penatalaksanaan demam (management fever)

7/26/2019 Penatalaksanaan Demam (Management Fever)

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Management of Adult Patients with Fever

Musofa Rusli

Dep/SMF

Ilmu

Penyakit

Dalam

Divisi

Tropik

-

Infeksi

FKUA

RSUD

Dr.

Soetomo

Surabaya

Musofa Rusli

Dep/SMF

Ilmu

Penyakit

Dalam

Divisi

Tropik

-

Infeksi

FKUA

RSUD

Dr.

Soetomo

Surabaya

PIT IDI 2015 - SURABAYA


2/19

TOPICS

o

Definition

o

Pathophysiology of fever

o

Management of fever

o

Fever of unknown origin

o

Drug fever

o

Definition

o

Pathophysiology of fever

o

Management of fever

o

Fever of unknown origin

o

Drug fever

2


3/19

Definition

Fever

o Fever:

! an elevation of body temperature that exceeds the normal daily variation

and occurs in conjunction with an increase in the hypothalamic set point

[e.g., above 37.2C].

! Heat conservation (vasoconstriction) and heat production (shivering, fat

tissue thermogenesis)

!Anatomic variations: rectal > oral > axillar" rectal 0.6 oC higher than oral

oNormal daily oral temperature:! 36.8 + 0.4 oC

! Low levels at 6 AM and higher levels at 4 6 PM

! Thus, 37.2 oC in the morning" fever

3


4/19

Definition

Pyrogens

any substance that causes

fever

o

Endogenous

!

class of biologically active proteins called

cytokines

"

pyrogenic cytokines

!

r

elated to activation

of

TLR

!

E.g.: IL

-

1, IL

-

6, TNF

-

!

, IFN

-

"

o

Exogenous!

derived from outside the

host

!

mainly microbes or their

products: toxins

Pyrogens"

any substance that causes

fever

o

Endogenous

!

class of biologically active proteins called

cytokines

"

pyrogenic cytokines

!

r

elated to activation

of

TLR

!

E.g.: IL

-

1, IL

-

6, TNF

-

!

, IFN

-

"

o

Exogenous!

derived from outside the

host

!

mainly microbes or their

products: toxins

4


5/19

Definition

Elevated body temperature

o

Hyperthermia

:

o

Hyperpyrexia

:

!

an extraordinarily high fever (>41.5C

)

o

Hyperthermia

:!An uncontrolled increase in body temperature that

exceeds the body's ability to lose heat"

thermoregulatory center is unchanged!Does not involve pyrogenic molecules

!Exogenous heat exposure and endogenous heat

productiono

Hyperpyrexia

:

!

an extraordinarily high fever (>41.5C

)

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6/19

Elevated body temperature

Fever Hyperthermia Hyperpyrexia

Infectious diseases

Autoimmune disease

Malignancy

Heat stroke

Neuroleptic Malignant Synd

drug-induced hyperthermia

serotonin syndromemalignant hyperthermia

Thyrotoxicosis

Pheochromocytoma

cerebral hemorrhage

status epilepticushypothalamic injury

Most commonly

occurs in patients

with CNS

hemorrhages

6


7/19

Definition

Temperature-pulse relationship

oThe temperature-pulse relationship is linear with an

increase in heart rate of 4.4 beats/ minute for each 1C

oTemperature-pulse dissociation (relative bradycardia)"typhoid fever, brucellosis, leptospirosis, some drug-

induced fevers and factitious fever

oFever may not be present during infection in newborns,the elderly, patients with chronic renal failure, and in

patients taking corticosteroids

oThe temperature-pulse relationship is linear with an

increase in heart rate of 4.4 beats/ minute for each 1C

oTemperature-pulse dissociation (relative bradycardia)"typhoid fever, brucellosis, leptospirosis, some drug-

induced fevers and factitious fever

oFever may not be present during infection in newborns,the elderly, patients with chronic renal failure, and in

patients taking corticosteroids

7


8/19

Pattern of temperature changes

The pattern of temperature changes may occasionally hint at the

diagnosis

Patterns:

oContinuous fever: Temperature remains above normal throughout

the day and does not fluctuate more than 1 C in 24 hours

o

Intermittent fever: The temperature elevation is present only for acertain period, later cycling back to normal

oRemittent fever: Temperature remains above normal throughout

the day and fluctuates more than 1 C in 24 hours

The pattern of temperature changes may occasionally hint at the

diagnosis

Patterns:

oContinuous fever: Temperature remains above normal throughout

the day and does not fluctuate more than 1 C in 24 hours

o

Intermittent fever: The temperature elevation is present only for acertain period, later cycling back to normal

oRemittent fever: Temperature remains above normal throughout

the day and fluctuates more than 1 C in 24 hours8


9/19

Fever Onset

9

< 1 week< 1 week Within 1-3 weeksWithin 1-3 weeks > 3 weeks> 3 weeks

Dengue

ChikungunyaLeptospirosis

JEV

SARSEbola

Hepatitis A

Dengue

ChikungunyaLeptospirosis

JEV

SARSEbola

Hepatitis A

Typhoid fever

TyphusLeptospirosis

Ebola

CMVRabies

Acute HIV

Typhoid fever

TyphusLeptospirosis

Ebola

CMVRabies

Acute HIV

Tuberculosis

HIVCMV

Autoimmune disease

Malignancies

Tuberculosis

HIVCMV

Autoimmune disease

Malignancies


10/19

PATHOGENESIS OF FEVER

10

Heat conservationHeat production


11/19

TREATING FEVER

11

Antimicrobial

drugs

Anti-cytokines

drugs

CorticosteroidsAcetaminophen

NSAIDs

Antimicrobial

drugs


12/19

Treatment of Fever

oAntipyretics:

!Acetaminophen

!NSAIDs

"side effects !

oCorticosteroids" side effects !!!

oCool damp sponges

oSubmersion should be avoided

oAntipyretics:

!Acetaminophen

!NSAIDs

"side effects !

oCorticosteroids" side effects !!!

oCool damp sponges

oSubmersion should be avoided

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13/19

Benefit and complication of fever

Benefit:

o fever is associated with release of endogenous pyrogens, which activate the T

cells and thus enhance the host defence mechanism.

o Some febrile diseases have characteristic patterns" diagnostic benefit

Complications:

o a state of catabolism" detrimental to body

o fluid and electrolyte imbalance - due to sweating and loss of minerals

o high grade fevers can lead to convulsions, brain damage, circulatory overload

and arrhythmia

o increase oxygen consumption"COPD, CHD

Benefit:

o fever is associated with release of endogenous pyrogens, which activate the T

cells and thus enhance the host defence mechanism.

o Some febrile diseases have characteristic patterns" diagnostic benefit

Complications:

o a state of catabolism" detrimental to body

o fluid and electrolyte imbalance - due to sweating and loss of minerals

o high grade fevers can lead to convulsions, brain damage, circulatory overload

and arrhythmia

o increase oxygen consumption"COPD, CHD

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14/19

Drug Fever

Definition (Mackowiak & LeMaistre, 1987):o a disorder characterized by fever coinciding with administration of a drug and

disappearing after the discontinuation of the drug

o no other cause for the fever is evident after a careful physical examination andlaboratory investigation

o usually a diagnosis of exclusion

Important drugs related to drug fever:

o Antimicrobials: beta-lactams, sulfonamides and nitrofurantoin

o Anticonvulsant

o Minocycline

o Allopurinol

o Sympathomimetic drugs: amphetamines, cocaine

Definition (Mackowiak & LeMaistre, 1987):o a disorder characterized by fever coinciding with administration of a drug and

disappearing after the discontinuation of the drug

o no other cause for the fever is evident after a careful physical examination andlaboratory investigation

o usually a diagnosis of exclusion

Important drugs related to drug fever:

o Antimicrobials: beta-lactams, sulfonamides and nitrofurantoin

o Anticonvulsant

o Minocycline

o Allopurinol

o Sympathomimetic drugs: amphetamines, cocaine

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15/19

Fever of Unknown Origin

Definition (Petersdorf & Beeson, 1961):

o Fever higher than 38.3C on several occasions

o Duration of fever for at least three weeks

o Uncertain diagnosis after one week of study in the hospital

Classicetiology:

o Infections: tuberculosis, infectious mononucleosis

o Malignancies

o Noninfectious inflammatory diseases (eg, vasculitis, systemic lupus erythematosus,

polymyalgia rheumatica)

o Connective tissue diseases (eg, vasculitis, rheumatoid arthritis)

Definition (Petersdorf & Beeson, 1961):

o Fever higher than 38.3C on several occasions

o Duration of fever for at least three weeks

o Uncertain diagnosis after one week of study in the hospital

o Classic, nosocomial, neutropenic and HIV-associated FUO (Durrack & Street, 1990)

Classicetiology:

o Infections: tuberculosis, infectious mononucleosis

o Malignancies

o Noninfectious inflammatory diseases (eg, vasculitis, systemic lupus erythematosus,

polymyalgia rheumatica)

o Connective tissue diseases (eg, vasculitis, rheumatoid arthritis)15


16/19

Virology TestsVirology Tests

Virus penyebabVirus penyebab Jenis UjiJenis Uji PenyakitPenyakit

DengueDengue IHA, IgM/ IgG Dengue, NS1DengueIHA, IgM/ IgG Dengue, NS1Dengue

Demam dengue (D) dan demamberdarah DDemam dengue (D) dan demamberdarah D

Cytomegalovirus (CMV)Cytomegalovirus (CMV) Anti-CMV IgM Elisa

Anti CMV IgG Elisa

Anti-CMV IgM Elisa

Anti CMV IgG Elisa

Infeksi - cytomegalovirusInfeksi - cytomegalovirus

Epstein - BarrEpstein - Barr Paul BunnelPaul Bunnel Mononukleosis InfeksiosaMononukleosis Infeksiosa

Virus (EBV)Virus (EBV) Anti EBVAnti EBV

Hepatitis A s/d EHepatitis A s/d E Virus A s/d E, berbagaikomponen antivirus A s/d EVirus A s/d E, berbagaikomponen antivirus A s/d E

Hepatitis akutHepatitis akut

Coxiella burnettiCoxiella burnetti IFAIFA Demam QDemam QHuman Immunodeficiency virus(HIV)Human Immunodeficiency virus(HIV)

Anti HIV-Elisa

Anti HIV-Western Blot

PCR

Anti HIV-Elisa

Anti HIV-Western Blot

PCR

AIDS

AIDS

AIDS

AIDS

AIDS

AIDS


17/19

DAFTAR UJI BAKTERIO-PARASITOLOGISDAFTAR UJI BAKTERIO-PARASITOLOGIS

Virus penyebabVirus penyebab Jenis UjiJenis Uji PenyakitPenyakit

Salmonella typhiSalmonella typhi Widal, Thypidot PCRWidal, Thypidot PCR Demam tifoidDemam tifoidS. Paratyphi A/B/CS. Paratyphi A/B/C WidalWidal Demam paratifoidDemam paratifoid

StreptokokkusStreptokokkus ASTOASTO Demam reumatikDemam reumatik

MikobakteriaMikobakteria Myco Dot TB PAP

Mantoux, IGRA

Myco Dot TB PAP

Mantoux, IGRA

TBC pulmonal dan TBC

Ekstrapulmonal

TBC pulmonal dan TBC

Ekstrapulmonal

Leptospira sppLeptospira spp MATMAT LeptospirosisLeptospirosis

Brucella sppBrucella spp AglutinasiAglutinasi BrusellosisBrusellosis

Rickettsia sppRickettsia spp Well felixWell felix RicketsiosisRicketsiosis

Mycoplasma pneumMycoplasma pneum IFIF MycoplasmosisMycoplasmosis

LegionellaLegionella IFIF LegionellosisLegionellosis

Toxoplasma gondiiToxoplasma gondii Elisa IgG/IgMElisa IgG/IgM TokoplasmosisTokoplasmosis

Entamoeba histoliticaEntamoeba histolitica IDTIDT AmubiasisAmubiasis

Filaria sppFilaria spp IFATIFAT FilariasisFilariasis

Candida sppCandida spp IHA atau IFATIHA atau IFAT CandidiasisCandidiasis

Histoplasma capsulatumHistoplasma capsulatum IDTIDT HistoplasmosisHistoplasmosis


18/19

Key Points

oHistory taking

oPhysical examination

oImagingoLaboratory tests:

!CBC, urinalisys, BUN/ SC, SGOT/ SGPT, LED,

[CRP, lactate, procalcitonine]

!Blood/ urine/ body fluid culture

!Serology, antigen-based test

oHistory taking

oPhysical examination

oImagingoLaboratory tests:

!CBC, urinalisys, BUN/ SC, SGOT/ SGPT, LED,

[CRP, lactate, procalcitonine]

!Blood/ urine/ body fluid culture

!Serology, antigen-based test

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19/19

THANK YOUTHANK YOU

19

penatalaksanaan demam (management fever)

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