FEVER & HYPERTHERMIA
Hypothalamus controls body temperature
Neurons in both preoptic anterior hypothalamus and
posterior thalamus receive 2 kinds of signals:
Peripheral nerves carrying information from warmth/cold
receptors in the skin
Temperature of the blood bathing the region
In neutral temperature environment, the metabolic rate
produces more heat than necessary to maintain the core
body temperature at 36.5-37.50C (97.7-99.50F)
Factors determining rate of heat production
BMR
Muscle activity
Thyroid hormones
Epinephrine and norepinephrine
Causes of heat loss from the body
Radiation
Conduction
Convection
Evaporation
Normal body temperature
Mean oral temperature: 36.80 0.40 C (98.20 0.70 F), with low levels
at 6 AM & higher levels at 4-6PM
Maximum normal oral temperature is 37.2 0 C (98.90 F) at 6 AM &
37.70 C (99.90 F) at 4 PM- 99th percentile for healthy individuals
Normal daily temperature variation - 0.50 C (0.90 F)
Rectal temperature 0.40 C (0.70 F) higher than oral temperature
Oral temperature is 0.60 C (10 F) higher than axillary temperature
Fever: Definition
It is an elevation of body temperature above the normal
circadian variation as a result of the change in the
thermoregulatory center, located in the hypothalamus.
An AM temperature of >37.20C (98.90F) or a PM
temperature of 37.70C (99.90F) would define fever.
A fever of >41.50C (>106.70F) - hyperpyrexia
Chills sensation of cold
Rigors profound chill with piloerection, associated with
teeth clattering and sever shivering
Occurs due to new reset higher temperature in
thermostat peripheral vasoconstriction and involuntary
contraction of skeletal muscles
Physiological changes with fever
Every 10F rise of temperature above 1000F
PR increase by 10
RR increase by 4
BMR increase by 7%
Oxygen consumption increases by 13%
Pathogenesis
Pyrogens: any substance that cause fever
Exogenous: endotoxin, enterotoxin
Endogenous: pyrogenic cytokines IL1 , IL6,
TNF, Ciliary Neurotrophic factor (CNTF), IFN
.
Patterns of Fever
Continuous fever temperature remains elevated
above normal without touching the baseline and the
fluctuation does not exceed 10F. E.g. lobar pneumonia,
infective endocarditis, enteric fever.
98.60F
Remittent fever
Temperature fluctuation exceeds 0.60C (10F),
but without touching the baseline.
Intermittent fever ( Quotidian fever)
Elevated temperature touches the baseline in
between. E.g. Sepsis
Relapsing fever
Febrile episodes are separated by normal
temperature for more than 1 day.
Tertian fever- occurs on first and third day, P. vivax, ovale,
falciparum
Quartan fever- occurs on first and fourth day. P. malariae
Pel-ebstein fever- fever last for 3-10 days with afebrile period
of 3-10 days e.g. lymphoma
Saddle back fever- fever lasts 2-3 days then afebrile for 2
days and fever reappears for 2-3 days e.g. dengue
Drug fever
Prolonged fever of any pattern
Relative bradycardia and hypotension
Pruritis, skin rash, and arthralgia
Begins 1-3 weeks after starting drugs and persists 2-3
days after the drug has been withdrawn
Eosinophilia may be present
Almost all drugs produce it
Sulphonamides, penicillins, iodides, Anti-TB drugs,
Procainamide, methyldopa, anticonvulsants, propylthiouracil
Infections without fever
Elderly
Newborn
CRF
steroids
Fever with relative bradycardia
Typhoid fever
Meningitis
Viral fever(influenza)
Brucellosis
Leptospirosis
Drug fever
Hyperpyrexia
Pontine hemorrhage
Rheumatic fever
Meningococcal meningitis
Septicaemia
Cerebral malaria
Investigations
Depends on suspicion of underlying cause
Investigations done are to establish cause
of fever
No advantage of measuring pyrogens
no added benefit
Decision to treat fever
Treatment of fever and its symptoms doesnot harm and
doesnot slow the resolution of common viral and
bacterial infections.
Routine use of antipyretics can mask an inadequately
treated bacterial infections
Control of fever is needed
Cardiac, pulmonary and CNS impairment
Children with h/o febrile or non febrile seizure
Mechanism of antipyretic agents
Inhibitors of cycloxygenase are potent
antipyretics
Drugs used are
Acetaminophen
NSAIDs
Glucocorticoids
Regimens for the treatment of fever
Objectives
Reduce the hypothalamic setpoint
Use of antipyretics
Facilitate heat loss
Use of cooling blankets, cold sponging
Hyperthermia
Characterized by uncontrolled increase in the
body temperature that exceeds the bodys ability
to loose heat.
Setting of hypothalamic thermoregulatory center is
unchanged
No role of pyrogens
Exogenous heat exposure and endogenous heat
production are two mechanisms
Causes of hyperthermic syndromes
Heat stroke
Exertional: Exercise in higher than normal heatand/or humidity
Nonexertional: Anticholinergics, antihistamines, antiparkinsonian drugs,
phenothiazines
Drug induced hyperthermia
Amphetamines, cocaine, phencyclidine, methylenedioxymethamphetamines
(MDMA, ectasy), lysergic acid diethylamide (LSD), salicylates, lithium,
anticholinergics, sympathomimetics
Neuroleptic Malignant Syndrome
Phenothiazines, haloperidol, fluoxetine, loxapine, TCA, metoclopramide,
domperidone, withdrawal of dopaminergic drugs.
Serotonin Syndrome
SSRIs, MAOIs, TCA
Malignant Hyperthermia
Inhalational anesthetics, succinylcholine
Endocrinopathy
Thyrotoxicosis, pheochromocytoma
CNS damage
Cerebral hemorrhage, status epilepticus, hypothalmic injury
Heat stroke
Exertional heat stroke typically occurs in individuals working at
elevated ambient temperatures and/or humidity
In dry environment and at maximal efficiency, sweating can
dissipate 600kcal/h, requiring the production of >1L of sweat
Dehydration, use of drugs with anticholinergic side effects heat
stroke
Non exertional heat stroke typically occurs in either very young or
elderly individuals, particularly during heat waves
The elderly, the bedridden, persons taking anticholinergic or
antiparkinsonian drugs or diuretics, and individuals confined to
poorly ventilated and non-air-conditioned environments are
susceptible
Heat stroke
Treatment
Physical cooling with sponging, fans, cooling blankets
and even ice bath should be initiated immediately
IV fluids to prevent dehydration
Internal cooling with gastric or peritoneal lavage
Hemodialysis or cardiopulmonary bypass with cooling
of blood may be performed
Malignant hyperthermia
Inherited abnormality of skeletal muscle sarcoplasmic reticulum
that causes rapid increase in intracellular calcium level in response
to halothane and other inhalational anaesthetics or succinylcholine
Elevated temperature, increased muscle metabolism, muscle
rigidity, rhabdomyolysis, acidosis, and cardiovascular instability
develops within minutes
Though rare is fatal
Treatment include cessation of anesthesia and IV administration of
dantrolene sodium 1-2.5mg/kg every 6 hrly atleast 24-48 hrs until
oral dantolene can be administered, if needed.
Procainamide given to prevent ventricular fibrillation
Neuroleptic malignant syndrome
Setting of use of neuroleptics (antipyschotic phenothiazines,
haloperidol, prochorperazine,metoclopramide) or withdrawal of
dopaminergic drugs
Lead-pipe muscle rigidity, extrapyramidal side-effects, autonomic
dysregulation, hyperthermia
Occurs due to inhibition of dopamine recepters in the hypothalamus
resulting in increased heat generation and decreased heat
dissipation
Treatment as in malignant hyperthermia-Dantrolene sodium
Bromocriptine, levodopa, amantadine, or nifedipine or by induction
of muscle paralysis with curare and pancuronium
Serotonin Syndrome
Drug-related complication that results from increased brain-stem
serotonin activity, usually precipitated by the use of one or more
serotonergic drugs.
Clinical presentation consists of autonomic dysfunction, alteration in
mental status, and neuromuscular disorder
Management includes
withdrawal of causative agents and
supportive measures such as hemodynamic stabilization,
sedation, temperature control, hydration, and monitoring for
complications.
Serotonin antagonists, specifically cyproheptadine, have been
used, but the documented benefits are purely anecdotal
