction, crush syndrome, rhabdomyolysis, cerebral hemorrhage, etc.
- Drug-induced fevers
- Directly caused by the drug, e.g. lamictal, progesterone, or chemotherapeutics causing tumor necrosis
- As an adverse reaction to drugs, e.g. antibiotics or sulfa drugs.
- After drug discontinuation, e.g. heroin or fentanyl withdrawal
- Neuroleptic Malignant Syndrome; rare, life-threatening hyperpyrexia caused by antidopaminergic drugs (mostly antipsychotics)
- Reaction to incompatible blood products
- Cancers, most commonly kidney cancer and leukemia and lymphomas
- Metabolic disorders, e.g. gout or porphyria
- Thrombo-embolic processes, e.g. pulmonary embolism or deep venous thrombosis
Persistent fever which cannot be explained after repeated routine clinical inquiries, is called fever of unknown origin.
Usefulness of fever
There are arguments for and against the usefulness of fever, and the issue is controversial.[8][9] There are studies using warm-blooded vertebrates[10] and humans[11] in vivo, with some suggesting that they recover more rapidly from infections or critical illness due to fever. A Finnish study suggested reduced mortality in bacterial infections when fever was present.[12]
Theoretically, fever can aid in host defense.[8] There are certainly some important immunological reactions that are sped up by temperature, and some pathogens with strict temperature preferences could be hindered.[13] Fevers may be useful to some extent since they allow the body to reach high temperatures, causing an unbearable environment for some pathogens. White blood cells also rapidly proliferate due to the suitable environment and can also help fight off the harmful pathogens and microbes that invaded the body.[citation needed]
Research[14] has demonstrated that fever has several important functions in the healing process:
- Increased mobility of leukocytes
- Enhanced leukocytes phagocytosis
- Endotoxin effects decreased
- Increased proliferation of T cells[15]
- Enhanced activity of interferon[15]
Treatment
Fever should not necessarily be treated. Fever is an important signal that there's something wrong in the body, and it can be used to govern medical treatment and gauge its effectiveness. Moreover, not all fevers are of infectious origin.
Even when treatment is not indicated, however, febrile patients are generally advised to keep themselves adequately hydrated, as the dehydration produced by a mild fever can be more dangerous than the fever itself. Water is generally used for this purpose, but there is always a small risk of hyponatremia if the patient drinks too much water. For this reason, some patients drink sports drinks or electrolyte-replacing products designed specifically for this purpose.
Most people take medication against fever because the symptoms cause discomfort. Fever increases heart rate and metabolism, thus potentially putting an additional strain on elderly patients, patients with heart disease, etc. This may even cause delirium. Therefore, potential benefits must be weighed against risks in these patients. In any case, fever must be brought under control in instances when fever escalates to hyperpyrexia and tissue damage is imminent.
Treatment of fever is normally done by lowering the set-point, but facilitating heat loss may also be effective. The former is accomplished with antipyretics such as ibuprofen or paracetamol (US acetominophen). Aspirin can also be given to adults, but can cause Reye's Syndrome in children. Heat removal is generally by wet cloth or pads, usually applied to the forehead,[16] but also through bathing the body in tepid water. This is particularly important for babies, for whom drugs should be avoided. However, using water that is too cold can induce vasoconstriction, and reduce effective heat loss.
Heat loss may also be accomplished by heat conduction, convection, radiation, or evaporation (sweating, perspiration), or a combination of these.
Fever in domestic animals
Fever is also an important feature for the diagnosis of disease in domestic animals. The body temperature of animals, which is taken rectally, is different from one species to another. For example, a horse is said to have a fever at 38.5 °C, while a cow is said to have a fever at 39.6 °C. [citation needed]
In species that allow the body to have a wide range of "normal" temperatures, such as camels, it is sometimes difficult to determine a febrile stage.
Diseases called "fever"
As fever is a prominent symptom of many diseases, in humans and animals, it will often appear in the common appellation of diseases.
In humans
- Puerperal fever
- Scarlet fever
- Typhoid fever
- Malaria, which was once called "marsh fever"
- Viral hemorrhagic fevers
- Drug-induced fever, which is technically a form of hyperthermia
In animals
- East Coast fever (an African disease of cattle)
- Malignant catarrhal fever (a worldwide disease of cattle)
- Rift valley fever (an African disease of sheep)
- Classical and African swine fevers (diseases of pigs)
- Milk fever, an oddly named disease of cattle; body temperature is not elevated in this disease
References
- ^ Body Temperature
- ^ Hart, B. L. (1988) "Biological basis of the behavior of sick animals". Neurosci Biobehav Rev. 12: 123-137.PMID 3050629
- ^ Johnson, R. (2002) "The concept of sickness behavior: a brief chronological account of four key discoveries". Veterinary Immunology and Immunopathology. 87: 443-450 PMID 12072271
- ^ Kelley, K. W., Bluthe, R. M., Dantzer, R., Zhou, J. H., Shen, W. H., Johnson, R. W. Broussard, S. R. (2003) "Cytokine-induced sickness behavior". Brain Behav Immun. 17 Suppl 1: S112-118 PMID 12615196
- ^ a b Fauci, Anthony; et al. (2008). Harrison's Principles of Internal Medicine (17 ed.). McGraw-Hill Professional. pp. 117–121. ISBN 9780071466332.
{{cite book}}
: Explicit use of et al. in:|author=
(help) - ^ Hilson, A.J.W.; DiNubile, M.J. (1995-07-06). "Correspondence". New England Journal of Medicine. 333: 66–67. doi:10.1056/NEJM199507063330118. PMID 7777006. Retrieved 2008-03-18.
{{cite journal}}
: CS1 maint: date and year (link). They cite Richard Asher's lecture Making Sense (Lancet, 1959, 2, 359) - ^ Febricula, definition from Biology-Online.org, consulted June 7, 2006 http://www.biology-online.org/dictionary/Febricula
- ^ a b Schaffner A. Fever—useful or noxious symptom that should be treated? Ther Umsch 2006; 63: 185-8. PMID 16613288
- ^ Soszynski D. The pathogenesis and the adaptive value of fever. Postepy Hig Med Dosw 2003; 57: 531-54. PMID 14737969
- ^ Su, F.; Nguyen, N.D.; Wang, Z.; Cai, Y.; Rogiers, P.; Vincent, J.L. Fever control in septic shock: beneficial or harmful? Shock 2005; 23: 516-20. PMID 15897803
- ^ Schulman, C.I.; Namias, N.; Doherty, J., et al. The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized, prospective study. Surg Infect (Larchmt) 2005; 6:369-75. PMID 16433601
- ^ Rantala S, Vuopio-Varkila J, Vuento R, Huhtala H, Syrjänen J. Predictors of mortality in beta-hemolytic streptococcal bacteremia: A population-based study. J Infect. March 2, 2009. PMID 19261333
- ^ Fischler, M.P.; Reinhart, W.H. Fever: friend or enemy? Schweiz Med Wochenschr 1997; 127: 864-70. PMID 9289813
- ^ Craven, R and Hirnle, C. (2006). Fundamentals of nursing: Human health and function. Fourth edition. p. 1044
- ^ a b Lewis, SM, Heitkemper, MM, and Dirksen, SR. (2007). Medical-surgical nursing: Assessment and management of clinical problems. sixth edition. p. 212
- ^ Craven,R and Hirnle,C. (2006). "Fundamentals of nursing: Human health and function. Forth edition". Antipyretics. 11 (7–8): 1044. PMID 15636181.
{{cite journal}}
: CS1 maint: multiple names: authors list (link)
Further reading
- Rhoades, R. and Pflanzer, R. Human physiology, third edition, chapter 27 Regulation of body temperature, p. 820 Clinical focus: pathogenesis of fever. ISBN 0-03-005159-2
External links
- What to do if your child has a fever from Seattle Children's Hospital
- Fever and Taking Your Child's Temperature
- US National Institute of Health factsheet
- BUPA factsheet