1996. clin norteemérica. patrone de fiebre

8/18/2019 1996. Clin Norteemérica. Patrone de Fiebre

1/8

THE CLINICAL SIGNIFICANCE OF FEVER PATTERNS Infectious Disease Clinics of North AmericaVolume 10, Issue 1 (March 1996): 33-44

THE CLINICAL SIGNIFICANCE OF FEVER PATTERNS

Burke A. Cunha MDFrom the Infectious Disease Division, Winthrop-University Hospital, Mineola; and the State University of New YorkSchool of Medicine, Stony Brook, New York

Address reprint requests toBurke A. Cunha, MDInfectious Disease DivisionWinthrop-University Hospital259 First StreetMineola, NY 11501

Fever patterns have been appreciated for centuries by clinicians as important diagnosticsigns. When methods for diagnosing infectious diseases were primitive or nonexistent, analysis of

fever curves often provided the only way to differentiate acute febrile illnesses. Magnitude andfrequency of fever spikes, as well as the fever's characteristic fever curves, were associated with avariety of infectious disorders. Although fever curves were helpful in only a relatively few infectiousdiseases, it was noted that certain infections regularly and reproducibly were associated with aparticular fever pattern. To this day, in spite of extensive research in chemical mediators of thefebrile response (e.g., cytokines), it is not understood why certain fever patterns are characteristic ofcertain infectious diseases. It is remarkable and somewhat amazing that typhoid fever still isaccompanied by a stepwise increase in temperature with a sustained fever pattern. Why this or anyother fever pattern is associated with particular infectious diseases remains a mystery. [2] [7] [10] [12]

The classical fever patterns were regarded as a key diagnostic sign by clinicians, but theirusefulness has been questioned by some in the past few decades. [9] Fever curves have limited

diagnostic usefulness in hospital-acquired infections.[4]

In community-acquired infections,characteristic fever curves are more important, but are a function of geographic location. Forexample, the double quotidian fever curve seen with visceral leishmaniasis (kala-azar) is only usefulto clinicians in those parts of the world where the disease is prevalent. Reassessment of theusefulness of fever curves for diagnostic purposes is related to the ratio of community-acquired tohospital-acquired infections and geographically dependent epidemiology. [3]

THE CLINICAL APPROACH

Fever may indicate an infectious, inflammatory, or neoplastic disorder. Although theabsence of fever is diagnostically unhelpful, the abruptness of the onset, appearance of the patient,fever magnitude/ pattern, and associated clinical or laboratory findings usually point to the probable

cause of the fever. Diseases behave biologically in a predictable manner even though the clinicalpresentation may be quite varied, and the pattern of organ involvement and key characteristicaspects of the fever determine the differential diagnosis. [2] [3] [4] [5]

For diagnostic purposes, fevers may be viewed as acute, subacute, or chronic, and with orwithout localizing signs. [6] Febrile patients with localizing signs present few difficulties in diagnosis.Diagnosing patients without localizing signs, however, is a diagnostic challenge. In patients with onlyfever, the fever pattern may be the only way to arrive at a working diagnosis. [8] [9] [10] [11] [12] Clinically,fever should be viewed as an important diagnostic clue as well as an essential host defensemechanism. [4] [7]

FEVER WITHOUT LOCALIZING SIGNS

Fever can be approached from a diagnostic perspective as presenting with or withoutlocalizing signs. Infectious diseases presenting as acute febrile illnesses without localizing signs, such

http://www.mdconsult.com/das/clinicslist/view/245751275-10/home/0891-5520/0?issn=0891-5520http://www.mdconsult.com/das/clinicslist/view/245751275-10/issue/2029?ANCHOR=51757&issn=0891-5520http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033007http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033009http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033005http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033006http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033009http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033011http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033007http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033007http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033011http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033009http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033006http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033005http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033004http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033009http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033007http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/clinicslist/view/245751275-10/issue/2029?ANCHOR=51757&issn=0891-5520http://www.mdconsult.com/das/clinicslist/view/245751275-10/home/0891-5520/0?issn=0891-5520


2/8

as typhoid fever, malaria, ehrlichiosis, roseola infantum, typhoidal tularemia, typhoidal Epstein-Barrvirus (EBV), mononucleosis, and miliary tuberculosis, are the most difficult diagnostic problem. Thepreeruptive stages of Rocky Mountain spotted fever (RMSF), viral hepatitis, and the childhoodexanthems are further examples. If no localizing signs are present, analysis of temperature andcharacteristic fever patterns are of clinical importance, and may provide the only clue to guidefurther testing or suggest the diagnosis. [2] [3] [10]

FEVER PATTERNS

Fever patterns are of most help in diagnosing febrile illnesses without localizing signs, andare of limited usefulness in nosocomial fevers. Classical fever patterns retain their usefulness/validityin many areas of the world where traditional infectious diseases are common and retain theirimportance. [8] [10] [12] Intermittent fevers are temperature elevations that return to normal at least once during most days.Sustained or continuing fevers do not vary more than 1°F per day; remittent fevers do not return tonormal each day. Relapsing fevers are recurrent over days or weeks and may have any underlyingfever pattern (e.g., intermittent, continuous, remittent). Biphasic illnesses are not truly recurrent andoccur only once, and relapsing fevers are different from febrile diseases prone to relapse (Fig. 1) . [2] [10]

[12]

Magnitude of Fever

Although temperature elevation does not correlate with disease severity, the height of thetemperature elevation has important diagnostic significance at temperature extremes (e.g.,hyperpyrexia or hypothermia). Temperatures more than 106°F are not due to infectious diseases, anda noninfectious origin should be the focus of the diagnostic approach (Table 1) (Table Not Available) .Hypothermia or subnormal temperatures, if associated with bactermia, are a bad prognostic sign.Slight hypothermia may be a normal variant in the elderly. Not infrequently, hypothermia is due tooverzealous antipyretic medications.

Most temperature elevations are encountered clinically between the extremes of

hyperpyrexia and hypothermia. Temperatures between 98°F and 102°F may be on an infectious basis,but are usually due to noninfectious conditions common in hospitalized patients, especially in criticalcare units. For diagnostic purposes, it is clinically useful to divide fevers into those capable of 102°F ormore and those that nearly always remain below 102°F. The differential diagnosis of most commonlyencountered causes of fever in the hospital/intensive care unit may be approached efficiently byapplying the "102°F rule" (Table 2) (Table Not Available) . [2] [3]

TABLE 1 -- DIAGNOSTIC SIGNIFICANCE OF EXTREME HYPERPYREXIA AND HYPOTHERMIA Adapted from Cunha BA: Clinical implications of fever. Postgrad Med 85(5): 188-200, 1989; withpermission.

(Not Available)

TABLE 2 -- DIFFERENTIAL DIAGNOSIS OF FEVER IN HOSPITALIZED PATIENTS BASED ONTEMPERATURE--THE 102°F RULE

Adapted from Cunha BA: Clinical implications of fever. Postgrad Med 85(5): 188-200, 1989; withpermission.

(Not Available)

http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003301http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003301http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002


3/8

Figure 1. A, Intermittent (hectic/septic) fevers; B, remittent fever; C, sustained/continuous fever.

Frequency of Fever Fevers may be described as intermittent, continuous/sustained, or remittent. Relapsing

fevers recur at various intervals after the initial febrile episode. Single isolated fever spikes are nevercaused by infection and are commonly due to the transfusion of blood and blood products or themanipulation of a colonization/infected mucosal surface.


4/8

The most specific fever pattern is the double quotidian fever because only a few diseasesare associated with two fever spikes a day (e.g., adult Still's disease, right-sided gonococcalendocarditis, visceral leishmaniasis [kala-azar], etc). A double quotidian fever is an important clue tothe diagnosis of adult Still's disease because there are no other physical or laboratory findings toestablish the diagnosis (Fig. 2) .

Most infectious diseases have no specific fever pattern. The classic fever curves are oflimited diagnostic usefulness in hospitalized patients as most nosocomial infections are not causedby classic infectious diseases (Table 3) (Table Not Available) . [3] [10] [12]

TABLE 3 -- DIAGNOSTIC SIGNIFICANCE OF FEVER PATTERNS Adapted from Cunha BA: Infectious Diseases. In Samiy AH, Bardoness J, Douglas RG (eds): Textbook ofDiagnostic Medicine. Philadelphia, Lea & Febiger, 1987; with permisson.

(Not Available)

Fever Duration The magnitude of acute infectious diseases improves or worsens within 2 weeks. Not

uncommonly, many infectious diseases have persistent fever after clinical improvement that may last2 to 4 weeks. The diagnosis of the cause of such fevers is usually straightforward, but the cause ofsome remains obscure. These are best termed prolonged feversto avoid confusing them with bonafide fevers of unknown origin (FUOs). FUOs by definition must have fever of 101°F or more for atleast 3 weeks and remain undiagnosed after a week of inpatient/outpatient workup. [2] [6] [12]

Recurring Fever Relapsing fevers may be due to a variety of infectious and noninfectious diseases.

Multisystem disease characterized by exacerbation/remission may mimic infectious relapsing fever.Most temperature elevations occur at night as an exaggeration of our normal diurnal temperaturevariation.

A biphasic fever is characterized by two fever spikes during the illness, usually over thecourse of 1 or more weeks (e.g., African hemorrhagic fevers). This is in contrast to relapsing feversthat are recurrent and not necessarily biphasic (Table 4 ; Fig. 3 ). [8] [10] [11] [12]

Figure 3. Relapsing (camelback/dromedary) fever.

Pulse/Temperature Relationships The relationship of the pulse to the temperature is often more useful than the fever pattern.

If the pulse is elevated out of proportion to the temperature, the relationship is termed relativetachycardia. Relative tachycardia is associated with noninfectious conditions and toxin-mediatedinfections, such as gas gangrene. When the pulse is not elevated proportionately to the temperatureelevation, a pulse-temperature deficit exists (e.g., relative bradycardia). The finding of relativebradycardia has important diagnostic significance. For example, if a hospitalized patient presentswith fevers and relative bradycardia, the differential diagnosis is limited to legionnaires' disease ordrug fever. If the chest radiograph is negative, the workup should be focused toward drug fever.Drug fever is usually accompanied by relative bradycardia; associated findings include negative blood

http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003302http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033006http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#T003304http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003303http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033011http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033011http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033008http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003303http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#T003304http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033006http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033010http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003302


5/8

cultures (excluding contaminants), slightly elevated serum transaminases, elevated erythrocytesedimentation rate (ESR), and eosinophils in the peripheral smear without eosinophilia, which isuncommon (Fig. 4) (Figure Not Available) . [2] [3] [12]

Figure 4. (Figure Not Available) Temperature chart showing relative bradycardia in a patient with Legionn

aire's disease prior to initiation of doxycycline treatment on day 5. Solid line represents temperature;dotted line represents pulse. ( Adapted from Cotton LM, Strampfer MJ, Cunha BA: Legionella and mycoplasma

pneumonia: A community hospital experience. Clin Chest Med 8:441-453, 1987.)

Figure 2. Double quotidian fever.

Fever Defervescence Patterns Viral illnesses have a slow temperature defervescence, usually over a week. Febrile,

noninfectious diseases will not decrease without specific therapy. Steroids and antipyretics decreasetemperatures nonspecifically; this needs to be taken into account in assessing therapeuticresponses. Clinicians may be misled into thinking an antibiotic is being effective as evidenced by adecrease in temperature only to learn later the patient was concomitantly receiving an antipyreticmedication. For this and other reasons, fevers should not be eliminated without reason.

Bacterial infections usually manifest a prompt drop in temperature with appropriatetreatment. Infections respond at different rates, however, and this may be useful clinically. Forexample, enterococcal subacute bacterial endocarditis (SBE) defervesces slowly over a week incontrast to viridans streptococcal SBE. Similarly, temperature from Haemophilus influenzaeorKlebsiella pneumoniaecomes down more slowly than if the patient had pneumococcal pneumonia.Pneumococcal and H. influenzaemeningitis, in contrast, have a slower rate of temperature decreasethan does meningococcal meningitis. Even the febrile response to antibiotic therapy may vary, as isthe case with pneumococcal pneumonia, which has three patterns of febrile defervescences. Theusual pattern of proven pneumonia is rapidly decreasing temperature during the first 24 to 36 hoursof antibiotic therapy. The second pattern is a more gradual decrease over 3 to 4 days, usually seen incompromised hosts (e.g., alcoholics). Lastly, after initial defervescence, a small group of patients willhave another temperature spike on day 3 or 4 (Fig. 5) .

After an initial response to antimicrobial therapy, patients usually continue with low-gradeto no fever until discharge. Reappearance of fever during treatment suggests an infectiouscomplication (i.e., septic emboli in a patient with subacute bacterial endocarditis) or drug fever. Thereappearance of fever after an initial response is virtually never because of resistant organisms, but

may be due to superinfection. The diagnostic approach should be directed accordingly, and

http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003305http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#F003305http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033012http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033003http://www.mdconsult.com/das/article/body/245751275-10/jorg=clinics&source=MI&sp=811054&sid=1159231862/N/51757/1.html?issn=0891-5520#R0033002


6/8

antibiotic therapy should not be changed because of the possibility of resistant organisms.Immunocompromised hosts, in general, respond more slowly to antibiotic therapy.

CONCLUSION

The clinical validity of fever curves remains intact. Clinicians of old were not wrong in their

astute observations. The diagnostic usefulness of fever curves is best applied to difficult-to-diagnoseinfectious diseases where present day investigations are relatively unhelpful (i.e., adult Still's disease[adult juvenile rheumatoid arthritis]). Fever patterns are particularly useful in eliminating diagnosesfrom consideration and suggesting otherwise unsuspected disorders that may be diagnosed byfurther procedures.

TABLE 4 -- FEVERS PRONE TO RELAPSE

Infectious Causes

Relapsing fever (Borrelia recurrrentis) Colorado tick fever

Trench fever (Rochalimaea quintana) Dengue fever

Q Fever Leptospirosis

Typhoid fever Brucellosis

Vibrio fetus Bartonellosis (Oroyo fever)

Syphilis Acute rheumatic fever

Tuberculosis Rat-bite fever (Spirillum minus)

Histoplasmosis Visceral leishmaniasis

Coccidioidomycosis Lyme disease

Blastomycosis Malaria

Pseudomonas pseudomallei (meliodosis) Babesiosis

LCM Noninfluenzal respiratory viruses

Dengue fever Epstein-Barr virus

Yellow fever Cytomegalovirus

Chronic meningococcemia

Noninfectious Causes

Bechet's disease Familial Mediterranean fever

Crohn's disease Fever, Adenitis, Pharyngitis,

Weber-Christian disease (panniculitis) Aphthous Ulcer syndrome

Leukoclastic angiitis Systemic lupus erythematosus

Sweet's syndrome Hyper IgD syndrome


7/8

Figure 5. Pneumococcal pneumonia fever defervescence patterns. A, common pattern; B, uncommon pattern;C, pattern in compromised hosts.


8/8

References

1. Canizares O, Harman RRM (eds): Clinical Tropical Dermatology, ed 2. Boston, Blackwell Scientific Publications, 1992

2. Cunha BA: Clinical Implications of fever. Postgrad Med 85:188, 1989

3. Cunha BA: Infectious diseases. InSamiy AH, Bardoness J, Douglas RG (eds): Textbook of Diagnostic Medicine. Philadelphia,

Lea & Febiger, 1987

4. Cunha BA: Approach to fever. In Gorbach SL, Bartlett JB, Blacklow NR (eds): Infectious Diseases, ed 2. Philadelphia, WBSaunders Company, 1996

5. Keefer CS, Leard SE (eds): Prolonged and Perplexing Fevers. Boston, Little, Brown and Company, 1955

6. Isaac B, Kernbaum S, Burke M (eds): Unexplained Fever. Boca Raton, Florida, CRC Press Inc, 1991

7. Kluger MJ (ed): Fever: Its Biology, Evolution, and Function. New Jersey, Princeton University Press, 1979

8. Manson-Bahr PEC, Bell DR (eds): Manson's Tropical Diseases, ed 19. London, Bailliere Tindall, 1987

9. Musher DM, Fainstein V, Young EJ, et al: Fever patterns: Their lack of significance. Arch Intern Med 139:1225, 1979

10. Saunders WE: Nonspecific resistance to infections, fever, and other acute phase reactions. InCluff LE, Johnson JE (eds):Clinical Concepts of Infectious Diseases, ed 3. Boston, Williams & Wilkins, 1982, p 63

11. Strickland GT (ed): Hunter's Tropical Medicine, ed 7. Philadelphia, WB Saunders Company, 1991

12. Woodward TE: Fever pattern as a clinical diagnostic aid. InMackowiak PA (ed): Fever: Basic Mechanisms and Management.New York, Raven Press, 1991

1996. clin norteemérica. patrone de fiebre

Documents