Definition of the concept
Fever is an increase in body temperature as a result of changes in the thermoregulatory center of the hypothalamus. It is a protective-adaptive reaction of the body that occurs in response to the action of pathogenic stimuli.
Hyperthermia should be distinguished from fever - an increase in temperature when the process of thermoregulation of the body is not disturbed, and the increased body temperature is caused by a change external conditions, for example, overheating of the body. The body temperature during infectious fever usually does not exceed 41 0 C, in contrast to hyperthermia, in which it is above 41 0 C.
Temperatures up to 37 °C are considered normal. Body temperature is not a constant value. The temperature value depends on: time of day(maximum daily fluctuations are from 37.2 °C at 6 a.m. to 37.7 °C at 4 p.m.). Night workers may have the opposite relationship. The difference between morning and evening temperatures is healthy people does not exceed 1 0 C); motor activity(rest and sleep help lower the temperature. Immediately after eating, a slight increase in body temperature is also observed. Significant physical stress can cause an increase in temperature by 1 degree); phases of the menstrual cycleamong women With a normal temperature cycle, the morning vaginal temperature curve has a characteristic two-phase shape. The first phase (follicular) is characterized by low temperature (up to 36.7 degrees), lasts about 14 days and is associated with the action of estrogens. The second phase (ovulation) manifests itself more high temperature(up to 37.5 degrees), lasts about 12-14 days and is caused by the action of progesterone. Then, before menstruation, the temperature drops and the next follicular phase begins. The absence of a decrease in temperature may indicate fertilization. It is characteristic that morning temperature measured in the axillary region, in the oral cavity or rectum gives similar curves.
Normal body temperature in the armpit:36.3-36.9 0 C, in the oral cavity:36.8-37.3 0, in the rectum:37.3-37.7 0 C.
The causes of fever are many and varied:
1. Diseases that directly damage the thermoregulation centers of the brain (tumors, intracerebral hemorrhages or thrombosis, heat stroke).
3. Mechanical injury (crumbling).
4. Neoplasms (Hodgkin's disease, lymphoma, leukemia, kidney carcinoma, hepatoma).
5. Acute metabolic disorders (thyroid crisis, adrenal crisis).
6. Granulomatous diseases (sarcoidosis, Crohn's disease).
7. Immune disorders (connective tissue diseases, drug allergies, serum sickness).
8. Acute vascular disorders (thrombosis, infarctions of the lung, myocardium, brain).
9. Disturbance of hematopoiesis (acute hemolysis).
10. Under the influence of medications (neuroleptic malignant syndrome).
Human body temperature is a balance between the formation of heat in the body (as a product of all metabolic processes in the body) and the release of heat through the surface of the body, especially the skin (up to 90-95%), as well as through the lungs, feces and urine. These processors are regulated by the hypothalamus, which acts like a thermostat. In conditions that cause an increase in temperature, the hypothalamus commands the sympathetic nervous system to vasodilate the blood vessels of the skin, increasing sweating, which increases heat transfer. When the temperature drops, the hypothalamus gives the command to retain heat by constricting the blood vessels of the skin and muscle tremors.
Endogenous pyrogen - a low-molecular protein produced by blood monocytes and macrophages of the tissues of the liver, spleen, lungs, and peritoneum. In some tumor diseases - lymphoma, monocytic leukemia, kidney cancer (hypernephroma) - autonomous production of endogenous pyrogen occurs and, therefore, fever is present in the clinical picture. Endogenous pyrogen, after being released from the cells, acts on the thermosensitive neurons of the preoptic region of the hypothalamus, where the synthesis of prostaglandin E1, E2 and cAMP is induced with the participation of serotonin. These biologically active compounds, on the one hand, cause an intensification of heat production by restructuring the hypothalamus to maintain body temperature at a higher temperature. high level, and on the other hand, they affect the vasomotor center, causing narrowing of peripheral vessels and a decrease in heat transfer, which generally leads to fever. The increase in heat production occurs due to an increase in the intensity of metabolism, mainly in muscle tissue.
In some cases, stimulation of the hypothalamus may be caused not by pyrogens, but by dysfunction of the endocrine system (thyrotoxicosis, pheochromocytoma) or autonomic nervous system(neurocirculatory dystonia, neuroses), the influence of certain medications (drug fever).
The most common causes of drug fever are penicillins and cephalosporins, sulfonamides, nitrofurans, isoniazid, salicylates, methyluracil, procainamide, antihistamines, allopurinol, barbiturates, intravenous infusions of calcium chloride or glucose, etc.
Fever of central origin is caused by direct irritation of the thermal center of the hypothalamus as a result of acute cerebrovascular accident, tumor, or traumatic brain injury.
Thus, an increase in body temperature may be due to the activation of the system of exopyrogens and endopyrogens (infections, inflammation, pyrogenic substances of tumors) or other reasons without the participation of pyrogens at all.
Since the degree of increase in body temperature is controlled by the “hypothalamic thermostat,” even in children (with their immature nervous system) fever rarely exceeds 41 0 C. In addition, the degree of increase in temperature largely depends on the condition of the patient’s body: for the same disease It may be different for different individuals. For example, with pneumonia in young people, the temperature reaches 40 0 C and higher, but in old age and in exhausted people such a significant rise in temperature does not occur; sometimes it doesn’t even exceed the norm.
Fever is considered acute", if it lasts no more than 2 weeks, the fever is called " chronic» with a duration of more than 2 weeks.
In addition, during the course of a fever, a distinction is made between a period of increasing temperature, a period of peak fever, and a period of decreasing temperature. Temperature reduction occurs in different ways. A gradual, step-like decrease in temperature over 2-4 days with minor evening rises is called lysis. The sudden, rapid end of fever with a drop in temperature to normal within 24 hours is called crisis. As a rule, a rapid drop in temperature is accompanied by profuse sweat. This phenomenon was given special significance before the era of antibiotics, since it symbolized the beginning of a period of recovery.
Increased body temperature from 37 to 38 0 C is called low-grade fever. Moderately elevated body temperature from 38 to 39 0 C is called febrile fever. High body temperature from 39 to 41 0 C is called pyretic fever. Excessively high body temperature (over 41 0 C) is hyperpyretic fever. This temperature in itself can be life-threatening.
There are 6 main types of fever and 2 forms of fever.
It should be noted that our predecessors attached great importance to temperature curves when diagnosing diseases, but in our time all these classical types of fever are of little help in the work, since antibiotics, antipyretics and steroid drugs change not only the nature of the temperature curve, but also the entire clinical picture diseases.
1. Constant or persistent fever. There is a constantly elevated body temperature and during the day the difference between morning and evening temperatures does not exceed 1 0 C. It is believed that such an increase in body temperature is characteristic of lobar pneumonia, typhoid fever, and viral infections (for example, influenza).
2. Relieving fever (remitting). There is a constantly elevated body temperature, but daily temperature fluctuations exceed 1 0 C. A similar increase in body temperature occurs with tuberculosis, purulent diseases (for example, with a pelvic abscess, empyema of the gallbladder, wound infection), as well as with malignant neoplasms.
By the way, fever with sharp fluctuations in body temperature (the range between morning and evening body temperature is more than 1°C), accompanied in most cases by chills, is usually called septic(see also intermittent fever, hectic fever).
3. Intermittent fever (intermittent). Daily fluctuations, as in relapsing-remitting conditions, exceed 1 0 C, but here the morning minimum is within normal limits. Moreover, elevated body temperature appears periodically, at approximately equal intervals (most often around noon or at night) for several hours. Intermittent fever is especially characteristic of malaria, and is also observed with cytomegalovirus infection, infectious mononucleosis, and purulent infections (eg, cholangitis).
4. Wasting fever (hectic). In the morning, as with intermittent, normal or even decreased body temperature is observed, but daily temperature fluctuations reach 3-5 0 C and are often accompanied by debilitating sweats. Such an increase in body temperature is characteristic of active pulmonary tuberculosis and septic diseases.
5. Reverse or perverted fever differs in that the morning body temperature is higher than the evening one, although from time to time the usual slight evening increase in temperature still occurs. Reverse fever occurs with tuberculosis (more often), sepsis, and brucellosis.
6. Irregular or irregular fever manifests itself as alternation various types fever and is accompanied by varied and irregular daily fluctuations. Abnormal fever occurs with rheumatism, endocarditis, sepsis, and tuberculosis.
1. Undulating fever characterized by a gradual rise in temperature over a certain period of time (persistent or remitting fever for several days), followed by a gradual decrease in temperature and more or less long periods of normal temperature, which gives the impression of a series of waves. The exact mechanism of this unusual fever is unknown. Often observed in brucellosis and lymphogranulomatosis.
2. Relapsing fever (recurrent) characterized by alternating periods of fever with periods of normal temperature. In its most typical form it occurs in relapsing fever and malaria.
One-day, or ephemeral fever: elevated body temperature is observed for several hours and does not recur. Occurs with mild infections, overheating in the sun, after a blood transfusion, and sometimes after intravenous administration of drugs.
Daily repetition of attacks - chills, fever, drop in temperature - in malaria is called daily fever.
Three-day fever is the repetition of attacks of malaria every other day.
Quadrennial fever is a recurrence of attacks of malaria after 2 fever-free days.
Five-day paroxysmal fever (synonyms: Werner-His disease, trench or trench fever, paroxysmal rickettsiosis) is an acute infectious disease caused by rickettsia, carried by lice, and typically occurs in a paroxysmal form with repeated four- or five-day attacks of fever separated by several days remission, or in typhoid form with multi-day continuous fever.
Fever is characterized not only by an increase in body temperature. Fever is accompanied by increased heart rate and breathing; blood pressure often decreases; patients complain of a feeling of heat, thirst, headache; the amount of urine excreted decreases. Fever increases metabolism, and since along with this appetite is reduced, patients with long-term fevers often lose weight. Feverish patients note: myalgia, arthralgia, drowsiness. Most of them have chills and chilliness. With tremendous chills and severe fever, piloerection (“goose bumps”) and trembling occur, and the patient’s teeth chatter. Activation of heat loss mechanisms leads to sweating. Abnormalities in mental status, including delirium and seizures, are more common in very young, very old, or debilitated patients.
1. Tachycardia(cardiopalmus). The relationship between body temperature and pulse deserves great attention, since, other things being equal, it is quite constant. Typically, with an increase in body temperature by 1°C, the heart rate increases by at least 8-12 beats per minute. If at a body temperature of 36 0 C the pulse is, for example, 70 beats per minute, then a body temperature of 38 0 C will be accompanied by an increase in heart rate to 90 beats per minute. The discrepancy between high body temperature and pulse rate in one direction or the other is always subject to analysis, since in some diseases this is an important recognition sign (for example, fever in typhoid fever, on the contrary, is characterized by relative bradycardia).
2. Sweating. Sweating is one of the mechanisms of heat transfer. Profuse sweating occurs as the temperature drops; when the temperature rises, on the contrary, the skin is usually hot and dry. Sweating is not observed in all cases of fever; it is characteristic of purulent infection, infective endocarditis and some other diseases.
4. Herpes. Fever is often accompanied by the appearance of a herpetic rash, which is not surprising: 80-90% of the population is infected with the herpes virus, although clinical manifestations of the disease are observed in 1% of the population; activation of the herpes virus occurs at the time of decreased immunity. Moreover, when talking about fever, ordinary people often mean herpes by this word. With some types of fever, herpetic rash occurs so often that its appearance is considered one of the diagnostic signs of the disease, for example, lobar pneumococcal pneumonia, meningococcal meningitis.
5. Febrile seizuresOgi. Seizures with fever occur in 5% of children aged 6 months to 5 years. The likelihood of developing a convulsive syndrome during fever depends not so much on the absolute level of increase in body temperature, but on the speed of its rise. Typically, febrile seizures last no more than 15 minutes (average 2-5 minutes). In many cases, seizures occur early in the development of fever and usually go away on their own.
Convulsive syndrome can be associated with fever if:
the child’s age does not exceed 5 years;
there are no diseases that can cause seizures (for example, meningitis);
no seizures were observed in the absence of fever.
First of all, in a child with febrile seizures, you should think about meningitis (lumbar puncture is indicated if the clinical picture is appropriate). To exclude spasmophilia in infants, calcium levels are assessed. If convulsions lasted more than 15 minutes, it is advisable to perform electroencephalography to exclude epilepsy.
6. Change in urine test. With kidney disease, leukocytes, casts, and bacteria can be found in the urine.
In the case of acute fever, it is desirable, on the one hand, to avoid unnecessary diagnostic tests and unnecessary therapy for diseases that can result in spontaneous recovery. On the other hand, it must be remembered that under the guise of a banal respiratory infection, a serious pathology may be hidden (for example, diphtheria, endemic infections, zoonoses, etc.), which must be recognized as early as possible. If an increase in temperature is accompanied by characteristic complaints and/or objective symptoms, then this allows one to immediately navigate the diagnosis of the patient.
The clinical picture should be carefully assessed. They study in detail the anamnesis, life history of the patient, his travels, and heredity. Next, a detailed functional examination of the patient is carried out, repeating it. Laboratory tests are performed, including a clinical blood test with the necessary detail (plasmocytes, toxic granules, etc.), as well as examination of pathological fluid (pleural, joint fluid). Other tests: ESR, general urine analysis, determination of functional activity of the liver, blood cultures for sterility, urine, sputum and feces (for microflora). Special methods studies include x-rays, MRI, CT (to detect abscesses), radionuclide studies. If non-invasive research methods do not allow a diagnosis to be made, a biopsy of organ tissue is performed; bone marrow puncture is advisable in patients with anemia.
But often, especially on the first day of the disease, it is impossible to determine the cause of the fever. Then the basis for decision making becomes the patient's health status before the onset fevers and disease dynamics.
1. Acute fever in the background full health
If fever occurs against a background of complete health, especially in a young or middle-aged person, in most cases one can assume an acute respiratory viral infection (ARVI) with spontaneous recovery within 5-10 days. When diagnosing ARVI, it should be taken into account that with infectious fever, catarrhal symptoms of varying degrees of severity are always observed. In most cases, no tests (other than daily temperature measurements) are required. When re-examined after 2-3 days, the following situations are possible: improved health, decreased temperature. The appearance of new signs, such as skin rashes, plaque in the throat, wheezing in the lungs, jaundice, etc., which will lead to a specific diagnosis and treatment. Deterioration/no change. In some patients, the temperature remains quite high or their general condition worsens. In these situations, repeated, more in-depth questioning and additional research are required to search for diseases with exo- or endogenous pyrogens: infections (including focal ones), inflammatory or tumor processes.
2. Acute fever with a changed background
If the temperature rises against the background of an existing pathology or the patient’s serious condition, the possibility of self-healing is low. An examination is immediately prescribed (the diagnostic minimum includes general blood and urine tests, chest x-ray). Such patients are also subject to more regular, often daily monitoring, during which indications for hospitalization are determined. Main options: Patient with chronic disease. Fever may be associated primarily with a simple exacerbation of the disease if it is of an infectious-inflammatory nature, for example, bronchitis, cholecystitis, pyelonephritis, rheumatism, etc. In these cases, targeted additional examination is indicated. Patients with reduced immunological reactivity. For example, those suffering from oncohematological diseases, HIV infection, or receiving glucocorticosteroids (prednisolone more than 20 mg/day) or immunosuppressants for any reason. The appearance of fever may be due to the development of an opportunistic infection. Patients who have recently undergone invasive diagnostic tests or therapeutic procedures. Fever may reflect the development of infectious complications after examination/treatment (abscess, thrombophlebitis, bacterial endocarditis). There is also an increased risk of infection among drug addicts who inject drugs intravenously.
3. Acute fever in patients over 60 years of age
Acute fever in the elderly and senile age is always a serious situation, because due to a decrease in functional reserves, acute disorders can quickly develop under the influence of fever in such patients, for example, delirium, cardiac and respiratory failure, and dehydration. Therefore, such patients require immediate laboratory and instrumental examination and determination of indications for hospitalization. One more important circumstance should be taken into account: at this age, clinical manifestations may be asymptomatic and atypical. In most cases, fever in old age has an infectious etiology. The main causes of infectious and inflammatory processes in old age: Acute pneumonia is the most common cause of fever in old age (50-70% of cases). Fever, even with extensive pneumonia, may be low, auscultatory signs of pneumonia may not be expressed, and general symptoms (weakness, shortness of breath) will be in the foreground. Therefore, for any unclear fever, an X-ray of the lungs is indicated - this is the law ( pneumonia is the old man's friend). When making a diagnosis, the presence of intoxication syndrome (fever, weakness, sweating, cephalalgia), disorders of broncho-drainage function, auscultatory and radiological changes are taken into account. The differential diagnosis includes the possibility of pulmonary tuberculosis, which is often encountered in geriatric practice. Pyelonephritis is usually manifested by fever, dysuria and lower back pain; a general urine test reveals bacteriuria and leukocyturia; Ultrasound reveals changes in the collecting system. The diagnosis is confirmed by bacteriological examination of urine. The occurrence of pyelonephritis is most likely in the presence of risk factors: female gender, bladder catheterization, urinary tract obstruction (urolithiasis, prostate adenoma). Acute cholecystitis can be suspected when fever and chills are combined, pain in the right hypochondrium, jaundice, especially in patients with already known chronic gallbladder disease.
Other, less common causes of fever in old and senile age include herpes zoster, erysipelas, meningoencephalitis, gout, polymyalgia rheumatica and, of course, ARVI, especially during the epidemic period.
4. Prolonged fever of unknown origin
The conclusion “fever of unknown origin” is valid in cases where an increase in body temperature above 38°C lasts more than 2 weeks, and the cause of the fever remains unclear after routine studies. In the International Classification of Diseases, 10th revision, fever of unknown origin has its code R50 in the “Symptoms and Signs” section, which is quite reasonable, since it is hardly advisable to elevate the symptom to a nosological form. According to many clinicians, the ability to understand the causes of prolonged fever of unknown origin is the touchstone of a doctor’s diagnostic abilities. However, in some cases it is completely impossible to identify difficult-to-diagnose diseases. Among febrile patients who were initially diagnosed with “fever of unknown origin,” cases that have not been fully deciphered account, according to various authors, from 5 to 21% of such patients. Diagnosis of fever of unknown origin should begin with an assessment of the social, epidemiological and clinical characteristics of the patient. To avoid mistakes, you need to get answers to 2 questions: What kind of person is this patient (social status, profession, psychological picture)? Why did the disease manifest itself now (or why did it take this form)?
1. A thorough medical history is of paramount importance. It is necessary to collect all available information about the patient: information about previous diseases (especially tuberculosis and heart valve defects), surgical interventions, taking any medications, working and living conditions (travel, personal hobbies, contact with animals).
2. Conduct a careful physical examination and perform routine tests (complete blood count, complete urinalysis, biochemical blood test, Wassermann test, ECG, chest x-ray), including blood and urine cultures.
3. Think about the possible causes of fever of unknown origin in a particular patient and study the list of diseases manifested by prolonged fever (see list). According to various authors, the basis of long-term fever of unknown origin in 70% is the “big three”: 1. infections - 35%, 2. malignant tumors - 20%, 3. systemic connective tissue diseases - 15%. Another 15-20% are due to other diseases, and in approximately 10-15% of cases the cause of fever of unknown origin remains unknown.
4. Form a diagnostic hypothesis. Based on the data obtained, it is necessary to try to find a “leading thread” and, in accordance with the accepted hypothesis, prescribe certain additional studies. It must be remembered that for any diagnostic problem (including fever of unknown origin), first of all you need to look for common and frequently occurring diseases, and not some rare and exotic diseases.
5. If you get confused, go back to the beginning. If the formed diagnostic hypothesis turns out to be untenable or new assumptions arise about the causes of fever of unknown origin, it is very important to re-question the patient and examine him, and re-examine the medical documentation. Conduct additional laboratory tests (routine) and form a new diagnostic hypothesis.
5. Long-term low-grade fever
Subfebrile body temperature is understood to mean its fluctuations from 37 to 38°C. Prolonged low-grade fever occupies a special place in therapeutic practice. Patients whose long-term low-grade fever is the dominant complaint are seen quite often at appointments. To find out the cause of low-grade fever, such patients are subjected to various studies, they are given various diagnoses and (often unnecessary) treatment is prescribed.
In 70-80% of cases, prolonged low-grade fever occurs in young women with symptoms of asthenia. This is explained by the physiological characteristics of the female body, the ease of infection of the urogenital system, as well as the high frequency of psycho-vegetative disorders. It must be taken into account that prolonged low-grade fever is much less likely to be a manifestation of any organic disease, in contrast to prolonged fever with a temperature above 38°C. In most cases, prolonged low-grade fever reflects banal autonomic dysfunction. Conventionally, the causes of prolonged low-grade fever can be divided into two: large groups: infectious and non-infectious.
Infectious subfebrile condition. Low-grade fever always raises suspicion of an infectious disease. Tuberculosis. If you have an unclear low-grade fever, you must first rule out tuberculosis. In most cases this is not easy to do. From the anamnesis, the following are essential: the presence of direct and prolonged contact with a patient with any form of tuberculosis. The most significant is being in the same place with a patient with an open form of tuberculosis: an office, apartment, stairwell or entrance of the house where the patient with bacterial excretion lives, as well as a group of nearby houses united by a common yard. A history of previous tuberculosis (regardless of location) or the presence of residual changes in the lungs (presumably of tuberculosis etiology), previously detected during preventive fluorography. Any disease with ineffective treatment in recent years three months. Complaints (symptoms) suspicious for tuberculosis include: the presence of a general intoxication syndrome - prolonged low-grade fever, general unmotivated weakness, fatigue, sweating, loss of appetite, weight loss. If pulmonary tuberculosis is suspected, chronic cough (lasting more than 3 weeks), hemoptysis, shortness of breath, chest pain. If extrapulmonary tuberculosis is suspected, complaints about dysfunction of the affected organ, without signs of recovery during therapy. Focal infection. Many authors believe that prolonged low-grade fever may be due to the existence of chronic foci of infection. However, in most cases, chronic foci of infection (dental granuloma, sinusitis, tonsillitis, cholecystitis, prostatitis, adnexitis, etc.), as a rule, are not accompanied by an increase in temperature and do not cause changes in the peripheral blood. It is possible to prove the causal role of a focus of chronic infection only in the case when sanitation of the focus (for example, tonsillectomy) leads to the rapid disappearance of a previously existing low-grade fever. A constant sign Chronic toxoplasmosis in 90% of patients has low-grade fever. In chronic brucellosis, the predominant type of fever is also low-grade fever. Acute rheumatic fever (a systemic inflammatory disease of connective tissue involving the heart and joints in the pathological process, caused by beta-hemolytic streptococcus of group A and occurring in genetically predisposed people) often occurs only with low-grade body temperature (especially with the II degree of activity of the rheumatic process). Low-grade fever may appear after an infectious disease (“fever tail”), as a reflection of post-viral asthenia syndrome. In this case, low-grade fever is benign in nature, is not accompanied by changes in tests and usually goes away on its own within 2 months (sometimes the “temperature tail” can last up to 6 months). But in the case of typhoid fever, prolonged low-grade fever that occurs after a decrease in high body temperature is a sign of incomplete recovery and is accompanied by persistent adynamia, undiminished hepato-splenomegaly and persistent aneosinophilia.
6. Traveler's fever
The most dangerous diseases: malaria (South Africa; Central, South-West and South-East Asia; Central and South America), typhoid fever, Japanese encephalitis (Japan, China, India, South and North Korea, Vietnam, the Far East and Primorsky Krai of Russia), meningococcal infection (incidence is common in all countries, especially high in some African countries (Chad, Upper Volta, Nigeria, Sudan), where it is 40-50 times higher than in Europe), melioidosis (South-East Asia, the Caribbean and Northern Australia), amoebic liver abscess (prevalence of amebiasis - Central and South America, southern Africa, Europe And North America, Caucasus and Central Asian republics of the former USSR), HIV infection.
Possible causes: cholangitis, infective endocarditis, acute pneumonia, Legionnaires' disease, histoplasmosis (widespread in Africa and America, found in Europe and Asia, isolated cases described in Russia), yellow fever (South America (Bolivia, Brazil, Colombia, Peru , Ecuador, etc.), Africa (Angola, Guinea, Guinea-Bissau, Zambia, Kenya, Nigeria, Senegal, Somalia, Sudan, Sierra Leone, Ethiopia, etc.), Lyme disease (tick-borne borreliosis), Dengue fever (central and South Asia (Azerbaijan, Armenia, Afghanistan, Bangladesh, Georgia, Iran, India, Kazakhstan, Pakistan, Turkmenistan, Tajikistan, Uzbekistan), Southeast Asia (Brunei, Indochina, Indonesia, Singapore, Thailand, Philippines), Oceania, Africa, the Caribbean (Bahamas, Guadeloupe, Haiti, Cuba, Jamaica). Not found in Russia (only imported cases), Rift Valley fever, Lassa fever (Africa (Nigeria, Sierra Leone, Liberia, Ivory Coast, Guinea, Mozambique, Senegal, etc.)), Ross River fever, Rocky Mountain spotted fever (USA, Canada, Mexico, Panama, Colombia, Brazil), sleeping sickness (African trypanosomiasis), schistosomiasis (Africa, South America, Southeast Asia), leishmaniasis ( Central America(Guatemala, Honduras, Mexico, Nicaragua, Panama), South America, Central and South Asia (Azerbaijan, Armenia, Afghanistan, Bangladesh, Georgia, Iran, India, Kazakhstan, Pakistan, Turkmenistan, Tajikistan, Uzbekistan), South-West Asia ( United Arab Emirates, Bahrain, Israel, Iraq, Jordan, Cyprus, Kuwait, Syria, Turkey, etc.), Africa (Kenya, Uganda, Chad, Somalia, Sudan, Ethiopia, etc.), Marseilles fever (Mediterranean and Caspian countries basins, some countries of Central and Southern Africa, the southern coast of Crimea and the Black Sea coast of the Caucasus), Pappataci fever (Tropical and subtropical countries, the Caucasus and Central Asian republics of the former USSR), Tsutsugamushi fever (Japan, East and Southeast Asia, Primorsky and Khabarovsk Territories Russia), North Asian tick-borne rickettsiosis (tick-borne typhus - Siberia and the Russian Far East, some areas Northern Kazakhstan, Mongolia, Armenia), relapsing fever (endemic tick-borne - Central Africa, USA, Central Asia, the Caucasus and the Central Asian republics of the former USSR, severe acute respiratory syndrome (Southeast Asia - Indonesia, Philippines, Singapore, Thailand, Vietnam, China and Canada).
Mandatory tests in case of fever upon return from foreign trip include:
General blood analysis
Examination of a thick drop and smear of blood (malaria)
Blood culture (infectious endocarditis, typhoid fever, etc.)
Urinalysis and urine culture
Biochemical blood test (liver tests, etc.)
Wasserman reaction
Chest X-ray
Stool microscopy and stool culture.
7. Hospital fever
Hospital (nosocomial) fever, which occurs during the patient's stay in the hospital, is observed in approximately 10-30% of patients, and every third of them dies. Hospital fever aggravates the course of the underlying disease and increases mortality by 4 times compared to patients suffering from the same pathology not complicated by fever. The clinical condition of a particular patient dictates the scope of the initial examination and the principles of treatment of fever. The following main clinical conditions are possible, accompanied by hospital fever. Non-infectious fever: caused by acute diseases internal organs(acute myocardial infarction and Dressler's syndrome, acute pancreatitis, perforated gastric ulcer, mesenteric (mesenteric) ischemia and intestinal infarction, acute deep vein thrombophlebitis, thyrotoxic crisis, etc.); associated with medical interventions: hemodialysis, bronchoscopy, blood transfusion, drug fever, postoperative non-infectious fever. Infectious fever: pneumonia, urinary tract infection (urosepsis), sepsis due to catheterization, wound postoperative infection, sinusitis, endocarditis, pericarditis, aneurysm of fungal origin (mycotic aneurysm), disseminated candidiasis, cholecystitis, intra-abdominal abscesses, bacterial translocation of the intestine, meningitis, etc.
8. Fever simulation
A false increase in temperature may depend on the thermometer itself when it does not correspond to the standard, which is extremely rare. Fake fever is more common.
Simulation is possible, both for the purpose of depicting a feverish state (for example, by rubbing a reservoir mercury thermometer or preheating it), and for the purpose of hiding the temperature (when the patient holds the thermometer so that it does not heat up). According to various publications, the percentage of febrile state simulation is insignificant and ranges from 2 to 6 percent of the total number of patients with elevated body temperature.
Fake fever is suspected in the following cases:
If feigning a fever is expected, it is recommended to do the following:
Compare the data obtained with determining body temperature by touch and with other manifestations of fever, in particular, with pulse rate.
In the presence of a medical professional and using different thermometers, measure the temperature in both armpits and always in rectum.
Measure the temperature of freshly released urine.
All measures should be explained to the patient by the need to clarify the nature of the temperature, without offending him with suspicion of simulation, especially since it may not be confirmed.
According to the degree of increase, the temperature is distinguished: subfebrile - 37-38 °C, febrile - 38-39 °C, hyperpyretic - above 39 °C.
Regarding the course of development of fever, three periods are distinguished in the temperature curve:
A) the initial stage or period of temperature increase. In some diseases this period is very short and measured in hours, usually accompanied by chills, in others it extends over a more or less long period, for several days;
B) the stage of the height of fever. The peak of the temperature curve lasts from several hours to many days and even weeks;
B) stage of temperature decrease. In some diseases, the temperature decreases quickly within a few hours - a critical drop in temperature or crisis, in others - gradually over several days - a lytic drop or lysis.
Based on the nature of temperature fluctuations, the following types of fever are distinguished:
1) constant fever is characterized by the fact that during the day the difference between morning and evening temperatures does not exceed 1 ° C, while a high temperature is noted;
2) laxative fever gives daily temperature fluctuations within 2 ° C, with the morning minimum above 37 ° C. With a relieving fever, a rise in temperature is accompanied by chills, a decrease in temperature is accompanied by sweating;
3) intermittent fever is characterized by a sudden increase in temperature to 39 ° C or higher, and after a few hours the temperature drops to normal numbers. The rise in temperature is repeated every 1-2 or 3 days. This type of fever is characteristic of malaria;
4) heptic fever is characterized by an increase in temperature by 2-4 °C in the evening and a drop to normal or lower in the morning. This drop in temperature is accompanied by severe weakness with profuse sweating. Observed in sepsis, severe forms of tuberculosis;
5) the reverse type of fever is different in that the morning temperature is higher than the evening temperature. Occurs in pulmonary tuberculosis;
6) irregular fever is accompanied by varied and irregular daily fluctuations. Occurs with rheumatism, flu, etc.;
7) relapsing fever is characterized by alternating periods of fever with fever-free periods. A rise in temperature to 40 °C or more is followed by a drop after a few days to normal, which lasts for several days, and then the temperature curve repeats. This type of fever is characteristic of relapsing fever;
8) undulating fever is characterized by a gradual increase in temperature over several days and a gradual decrease to normal. Then there is a new increase followed by a decrease in temperature. This temperature occurs with lymphogranulomatosis and brucellosis.
Depending on the degree of temperature increase, the following are distinguished: types of fevers:
Subfebrile temperature - 37–38 °C:
a) low-grade fever - 37–37.5 °C;
b) low-grade fever - 37.5–38 °C;
Moderate fever - 38–39 ° C;
High fever - 39–40 ° C;
Very high fever - over 40 ° C;
Hyperpyretic - 41–42 °C, it is accompanied by severe nervous phenomena and is itself life-threatening.
Fluctuations in body temperature throughout the day and throughout the febrile period are of great importance for diagnosis.
In this regard, there are main types of fever:
Persistent fever – the temperature stays high for a long time. During the day, the difference between morning and evening temperatures does not exceed 1 °C; characteristic of lobar pneumonia, stage II of typhoid fever;
Remitting (remitting) fever – high temperature, daily temperature fluctuations exceed 1–2 °C, with a morning minimum above 37 °C; characteristic of tuberculosis, purulent diseases, focal pneumonia, in Stage III typhoid fever;
Wasting (hectic) fever - characterized by large (3–4 °C) daily temperature fluctuations, which alternate with a drop to normal or below, which is accompanied by debilitating sweats; typical for severe pulmonary tuberculosis, suppuration, sepsis;
Intermittent (intermittent) fever - short-term increases in temperature to high numbers strictly alternate with periods (1-2 days) of normal temperature; observed in malaria;
Undulating (undulating) fever - it is characterized by periodic increases in temperature, and then a decrease in the level to normal numbers. Such “waves” follow one another for a long time; characteristic of brucellosis, lymphogranulomatosis;
Relapsing fever is a strict alternation of periods of high temperature with fever-free periods. At the same time, the temperature rises and falls very quickly. The febrile and non-febrile phases last for several days each. Characteristic of relapsing fever;
Reverse type of fever - morning temperature is higher than evening temperature; sometimes observed in sepsis, tuberculosis, brucellosis;
Irregular fever – characterized by varied and irregular daily fluctuations; often observed in rheumatism, endocarditis, sepsis, tuberculosis. This fever is also called atypical (irregular).
It should be noted that types of fever during illness can alternate or transform into one another. The intensity of the febrile reaction may vary depending on the functional state of the central nervous system at the time of exposure to pyrogens. The duration of each stage is determined by many factors, in particular the dose of pyrogen, the time of its action, disorders that have arisen in the body under the influence of a pathogenic agent, etc. Fever can end with a sudden and rapid drop in body temperature to normal or even lower (crisis) or a gradual slow decrease body temperature (lysis). The most severe toxic forms of some infectious diseases, as well as infectious diseases in the elderly, weakened people, and young children often occur with almost no fever or even hypothermia, which is an unfavorable prognostic sign.
Fever is a protective-adaptive reaction of the body in response to the influence of endo- or exogenous pyrogens (agents that cause a temperature reaction), expressed in increasing the threshold of thermoregulation and temporarily maintaining a higher than usual body temperature.Fever is characterized not only by an increase in temperature, but also by disruption of all body systems. The degree of temperature increase is important, but not always decisive, in assessing the severity of the fever.
A rapid and severe increase in temperature (for example, with pneumonia) is usually accompanied by chills, which can last from several minutes to an hour, rarely longer.
With severe chills, the patient's appearance is characteristic: due to a sharp narrowing of the blood vessels, the skin becomes pale, the nail plates acquire a bluish color. Feeling cold, patients tremble and chatter their teeth. A gradual increase in temperature is characterized by slight chilling. At high temperatures, the skin has a characteristic appearance: red, warm (“fiery”). A gradual drop in temperature is accompanied by profuse sweat. With fever, the evening body temperature is usually higher than the morning. A rise in temperature above 37°C during the day is a reason to suspect the disease.
Main types of fever:
constant fever - the temperature remains high for a long time, during the day the difference between morning and evening temperatures does not exceed 1°C; characteristic of lobar pneumonia, stage II of typhoid fever;
laxative (remitting) fever - high temperature, daily temperature fluctuations exceed 1-2°C, with a morning minimum above 37°C; characteristic of tuberculosis, purulent diseases, focal pneumonia, in stage III of typhoid fever;
debilitating (hectic) fever - large (3-4°C) daily temperature fluctuations, alternating with a drop to normal or below, which is accompanied by debilitating sweats; typical for severe pulmonary tuberculosis, suppuration, sepsis;
intermittent (intermittent) fever - short-term increases in temperature to high numbers strictly alternate with periods (1-2 days) of normal temperature; observed in malaria;
undulating (undulating) fever - periodic increases in temperature, and then a decrease in the level to normal numbers, such “waves” follow one after another for a long time; characteristic of brucellosis, lymphogranulomatosis;
relapsing fever - a strict alternation of periods of high temperature with fever-free periods, with the temperature rising and falling very quickly, febrile and non-febrile phases lasting for several days each, characteristic of relapsing fever;
reverse type of fever - morning temperature is higher than evening temperature; sometimes observed in sepsis, tuberculosis, brucellosis;
irregular fever - varied and irregular daily fluctuations; often observed in rheumatism, endocarditis, sepsis, tuberculosis; this fever is also called atypical (irregular).
During a fever, there is a period of increasing temperature, a period of high temperature and a period of decreasing temperature. A sharp decrease in elevated temperature (within several hours) to normal is called a crisis, a gradual decrease (over several days) is called lysis.
With severe chills, the patient's appearance is characteristic: the skin is pale due to sharp capillary spasm, peripheral cyanosis is noted, muscle tremors may be accompanied by chattering of the teeth.
The second stage of fever is characterized by the cessation of temperature rise, heat transfer is balanced with heat production. Peripheral blood circulation is restored, the skin becomes warm to the touch and even hot, the pallor of the skin is replaced by a bright pink color. Sweating also increases.
In the third stage, heat transfer prevails over heat production, skin blood vessels dilate, and sweating continues to increase. The decrease in body temperature can occur quickly and sharply (critically) or gradually.
Sometimes there is a short-term increase in temperature for several hours (one-day, or ephemeral fever) with mild infections, overheating in the sun, after a blood transfusion, sometimes after intravenous administration of drugs. Fever lasting up to 15 days is called acute; fever lasting more than 45 days is called chronic.
The degree of temperature increase largely depends on the patient’s body: with the same disease, it can be different in different individuals. Thus, in young people with high reactivity of the body, an infectious disease can occur with a temperature of up to 40 ° C and above, while the same infectious disease in older people with weakened reactivity can occur with a normal or slightly elevated temperature. The degree of temperature increase does not always correspond to the severity of the disease, which is also associated with the individual characteristics of the body’s response.
Fever in infectious diseases is the earliest and most typical reaction to the introduction of a microbial agent. In this case, bacterial toxins or waste products of microorganisms (viruses) are exogenous pyrogens. They also cause another protective reaction, which consists in the development of stress mechanisms with increased release of neutrophil leukocytes.
An increase in temperature of non-infectious origin is often observed with malignant tumors, tissue necrosis (for example, during a heart attack), hemorrhages, rapid breakdown of red blood cells in the blood, and the subcutaneous or intravenous administration of foreign protein substances. Fever is much less common in diseases of the central nervous system, as well as of reflex origin. At the same time, temperature rises are more often observed in the daytime, so there is a need to measure it hourly.
Fever of central origin can be observed with injuries and diseases of the central nervous system; it has a severe malignant course. High temperature can develop without the participation of pyrogens during severe emotional stress.
Fever is characterized not only by the development of high temperature, but also by disruption of the functioning of all body systems. Maximum level The temperature curve is important, but not always decisive, for assessing the severity of fever.
In addition to high temperature, fever is accompanied by increased heart rate and breathing, decreased blood pressure, and the appearance of general symptoms of intoxication: headache, malaise, feelings of heat and thirst, dry mouth, lack of appetite; decreased urine output, increased metabolism due to catabolic processes. At the peak of a febrile state, in some cases, confusion, hallucinations, delirium, and even complete loss of consciousness can be observed. However for the most part these phenomena reflect the characteristics of the course of the infectious process itself, and not just the febrile reaction.
The pulse rate during fever is directly related to the level of high temperature only in benign fevers caused by low-toxic pyrogens. This does not happen with all infectious diseases. For example, typhoid fever is characterized by a pronounced decrease in heart rate against the background of severe fever. In such cases, the effect of high temperature on frequency heart rate weakens under the influence of other causative factors and mechanisms of disease development. The respiratory rate also increases with the development of high fever. At the same time, breathing becomes more shallow. However, the severity of decreased breathing does not always correspond to the level of high temperature and is subject to significant fluctuations.
During the febrile period, the function of the digestive tract is always impaired in patients. Usually there is a complete absence of appetite, which is associated with decreased digestion and absorption of food. The tongue becomes coated various shades(usually white), patients complain of dry mouth.
The volume of secretions from the digestive glands (salivary, gastric, pancreas, etc.) is significantly reduced. Motor dysfunction gastrointestinal tract are expressed in various kinds of motor dysfunctions, usually with a predominance of spastic phenomena. As a result, the movement of intestinal contents slows down significantly, as does the release of bile, the concentration of which increases.
There are no noticeable changes in kidney activity during fever. An increase in daily urination in the first stage (an increase in temperature) depends on an increase in blood flow in the kidneys due to the redistribution of blood in the tissues. On the contrary, a slight decrease in urination with increased urine concentration at the height of the febrile reaction is explained by fluid retention.
One of the most important components of the protective-adaptive mechanism of fever is an increase in the phagocytic activity of leukocytes and tissue macrophages, and, what is especially important, there is an increase in the intensity of antibody production. Activation of cellular and humoral immunity mechanisms allows the body to adequately respond to the introduction of foreign agents and stop infectious inflammation.
High temperature itself can create unfavorable conditions for the proliferation of various pathogens and viruses. In light of the above, the purpose of developing a feverish reaction developed during evolution is clear. That is why fever is a nonspecific symptom of a large number of different infectious diseases.
The duration of the febrile period allows us to divide all such conditions into short-term (acute) and long-term (chronic). The former include high fever lasting no more than two weeks, the latter - more than two weeks.
Acute fevers lasting no more than one week most often occur as a result of various viral infections of the upper respiratory tract and stop on their own without outside intervention. A number of short-term bacterial infections also cause acute fever. Most often they affect the pharynx, larynx, middle ear, bronchi, and genitourinary system.
If the fever persists for a longer period, then even with the apparent clarity of the clinical picture, the patient requires a more thorough examination. If prolonged fever is not consistent with other clinical manifestations or the general condition of the patient, the term “fever of unknown etiology” (FUE) is usually used.
The following febrile conditions are distinguished:
A. Acute:
I. Viral.
II. Bacterial.
B. Chronic:
I. Infectious:
viral (infectious mononucleosis, viral hepatitis B, cytomegalovirus infection, HIV);
bacterial (tuberculosis, brucellosis, septic endocarditis, etc.);
in persons with secondary immunodeficiency.
II. Tumor.
III. For systemic connective tissue diseases.
IV. For other conditions and diseases (endocrine, allergic, increased sensitivity threshold of the thermoregulation center).
Non-infectious causes of prolonged fever occur in no more than one third of cases. These include fever in subacute septic endocarditis, which is quite difficult to diagnose in the initial absence of a heart murmur. In addition, blood cultures do not detect the presence of bacteria in the blood in 15% of cases. Often there are no peripheral signs of the disease (enlarged spleen, Osler's nodes, etc.).
About 20-40% of fevers of unknown etiology (with an unknown cause) can be caused by systemic connective tissue pathology (systemic lupus erythematosus, systemic scleroderma, rheumatoid polyarthritis, Sjögren's disease, etc.). Among other causes, the most important are tumor processes. Among the latter, a special place is occupied by tumors originating from the hematopoietic system (leukemia, lymphogranulomatosis, etc.). In some cases, fever may be due to the addition of an infection, as, for example, with bronchial carcinoma, when obstruction (difficulty breathing) and pneumonia of the underlying part of the lung develops.
The mandatory minimum of laboratory tests in long-term febrile patients includes a general blood test with a leukocyte count, determination of malarial plasmodia in a smear, tests of the functional state of the liver, bacteriological cultures of urine, feces and blood up to 3-6 times. In addition, it is necessary to carry out the Wasserman test, tuberculin and streptokinase tests, serological testing for HIV, as well as an X-ray examination of the lungs and ultrasound of the abdominal organs.
Even the presence of minor complaints of moderate headache, mild changes in mental status require a puncture of the cerebrospinal fluid with its subsequent examination. In the future, if the diagnosis continues to remain unclear, based on the results of the initial examination, the patient should be determined to have such signs as antinuclear antibodies, rheumatoid factor, antibodies to Brucella, Salmonella, Toxoplasma, Histoplasma, Epstein-Barr virus, cytomegaly, etc. and also conduct research for fungal diseases (candidiasis, aspergillosis, trichophytosis).
The next stage of examination in case of an unknown diagnosis in a long-term febrile patient is a computed tomography, which makes it possible to localize tumor changes or abscesses of internal organs, as well as intravenous pyelography, bone marrow puncture and culture, and endoscopy of the gastrointestinal tract.
If the cause of prolonged fever cannot be determined, it is recommended that such patients be given a trial of treatment, usually antibiotic therapy or specific anti-tuberculosis drugs. If the patient is already receiving treatment, it should be discontinued for a while to exclude the medicinal nature of the fever.
In addition to staphylococcus, streptococcus and anaerobes, pathogens in inpatients with immunodeficiency can be fungi of the genus Candida and Aspergillus, pneumocystis, toxoplasma, listeria, legionella, cytomegalovirus and herpes viruses. The examination of such patients should begin with a bacteriological examination of cultures of blood, urine, feces and sputum, as well as cerebrospinal fluid (depending on the clinical manifestations of the infection).
It is often necessary to begin antibiotic therapy before obtaining the results of bacteriological culture. In such cases, you should focus on the most characteristic nature pathogen for a given localization of infection in a patient (streptococci and E. coli, as well as anaerobes for enterocolitis, E. coli and Proteus for urinary tract infections).
To recognize the causes of acute fevers, the nature of the temperature rise, its frequency and height, as well as the duration of the various periods of fever are of utmost importance. Varying durations of the period of temperature rise may be a characteristic sign of a number of acute infectious processes. For example, for brucellosis and typhoid fever, a gradual increase in the temperature curve over several days to a maximum is typical.
Influenza, typhus, measles and most viral diseases of the respiratory tract are characterized by a short - no more than a day - period of temperature rise to high numbers. The most acute onset of the disease, when the temperature reaches its maximum within a few hours, is characteristic of meningococcal infection, relapsing fever, and malaria. In the differential diagnosis of the causes of febrile conditions, one should rely not only on one symptom (fever), but on the entire symptom complex of features of the course of a period of high temperature.
Rickettsial infections are typically characterized by a combination of acute development of fever with persistent headache and insomnia, as well as facial redness and motor agitation of the patient. The appearance of a typical rash on the 4th-5th day of the disease makes it possible to diagnose the clinical picture of typhus.
This is observed at the height of the disease. On the 8-10th day of illness, patients with typhus may also experience an “incision” in the temperature curve, similar to the first. But then after 3-4 days the temperature drops to normal. Typical febrile reactions are rare when antibiotic therapy is used. With uncomplicated typhus, the fever usually lasts 2-3 days, less often - 4 days or more.
Borelliosis (relapsing louse and tick-borne typhus) is characterized by a rapid rise in temperature to high numbers, accompanied by severe symptoms of intoxication and tremendous chills. For 5-7 days, the high temperature remains at the achieved level, after which it critically drops to normal numbers, and then after 7-8 days the cycle repeats.
Erysipelas is also characterized by an acute onset and the absence of a preceding period. The temperature rise reaches 39-40°C and may be accompanied by vomiting and agitation. Usually, pain and burning immediately occur in the affected area of the skin, which soon becomes bright red in color with a ridge that sharply limits the area of inflammation.
With meningococcal infection, body temperature can range from slightly elevated to very high (up to 42°C). The temperature curve can be of a constant, intermittent and remitting type. During antibiotic therapy, the temperature decreases by the 2-3rd day; in some patients, a slightly elevated temperature remains for another 1-2 days.
Meningococcemia (meningococcal sepsis) begins acutely and proceeds rapidly. A characteristic symptom is a hemorrhagic rash in the form of irregular stars. Elements of the rash in the same patient can be of different sizes - from small pinpoints to extensive hemorrhages. The rash appears 5-15 hours after the onset of the disease. Fever with meningococcemia is often intermittent. Characteristics: pronounced symptoms of intoxication, temperature rises to 40-41°C, severe chills, headache, hemorrhagic rash, increased heart rate, shortness of breath, and cyanosis appear. Then blood pressure drops sharply. Body temperature drops to normal or slightly elevated levels. Motor excitement increases, convulsions appear. And in the absence of appropriate treatment, death occurs.
Meningitis may not only be of meningococcal origin. Meningitis, like encephalitis (inflammation of the brain), develops as a complication of any previous infection. Thus, the most harmless, at first glance, viral infections, such as influenza, chicken pox, rubella, can be complicated by severe encephalitis. Usually there is a high body temperature, a sharp deterioration in general condition, general cerebral disorders, headache, dizziness, nausea, vomiting, impaired consciousness, and general anxiety appear. Depending on the damage to a particular part of the brain, various symptoms may be detected - disorders of the cranial nerves, paralysis.
The headache is moderate, and excessive sweating (or heavy sweats) is typical. There is an increase in all groups of lymph nodes, an enlargement of the liver and spleen. The disease usually begins gradually, less often acutely. Fever in the same patient can be different. Sometimes the disease is accompanied by a wave-like temperature curve typical for brucellosis of a remitting type, when fluctuations between morning and evening temperatures are more than 1 ° C, intermittent - a decrease in temperature from high to normal, or constant - fluctuations between morning and evening temperatures do not exceed 1 ° C.
Feverish waves are accompanied by profuse sweating. The number of waves of fever, their duration and intensity are different. The intervals between waves range from 3-5 days to several weeks and months. Fever can be high, low-grade for a long time, or it can be normal. The disease often occurs with prolonged low-grade fever. The change from a long febrile period to a fever-free interval is also characteristic. of various durations. Despite the high temperature, the condition of the patients remains satisfactory. With brucellosis, various organs and systems are affected, primarily the musculoskeletal, urogenital (genitourinary), nervous systems are affected, the liver and spleen are enlarged.
An increase in body temperature can be observed with various diseases of the lungs, heart, and other organs. Thus, inflammation of the bronchi (acute bronchitis) can occur during acute infectious diseases (influenza, measles, whooping cough, etc.) and when the body cools. Body temperature in acute focal bronchitis can be slightly elevated or normal, and in severe cases it can rise to 38-39°C. Weakness, sweating, and cough are also concerning.
The development of focal pneumonia (pneumonia) is associated with the transition of the inflammatory process from the bronchi to the lung tissue. They can be of bacterial, viral, fungal origin. The most characteristic symptoms of focal pneumonia are cough, fever and shortness of breath. Fever in patients with bronchopneumonia varies in duration. The temperature curve is often of a laxative type (daily temperature fluctuations of 1°C, with the morning minimum above 38°C) or of an irregular type. Often the temperature is slightly elevated, and in old and senile age it may be completely absent.
Lobar pneumonia is more often observed when the body is hypothermic. Lobar pneumonia is characterized by a certain cyclical course. The disease begins acutely, with tremendous chills and an increase in body temperature to 39-40°C. Chills usually last up to 1-3 hours. The condition is very serious. Shortness of breath and cyanosis are noted. At the height of the disease, the condition of patients worsens even more. Symptoms of intoxication are pronounced, breathing is frequent, shallow, tachycardia up to 100/200 beats/min.
Against the background of severe intoxication, vascular collapse may develop, which is characterized by a drop in blood pressure, increased heart rate, and shortness of breath. Body temperature also drops sharply. The nervous system suffers (sleep is disturbed, there may be hallucinations, delusions). With lobar pneumonia, if antibiotic treatment is not started, the fever can last for 9-11 days and be permanent. The temperature drop can occur critically (within 12-24 hours) or gradually over 2-3 days. During the resolution stage, there is usually no fever. Body temperature returns to normal.
The temperature curve is remitting in nature, accompanied by weakness and sweating. After a few days, joint pain appears. Rheumatism is characterized by damage to the heart muscle with the development of myocarditis. The patient is concerned about shortness of breath, pain in the heart area, and palpitations. There may be a slight increase in body temperature. The febrile period depends on the severity of the disease. Myocarditis can also develop with other infections - scarlet fever, diphtheria, picquetheiasis, viral infections. Allergic myocarditis may occur, for example, when using various medications.
Diagnosis of primary bacterial endocarditis is particularly difficult, since at the onset of the disease there is no damage to the valve apparatus, and the only manifestation of the disease is fever of the wrong type, accompanied by chills, followed by profuse sweating and a decrease in temperature. Sometimes a rise in temperature may occur during the day or at night. Bacterial endocarditis can develop in patients with artificial heart valves. In some cases, there are fevers caused by the development of a septic process in patients with catheters in the subclavian veins, which are used in infusion therapy.
Often, fever is the only symptom of a malignant disease. Feverish conditions often occur with malignant tumors of the liver, stomach, intestines, lungs, and prostate gland. There are cases where fever for a long time was the only symptom of malignant lymphoma localized in the retroperitoneal lymph nodes. The main causes of fever in cancer patients are considered to be the addition of infectious complications, tumor growth and the effect of tumor tissue on the body. The third place in the frequency of febrile conditions is occupied by systemic connective tissue diseases (collagenosis). This group includes systemic lupus erythematosus, scleroderma, arteritis nodosa, dermatomyositis, and rheumatoid arthritis.
Systemic lupus erythematosus is characterized by a steady progression of the process, sometimes with rather long remissions. In the acute period there is always a fever of the wrong type, sometimes taking on a hectic character with chills and profuse sweat. Characterized by dystrophies, damage to the skin, joints, various organs and systems.
Among patients with prolonged fever, drug fever occurs in 5-7% of cases. It can occur in response to any medications, most often on the 7-9th day of treatment. Diagnosis is facilitated by the absence of an infectious or somatic disease, the appearance of a papular rash on the skin, coinciding with the time of taking medications. This fever is characterized by one feature: the symptoms of the underlying disease disappear during therapy, and the body temperature rises. After discontinuation of the drug, body temperature usually normalizes within 2-3 days.
Thermoregulation disorder is manifested by an almost constant feeling of heat, intolerance to heat, thermal procedures, and slightly elevated body temperature. An increase in temperature to high numbers (up to 40°C and above) is characteristic of a complication of diffuse toxic goiter - thyrotoxic crisis, which occurs in patients with a severe form of the disease. All symptoms of thyrotoxicosis sharply worsen. A pronounced excitement appears, reaching the point of psychosis, the pulse quickens to 150-200 beats/min. The skin of the face is red, hot, moist, the limbs are cyanotic. Muscle weakness, trembling of the limbs develop, paralysis and paresis are expressed.
Acute purulent thyroiditis is purulent inflammation of the thyroid gland. It can be caused by various bacteria - staphylococcus, streptococcus, pneumococcus, E. coli. It occurs as a complication of purulent infection, pneumonia, scarlet fever, abscesses. The clinical picture is characterized by an acute onset, an increase in body temperature to 39-40°C, chills, rapid heartbeat, severe pain in the neck, moving to the lower jaw, ears, aggravated by swallowing, and head movement. The skin over the enlarged and sharply painful thyroid gland is red. The duration of the disease is 1.5-2 months.
With allergic polyneuritis that develops after administration of the rabies vaccine (used to prevent rabies), an increase in body temperature may also be observed. Within 3-6 days after administration, high body temperature, uncontrollable vomiting, headache, and confusion may occur. There are constitutionally determined hypothalamopathies (“habitual fever”). This fever has a hereditary predisposition and is more common in young women. Against the background of vegetative-vascular dystonia and constant low-grade fever, an increase in body temperature to 38-38.5°C is noted. A rise in temperature is associated with physical activity or emotional stress.
The diagnosis of “artificial fever” can be suspected only after observing the patient, examining him and excluding other causes and diseases that cause an increase in body temperature. Fever can be observed in various acute surgical diseases (appendicitis, peritonitis, osteomyelitis, etc.) and is associated with the penetration of microbes and their toxins into the body. A significant increase in temperature in the postoperative period may be due to the body's reaction to surgical trauma.
When muscles and tissues are injured, the temperature may rise as a result of the breakdown of muscle proteins and the formation of autoantibodies. Mechanical irritation of thermoregulation centers (fracture of the base of the skull) is often accompanied by an increase in temperature. With intracranial hemorrhages (in newborns), postencephalitic brain lesions, a high temperature is also noted, mainly as a result of a central violation of thermoregulation.
When the appendiceal inflammatory seal suppurates, a periappendiceal abscess is formed. The condition of the patients is deteriorating. Body temperature becomes high and hectic. Sudden changes in temperature are accompanied by chills. Abdominal pain gets worse. A serious complication of acute appendicitis is diffuse purulent peritonitis. Abdominal pain is diffuse. The condition of the patients is serious. There is a significant increase in heart rate, and the pulse rate does not correspond to body temperature. Brain injuries can be open (with damage to the bones of the skull and brain matter) and closed. Closed injuries include concussion, bruise and contusion with compression.
With sunstroke and heatstroke, general overheating of the body is not necessary. Violation of thermoregulation occurs due to exposure to direct sunlight on an uncovered head or naked body. Weakness, dizziness, headache, nausea are a concern, and sometimes vomiting and diarrhea may occur. In severe cases, agitation, delirium, convulsions, and loss of consciousness are possible. As a rule, there is no high temperature.
Physical means include methods that provide cooling of the body: it is recommended to remove clothes, wipe the skin with water, alcohol, 3% vinegar solution, or apply ice to the head. You can apply a bandage moistened to your wrists and head. cold water. Gastric lavage through a tube with cold water (temperature 4-5°C) is also used, and cleansing enemas are given, also with cool water. In the case of infusion therapy, all solutions are administered intravenously cooled to 4°C. The patient can be blown with a fan to reduce body temperature. These measures allow you to reduce body temperature by 1-2°C within 15-20 minutes. You should not lower your body temperature below 37.5°C, as after this it continues to decrease on its own.
Analgin, acetylsalicylic acid, and brufen are used as medications. It is most effective to use the drug intramuscularly. So, use a 50% solution of analgin, 2.0 ml (for children - at a dose of 0.1 ml per year of life) in combination with antihistamines: 1% solution of diphenhydramine, 2.5% solution of pipolfen or 2 % solution of suprastin. To reduce body temperature and reduce anxiety, a 0.05% solution of chlorpromazine can be used orally. Children under 1 year old - 1 tsp., from 1 year to 5 years old - 1 tsp. l., 1-3 times a day. To prepare a 0.05% solution of chlorpromazine, take an ampoule of a 2.5% solution of chlorpromazine and dilute the 2 ml contained in it with 50 ml of water.
In more severe conditions, to reduce the excitability of the central nervous system, lytic mixtures are used, which include aminazine in combination with antihistamines and novocaine (1 ml of a 2.5% solution of aminazine, 1 ml of a 2.5% solution of pipolfen, 0 .5% solution of novocaine). A single dose of the mixture for children is 0.1-0.15 ml/kg body weight, intramuscularly.
To maintain adrenal function and lower blood pressure, corticosteroids are used - hydrocortisone (for children 3-5 mg per 1 kg of body weight) or prednisolone (1-2 mg per 1 kg of body weight). In the presence of respiratory disorders and heart failure, therapy should be aimed at eliminating these syndromes. When body temperature rises to high levels, children may develop a convulsive syndrome, to stop which seduxen is used (children under 1 year at a dose of 0.05-0.1 ml; 1-5 years - 0.15-0.5 ml 0. 5% solution, intramuscular).
To combat cerebral edema, use magnesium sulfate 25% solution in a dose of 1 ml per year of life intramuscularly. First aid for heat and sunstroke is as follows. It is necessary to immediately stop exposure to the factors that led to sunstroke or heatstroke. It is necessary to move the victim to a cool place, remove clothes, lay him down, and raise his head. Cool the body and head by applying compresses with cold water or dousing with cold water.
The victim is given ammonia to sniff, and soothing and cardiac drops (Zelenin drops, valerian, Corvalol) are given inside. The patient is given plenty of cool fluids. If respiratory and cardiac activity stops, it is necessary to immediately clear the upper respiratory tract from vomit and begin artificial respiration and cardiac massage until the first respiratory movements and cardiac activity appear (determined by pulse). The patient is urgently hospitalized in a hospital.
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