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Chapter 16 • Fatigue
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189
EVIDENCE-BASED PRACTICE
The Diabetes Prevention Program (DPP) is the largest diabetes
prevention trial conducted in the United States. It had more
than 3800 participants with impaired glucose tolerance randomly assigned to one of four conditions: (1) intensive lifestyle
adjustments, or standard lifestyle plus one of these treatment
arms: (2) placebo, (3) metformin, or (4) troglitazone. The troglitazone arm was discontinued early because of adverse drug
Data from Ratner RE: Diabetes Prevention Program Research: An update on the Diabetes Prevention Program, Endocr Pract 12:20-24, 2006.
Hepatic Function
Obtain aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) values to assess for general
inammation of the liver associated with hepatitis.
Can Prediabetes be Reversed?
effects. After 2.8 years of follow-up (the study was discontinued early because of an observed significant benefit to the
intervention group), both metformin and intensive lifestyle
adjustment were found to reduce the risk of developing
diabetes by 31% and 58% respectively. The DPP showed
that both metformin and intensive lifestyle modifications can
effectively delay or prevent the development of diabetes.
the adult years, and declines during the late years of
adulthood (see Chapter 31).
Total sleep time for the newborn is 14 to 18 hours a
day. As the child matures, the sleep cycle increases in
length and the total sleep time decreases. Sleep pat-
Thyroid-Stimulating Hormone
A serum thyroid-stimulating hormone (TSH) level
identies hyper or hypothyroidism.
terns of 8 to 10 hours develop during childhood. Many
adolescents need increased amounts of sleep.
Most healthy adults spend 7 to 9 hours sleeping
each day. Older adults sleep less and may experience
HIV Infection
An enzyme-linked immunosorbent assay (ELISA) will
rule out HIV infection as a cause.
Tuberculin Skin Testing
A Mantoux test is used to test for tuberculosis
antibodies.
more frequent awakenings during the night; some
need to compensate for this with rest periods during
the day.
Poor Nutritional Status
Assessment of nutritional risk is determined by data
from the history and physical examination, food recall
data, BMI (BMI ,18.5 5 underweight; BMI 18.5 to
Monospot
The Monospot is a rapid slide test that detects heterophil antibody agglutination. It is not specic for
Epstein-Barr virus (EBV). It is most sensitive 1 to
2 weeks after symptoms appear and remains positive
for up to 1 year. If chronic fatigue syndrome is being
considered as a differential diagnosis, specic EBV
antibody tests should be considered.
Chest Radiograph
A chest radiograph can reveal the presence of pneumonia, a lesion in the lungs, heart size, or the presence of
uid in the lungs as a result of congestive heart failure.
24.9 5 healthy weight; BMI 25 to ,30 5 overweight;
BMI .30 5 obesity), and waist circumference (WC).
A WC greater than 35 inches in women and 40 inches
in men is a risk factor for heart disease.
According to Dietary Guidelines for Americans
2010, adults are advised to do the following:
l
Eat a variety of fruits and vegetables. Choose ve or
more servings a day.
l
Eat a variety of grain products, including whole
grain. Choose six or more servings a day.
l
Include fat-free and low-fat milk products, sh,
legumes, skinless poultry, and lean meats.
l
Restrict total fat intake to 20% to 35% of calories,
with the majority of fats consisting of polyunsatu-
DIFFERENTIAL DIAGNOSIS
Physiological Causes
Poor Sleep and Rest
In general, total sleep time is greatest during infancy,
decreases in childhood, may increase again during
parts of adolescence, remains relatively stable during
rated and monounsaturated fatty acids.
l
Balance the number of calories you eat with the
number of calories you burn.
l
Engage in regular physical activity of moderate
intensity for at least 30 minutes on most days.
l
Limit your intake of high-calorie, low-nutrition
foods.
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l
Limit your intake of foods high in saturated and
Chapter 16 • Fatigue
trans fatty acids.
l
Eat less than 2300 mg (1 teaspoon of salt) of sodium
per day.
l
Drink no more than one alcohol drink a day if
a woman, and no more than two drinks a day if
a man.
l
Clean hands when handling food; cook foods to safe
temperatures; chill foods promptly; and defrost foods
properly.
Psychological Causes
Depression
About 30% of primary care patients will have symptoms of depression. The adult patient will most often
present with a loss of interest in usual activities, feelings of worthlessness and guilt, and thoughts of suicide
for more than 2 weeks duration. The practitioner must
assess the risk of suicide and intervene, or refer to a
mental health specialist (see Differential Diagnosis
box in Chapter 4).
Other symptoms include sleep and appetite disturbances, malaise, and decreased libido. Patients with
bipolar disease may have a history of a manic episode
associated with increased activity, increased libido,
and feelings of grandiosity. The physical examination
is usually normal.
Children will appear sad, angry, or irritable. They
may have somatic complaints or low self-esteem and
have problems with school performance. Adolescents
may exhibit euphoria, hypersomnia, and lack of interest
in activities.
Anxiety
Diagnostic criteria for anxiety (Diagnostic and statistical manual of mental disorders, ed 5, text revision
[DSM-V-TR]) will guide the diagnosis of anxiety disorder or panic attack. The patient may report a sense of
doom and fear of losing control, dyspnea and chest
discomfort, fatigue, restlessness, and sleep disturbance.
Physical ndings include tachycardia, palpitations,
and diaphoresis (see Differential Diagnosis table in
Chapter 4).
Organic Causes of Acute Fatigue
Infection
The prodrome stage of many viral infections may
produce fatigue before other symptoms such as
sore throat, nasal congestion, and myalgia appear.
Acute hepatitis A and B can cause fatigue before symptoms of jaundice or abdominal discomfort appear.
Endocarditis, an infection of the heart valves, can cause
fatigue.
Drugs
Alcoholism is one of the most common causes of acute
fatigue related to organic causes. Chronic alcohol
abuse is associated with undernutrition, a contributing
factor to fatigue.
Anemia
The fatigue associated with anemia is secondary to the
body’s compensation to increase oxygen in blood that
is oxygen-deprived because of the abnormal size or
quantity of RBCs. The body compensates by increasing the heart rate, but may not be able to make up for
this decit, which leads to increased breathlessness
with activity. A diet history may show inadequate
dietary intake of iron; a general history may reveal
heavy menstrual bleeding. Early symptoms are fatigue,
weakness, and shortness of breath. A CBC will identify
the cause of anemia. Serum iron, serum ferritin, and
transferrin levels may also support the diagnosis of
anemia.
Hypothyroidism (Myxedema)
Patients report cold intolerance, constipation, weight
gain, hoarseness, depression, and fatigue. Physical
examination reveals bradycardia, dry skin, generalized edema, and delayed recovery of deep tendon
reexes. An elevated TSH level is present in primary
hypothyroidism.
Hyperthyroidism (Graves Disease)
This disorder is associated with increased sweating,
heat intolerance, weight loss, irritability, disturbed
sleep, and menstrual irregularity. The physical examination may disclose tachycardia, atrial brillation,
tremor, warm moist skin, and lid lag. Graves disease is
associated with exophthalmos. Radioiodine uptake
scan will differentiate Graves disease, toxic nodule,
and thyroiditis.
Organic Causes of Chronic Fatigue
Sleep Apnea
Sleep apnea most often affects middle-age and older
men. Risk factors include obesity and hypertension.
Patients describe excessive daytime fatigue, morning
headaches, and erectile dysfunction. Bed partners
of patients report restless sleep, loud snoring, and
periods of apnea for at least 30 seconds during the
night.
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191
Medication
Antihypertensive medications such as b-blockers are
often associated with fatigue. Fatigue is a side effect
of some pain medications, antihistamines, and many
other medications.
Heart Failure
Heart failure is associated with dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, peripheral edema,
weight gain, cough with frothy sputum, palpitations,
and fatigue (see Chapter 11). People with a history of
heart disease or valvular disease are at greater risk.
Physical examination may reveal an altered level of
consciousness, anxiety, jugular venous distention,
tachypnea, rales and rhonchi, and a displaced PMI. An
S
and S4 can be heard on cardiac auscultation. Chest
3
radiographs will disclose basilar consolidation and in-
creased heart size. An echocardiogram shows a reduced
ejection fraction.
Cancer
Lymphoma and leukemia may rst be detected by
unexplained fatigue that increases with activity and
worsens over time. A CBC with differential will show
blood dyscrasias. Gastrointestinal cancer may produce
occult blood loss that leads to anemia and fatigue.
Mononucleosis
Mononucleosis is often a disease of young adults that is
caused by Epstein-Barr virus in 90% of cases. History
discloses a gradual onset of low-grade fever, mild sore
throat, posterior cervical lymphadenopathy, fatigue, and
malaise. Splenomegaly occurs in 50% of cases, and pala-
tine petechiae are a less common sign. Diagnosis can be
conrmed with a positive Monospot test and a CBC that
shows greater than 50% lymphocytosis. Ten percent of
patients may also have concurrent b-hemolytic streptococcal pharyngitis.
Hepatitis
Fatigue is generally associated with hepatitis B or C.
Patients will report a history of malaise, fatigue, ulike
symptoms, abdominal pain, arthralgia, and an aversion
to smoking. A health history will reveal risky sexual
behavior, exposure to body secretions through blood
transfusion or injectable drug use, or exposure to contaminated food or water. Physical ndings may include
jaundice, fever, and an enlarged and tender liver. Hepatitis serology for hepatitis A, B, and C will determine
the causative agent.
Fibromyalgia
Fibromyalgia occurs most often in women 20 to
50 years old. It is associated with chronic pain and
stiffness of the trunk and extremities, especially the
neck, shoulders, low back, and hips. Patients will
report fatigue, headaches, sleep disturbance, and symptoms of bowel irritability. To diagnose bromyalgia,
11 of 18 bilateral tender points must be conrmed by
physical examination.
Chronic Fatigue Syndrome
There is no single pathological mechanism to explain
this condition. It appears as an infectious or autoimmune disorder and has neurological, affective, and
cognitive symptoms. Chronic fatigue syndrome is severe fatigue lasting longer than 6 months in association
with (1) impaired memory or concentration, (2) sore
throat, (3) tender cervical or axillary lymph nodes,
(4) muscle pain, (5) multiple joint pain, (6) new-onset
headaches, (7) nonrestorative sleep, and (8) postexertional malaise.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
PHYSIOLOGICAL CAUSES
Poor sleep and
rest
Poor nutritional
status
Common Causes of Fatigue
Adolescent and younger
adult; history of overwork,
psychological stress, disturbed
sleep
Depression, decreased appetite,
lack of balanced nutrient
intake, excessive alcohol
intake
Normal examination None
BMI reflecting underweight or
overweight
Hematocrit increased or
decreased, low serum
ferritin
Continued
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Chapter 16 • Fatigue
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Fatigue — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
PSYCHOLOGICAL CAUSES
Depression:
children
Depression:
adults
Anxiety
ORGANIC CAUSES: ACUTE FATIGUE
Infection
Drugs and
alcohol
Anemia Breathlessness with exertion,
Hypothyroidism
(myxedema)
Hyperthyroidism
(Graves
disease)
Feeling sad, angry, irritable
Decrease in academic performance
Somatic complaints
Loss of interest in usual activities
Feelings of worthlessness
Sleep problems
Numerous somatic complaints,
breathlessness
Sudden onset; history of expo-
sure; recent viral illness
History of smoking, alcohol use,
antihistamines, analgesics,
antihypertensive medications
menstruating or postpartum
female, recent surgery
Poor appetite, fatigue, weight
gain, cold intolerance
Hyperactivity, heat intolerance,
sleep problems
Normal examination DSM-PC, DSM-V
Depressed affect, normal
examination
Tachycardia, palpitations, diaphoresis None
Fever; lymphadenopathy, localized
signs of erythema, edema
Bilaterally enhanced or depressed
DTRs, pupillary changes, reduced
attention span, poor judgment
Increased pulse rate, pale mucosa,
smooth red tongue
Decreased pulse rate; dry skin,
coarse dry hair; thyroid possibly
enlarged, hoarseness
Lid lag, fine thinning hair,
tachycardia
Depression screening
instrument
CBC, ESR, Monospot
CAGE alcohol screening
CBC with indices,
serum iron, ferritin,
transferrin
T4 low, T3 low, TSH
elevated
T4 increased, T3
increased, TSH
depressed
ORGANIC CAUSES: CHRONIC FATIGUE
Sleep apnea Male, middle-age or older;
partner reports periods of no
Medications History of allergies treated with
Heart failure Dyspnea, weight gain, fatigue,
Cancer Fatigue, unexplained weight loss Observe, palpate, and percuss all
Mononucleosis
(Epstein-Barr
virus)
Hepatitis Jaundice, anorexia, fatigue,
Fibromyalgia Female 20-50 yr; history of de-
Chronic fatigue
syndrome
ABGs, Arterial blood gases; BMI, body mass index; CBC, complete blood count; DTR, deep tendon reflex; ECG, echocardiogram; PMI, point of maximal
impulse; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.
breathing during sleep; fatigue
antihistamines, medications
for hypertension, heart
disease, chronic pain
cough
Young adult; slow onset of
malaise, low-grade fever, mild
sore throat
abdominal pain, fever
pression, sleep disturbance,
chronic fatigue, general
muscle and joint aches
Fatigue lasting longer than
6 mo; sudden onset of flulike
symptoms that persist or recur
Hypertension, obesity, narrowed
upper airway
Nasal congestion, cough, injected
conjunctiva
Anxiety, jugular venous distention,
displaced PMI, rales
systems for lumps, lesions, or
consolidation; physical examination may be normal
Palatine petechiae, posterior cervical
lymphadenopathy, splenomegaly
Jaundice, weight loss, arthralgia,
skin rash
Palpation of tender points will
produce pain; normal physical
examination
Physical examination may be
normal; cervical and axillary
lymphadenopathy
Sleep studies
Evaluate medication
choices
ECG, chest radiograph,
ABGs
CBC to rule out anemia;
leukocyte count
Positive Monospot; CBC
with differential;
.50% leukocytes
Bilirubin increased;
hepatitis panel
None
CBC, ESR
Chapter 16 • Fatigue
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193
References and Readings
American Diabetes Association (ADA): Clinical practice recom-
mendations, Diabetes Care 36:S3, 2013.
Cavanaugh R: Evaluating adolescents with fatigue: Ever get tired
of it? Pediatr Rev 23:337, 2002.
Centers for Disease Control and Prevention: Chronic fatigue syndrome,
2013. Retrieved from http://www.cdc.gov/cfs/.
Craig T, Kakumanu S: Chronic fatigue syndrome: Evaluation and
treatment, Am Fam Physician 65:1083, 2002.
Jensen H: Epstein-Barr virus, Peds Rev 32:375, 2011.
Morrison RE, Keating HJ III: Fatigue in primary care, Obstet Gynecol
Clin North Am 28:225, 2001.
National Heart Lung and Blood Institute: Assessing your weight
and health risk, 2013. Retrieved from http://www.nhlbi.nih.gov/
health/public/heat/obesity/lose_wt/risk.htm.
Pinching A: Chronic fatigue syndrome: Believing in ME, Nurse
Prescribing 7:358, 2009.
Rosenthal TC, Majeroni BA, Pretorius R, Malik K: Fatigue: An
overview, Am Fam Physician 78:1173, 2008.
Sheperd C: The debate: Myalgic encephalomyelitis and chronic
fatigue syndrome, Br J Nurs 15:662, 2006.
Solomon L, Reeves WC: Factors inuencing the diagnosis of
chronic fatigue syndrome, Arch Intern Med 164:2241, 2004.
U.S. Department of Agriculture: The dietary guidelines for Americans
2010, Washington, D.C., 2010. Retrieved from http://www.cnpp.
usda.gov/dietaryguidelines.htm.
CHAPTER
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17
ever is an elevation of temperature above the
F
normal daily variation and is a symptom of
an underlying process. The most common cause
of fever is infection; however, noninfectious processes may present with fever. Fever of unknown
origin (FUO) occurs in a small percentage of cases.
These fevers are usually caused by an infection that
has not yet been identied. A meticulous history
and physical examination supported by laboratory
investigation are necessary to nd the origin of the
fever.
There are three types of fevers, each caused by a
specic pathophysiological process. The rst involves
the raising of the hypothalamic set point. The receptors
in the area of the hypothalamus regulating body temperature are triggered to reset at a higher core body
temperature. This results in an elevation of the helper
T-cell production and an elevation in the effectiveness
of interferon. Infection, collagen disease, vascular disease, and malignancy are commonly responsible for
these fevers.
A second type of fever is a result of heat production
exceeding heat loss. Here the set point is normal and
heat loss mechanisms are active. Fever occurs either
because the body raises its metabolic heat production
or because the environmental heat load exceeds normal
heat loss mechanisms. Aspirin overdose, malignant
hyperthermia, hyperthyroidism, or hypernatremia may
cause this type of fever.
A third type of fever is caused by a defective heat
loss mechanism that cannot cope with normal heat
load. Heat stroke, poisoning with anticholinergic drugs,
ectodermal dysplasia, and burns are causes of this kind
of fever.
For the rst type of fever, antipyretics are given
to lower the hypothalamic set point. Antipyretics
are ineffective for the second and third types of
fever.
Fever
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is this really a fever?
Key Questions
l
How do you know you have a fever?
l
Have you taken your temperature?
l
How did you measure your temperature?
Occurrence of Fever
Fever is a common presenting problem and a cardinal
manifestation of disease. Patients often report a subjective fever (i.e., clinical symptoms such as ushing,
chills, shaking chills, headache, malaise, muscle aches)
that is assumed by the patient to be a fever, although
not validated with a thermometer. Nevertheless, the
absence of fever in a single patient visit does not
eliminate a febrile illness.
Measurement of Temperature
Many people use touch to determine whether a fever
is present. Although not a precise indication, touch
can signal a high fever. During the early stages of
fever, perfusion to the skin is decreased and skin
temperature falls. In later stages, when temperature
within the muscles has risen signicantly, increased
body temperature is reected by increased skin temperature. In children, hands and feet should not be
used to gauge a fever because there may be circulatory vasoconstriction causing them to feel cold. An
accurate temperature should be measured orally, rectally, or in the axilla using a thermometer; a special
thermometer is used for the ear; and thermosensitive
strips are used on a dry forehead. Because of the
diurnal variation in normal body temperature and the
effect of physiological factors and body rhythms,
frequent recordings throughout the day are needed to
monitor fever.
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Chapter 17 • Fever
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195
Should sepsis or meningitis be of concern?
Key Questions
l
Have you had any recent head trauma?
l
Do you have recurrent ear infections?
l
Have you had contact with anyone who has been ill?
l
Have you had a headache, lethargy, confusion, or a
stiff neck?
l
If an infant: How old is the baby?
Head Trauma, Otitis Media, and Contact
Recent head trauma, especially at the base of the skull,
may provide an entrance for infectious organisms. Children
with recurrent or chronic otitis media may have mastoid-
itis spreading to the meninges. Contact with anyone with
meningococcal disease and/or Haemophilus inuenzae
places the individual at risk for contracting the disease.
Headache, Vomiting, Lethargy, or Stiff Neck
Headache, fever, lethargy, confusion, vomiting, and
stiff neck characterize meningitis. However, the pre-
sentation is highly variable. Any patient with even
minimal neurological signs and symptoms should be
evaluated for meningitis.
Infant
Fever in children less than 2 months of age is uncom-
mon but must be viewed as serious. Generally neonates
and young infants are less able to mount a febrile re-
sponse; when they do, it is a signicant nding. Fever
can be viral or bacterial in nature. Fevers in the neonate
may also be an indication of an underlying anatomical
defect. Urinary tract infection and bacteremia are often
the rst indications of a structural abnormality of the
urinary tract. Also, infants with galactosemia may
present in the rst weeks to 1 month of life with gram-
negative sepsis. Occasionally, infants present with
sepsis associated with delivery (prolonged rupture of
membranes); acquired from instrumentation used dur-
ing delivery, such as scalp electrodes; or from a proce-
dure performed in a neonatal intensive care unit.
All infants younger than 2 months with fever are
considered to have sepsis or meningitis until proven
otherwise.
What does the pattern of fever tell me?
Key Questions
l
How long have you had the fever?
l
What has been the highest temperature reading?
Duration of Fever
In adults, fevers from an acute process usually resolve
in 1 to 2 weeks. Fevers that last 3 weeks or longer, that
exceed temperatures of 38.4° C (101.1° F), and that
remain undiagnosed after 1 week of intensive diagnostic study are classied as FUOs.
Fevers in children can be grouped into three categories: short-term fever, fever without localizing signs,
and fever of unknown origin. Short-term fever is
dened as a fever of short duration, readily diagnosed,
and that resolves within 1 week. Fever without localizing signs is a fever with no localizing signs and of
brief duration (usually less than 10 days) that is not
explained by ndings on history or physical examination. FUO is a fever usually greater than 38.5° C
(101.2° F) that lasts longer than 2 weeks on more than
four occasions.
Height of Fever
Dehydration and febrile seizures are related to the
height of the fever. Generally, body temperatures
greater than 41.1° C (106° F) are seen in heat illness,
central nervous system disease, or either of these in
combination with infection. The higher the fever, the
greater is the likelihood of bacteremia.
Is the fever caused by a localized infection?
Key Questions
l
Do you have frequency, burning, or urgency with
urination?
l
Are you having unusual vaginal/penile discharge?
l
Do you have face or sinus pain?
l
Do you have nasal discharge? If so, what color is the
discharge?
l
Do you have a cough? Is it productive? What color
is the sputum?
l
Do you have ear pain?
l
Is your throat sore?
l
Do you have any sores (aphthous ulcers) in your
mouth?
l
Are you having any nausea/vomiting or diarrhea?
l
Do any of your joints hurt?
Location of Symptoms
Localizing symptoms will point to the site of the infection. These diagnostic clues include headache or sinus
pain, purulent nasal discharge, ear pain, toothache, sore
throat, breast tenderness, chest pain, cough, dyspnea,
abdominal pain, ank pain, dysuria, vaginal discharge,
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Chapter 17 • Fever
pelvic pain, rectal pain, testicle pain, calf pain, neck stiffness, joint stiffness, pain or heat, or focal neurological
decits (see appropriate chapters).
Genitourinary Tract
Upper urinary tract infection (UTI) in female adults
commonly produces systemic symptoms with ank
pain and fever (see Chapters 18, 34, and 35). Fever
with cystitis is uncommon in adults, but children with
UTIs present with systemic rather than localized signs
and symptoms. UTI is the most common infection
in girls younger than 2 years who present with a high
fever and in all infants younger than 90 days with
fever. Pelvic inammatory disease in women may
cause fever as well as an increased amount of vaginal
discharge and bleeding after intercourse. Acute UTIs
are rare in men but often present with chills, high
fever, urinary frequency and urgency, perineal pain, and
low back pain. They may also have penile discharge.
Ear, Nose, and Throat Symptoms
Viral infections of the upper respiratory tract are common and usually produce fever (see Chapters 15, 25,
and 32). Otitis media is common in children. Fever
may accompany both viral and bacterial pharyngitis.
Pharyngitis is frequently manifested only by fever,
with the infection localizing 1 or 2 days later. Acute
sinusitis can produce a fever. Aphthous ulcers with
pharyngitis and cervical lymphadenopathy are seen in
children with periodic fevers.
Respiratory or Gastrointestinal Symptoms
Most febrile illnesses are caused by viral upper respiratory infection (URI), lower respiratory infection (LRI)
(see Chapters 11 and 14), or gastrointestinal (GI) tract
infection (see Chapter 3). Localized symptoms can
help pinpoint the cause of the fever. Vomiting occasionally signals pneumonia, especially in children.
Joint Pain
Joint pain may indicate connective tissue disorders in
adults and in children more than 6 years of age (see
Chapters 22 and 23). Osteomyelitis or septic arthritis
may also produce fever.
Can I narrow the diagnostic possibilities or eliminate
a cause?
Key Questions
l
Have you noticed a rash?
l
Do you ache all over?
Skin Rash
The prodromal period of a rash is an important historical clue to diagnosis (see Chapter 28). Fever and rash
usually appear together 1 to 5 days after infection.
Common eruption periods are as follows:
l
Varicella, rubella, erythema infectiosum: 1 day
l
Scarlet fever: 2 days
l
Rocky Mountain spotted fever: 3 days
l
Measles: 4 days
l
Roseola infantum: 5 days
l
Hand, foot and mouth: 3 days
Ache
Fevers localized to a site without general body manifestations are often bacterial in nature. Fevers accompanied by muscle aches (myalgias), malaise, and/or
respiratory symptoms are often viral in nature.
Does the patient have an increased risk
for complications?
Key Questions
l
Do you have any chronic health problems?
l
Have you had recent surgery?
l
Have you been diagnosed with an infectious disease
recently?
l
Are you sexually active? If so, how many partners do
you have?
l
Are your immunizations up to date?
l
Do you or anyone in your family have tuberculosis
(TB) or hepatitis?
Chronic Disease
Chronic conditions and systemic disorders (such as
diabetes mellitus, human immunodeciency virus
[HIV], malignancies, neutropenia, and sickle cell anemia) compromise host resistance and increase susceptibility to infection. Prosthetic devices, such as heart
valves or joint prostheses, also increase susceptibility
to infection.
Health Problems, Surgery, and Recent Infection
Current health problems, recurrent infection, or incomplete treatment of infection may be the cause
of fever. Such risk factors as diabetes mellitus, neutropenia, HIV or other immune system disorders,
and sickle cell anemia heighten the likelihood of bacterial infection. Patients with a past history of infection (such as URI or streptococcal pharyngitis) may
be prone to relapse or recurrence. Recent surgical
Chapter 17 • Fever
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procedures can provide a locus for occult infection;
however, a surgical procedure can also induce an
inammatory response, which causes a fever without
infection.
Sexual Activity
High-risk sexual activity may raise the index of suspicion for HIV or hepatitis B infection and for pelvic
inammatory disease (PID) in women.
Immunizations
Children and adults who have not been properly immunized are at greater risk for infectious diseases.
Tuberculosis or Hepatitis Exposure
Exposure to populations with a high incidence of TB or
viral hepatitis increases the risk of infection. Inquire
further about constitutional symptoms such as cough,
night sweats (TB), malaise, and abdominal discomfort
(hepatitis).
Does the parent report a behavior change in the child?
Key Questions
l
Is the child sleepier than normal?
l
Is the child more irritable?
l
How is the child’s behavior?
In infants and children, behavior changes may be the
only indication that the child is ill. Mildly ill infants
may act alert, be active, smile, and feed well. Moderately ill infants may be fussy or irritable but continue
to feed, be consolable, and may smile. Severely ill infants appear listless, cannot be consoled, and feed
poorly or not at all.
Could the fever be caused by something acquired
while traveling?
Key Questions
l
Have you been out of the country recently?
l
Have you spent time in the woods or been camping
recently?
Travel
Patients can be exposed to an emerging infectious
disease based on their travel activities. A history of
travel out of the country presents the possibility of
infection with amebiasis, malaria, schistosomiasis,
typhoid fever, or hepatitis A and B. Dengue is the
most common vector-borne disease worldwide and is
a differential diagnosis for acute febrile illnesses in
patients who live or have recently traveled to the
tropics or subtropical areas of the United States.
Epidemiological surveillance data continually provide updates on patterns of occurrence of infections
such as severe acute respiratory syndrome (SARS),
avian inuenza or “bird u,” and West Nile virus
(Box 17-1).
Camping
Camping or exposure to wooded areas may indicate
exposure to ticks, Q fever, tularemia, Rocky Mountain
spotted fever, Giardia, or Lyme disease.
Could the fever be medication-related or caused
by poisoning?
Key Questions
l
Have you recently taken any new medications?
l
Can you tell me what foods you have eaten in the
past 3 days?
l
Could the child have eaten a poisonous plant? Are
prescription and over-the-counter (OTC) medications out of reach of the child?
Medications
Medications may hide an occult infection. Many
drugs (e.g., penicillin, atropine, sulfonamides, streptomycin, and diphenylhydantoin) can induce fever
in predisposed individuals. The fever starts about
7 days after the drug is taken for the rst time,
or soon after the rst dose in a patient previously
sensitized. Any patient who is taking immunosuppressive agents is at a higher risk for infection. Some
medications interfere with thirst recognition (e.g.,
sedatives, haloperidol) or sweating (e.g., anticholinergics, phenothiazines).
Aspirin overdose can also cause fever. Earliest signs
are vertigo and tinnitus, but fever can occur shortly
thereafter and may be the only symptom that patients
recognize.
Food Poisoning
Food poisoning fevers may occur up to 72 hours after
ingestion of contaminated food.
Plants
Plants containing the alkaloid atropine (deadly nightshade, jessamine, and thornapple) cause dilated pupils,
ushed skin, and fever because they interfere with the
normal heat loss mechanism.
198
https://t.me/med1917
Chapter 17 • Fever
Box 17-1
AVIAN INFLUENZA
A highly pathogenic strain of avian influenza A virus, H5N1,
infects birds and mutates rapidly to acquire genes from
viruses infecting other animal species. Avian influenza is
transmitted to humans usually through the slaughtering and
processing of infected birds. Symptoms of infection can range
from flulike symptoms (e.g., fever, cough, sore throat, muscle
aches) to pneumonia and severe respiratory distress. Suspect
infection in people showing flulike symptoms, such as high
fever and cough, who have confirmed contact with birds in an
area where confirmed outbreaks have occurred. Clinical deterioration is rapid over 4 to 13 days. Laboratory findings include leukopenia, thrombocytopenia, and elevated levels of
aminotransferases. Although avian influenza is a rare disease,
more than half of reported cases have been fatal and there is
great potential for this virus to evolve into a world pandemic.
(EVD) EBOLA VIRUS DISEASE
Ebola is viral infection that is spread through contact with
body fluids, infected objects, or infected animals, including
contact with someone who has died from Ebola. A person is
infectious once symptoms are present. Symptoms can appear
from 2 to 21 days after exposure and include fever, headache, diarrhea, vomiting, stomach pain, muscle pain, and
unexplained bleeding or bruising. The earliest indication of
potential infection is history of travel to infected regions,
predominately West Africa. A person is also at risk who has
had close contact with someone who has recently travelled to
an Ebola affected area, or someone who is symptomatic.
Recovery from Ebola depends on good supportive clinical
care and the patient’s immune response. People who recover
NOTE: The most current information on these diseases can be found online at the Centers for Disease Control and Prevention, http://cdc.gov and
The World Health Organization, http://who.int.
Emerging Infectious Diseases Associated With Fever
from Ebola infection develop antibodies that last for at least
10 years. In 2014 the world experienced the largest Ebola
outbreak to date that originated in West Africa.
SARS (SEVERE ACUTE RESPIRATORY SYNDROME)
SARS is a febrile, severe lower respiratory tract illness that is
caused by infection with SARS-associated coronavirus
(SARS-CoV). From 2002 through 2003, the World Health
Organization received reports of more than 8000 cases and
nearly 800 deaths. No specific laboratory test distinguishes
SARS-CoV from other febrile respiratory illness. Lymphopenia
and elevated levels of hepatic transaminases, creatinine, and
C-reactive protein have been seen in some patients. Diagnosis is based on clinical features (e.g., fever, difficulty breathing, pneumonia) and epidemiologic history of exposure either
to a SARS patient or to a setting in which the SARS-CoV
transmission is occurring.
WEST NILE VIRUS
West Nile virus (WNV) is a potentially serious illness caused
most often by the bite of an infected mosquito. It occurs mostly
in summer and fall in North America. Symptoms develop 3 to
14 days after being bitten. Approximately 80% of people who
are infected with WNV will not show symptoms; however, up to
20% have symptoms called West Nile fever, characterized by
fever, headache, fatigue, truncal rash, lymphadenopathy, and
eye pain lasting from days to several weeks. People more than
50 years of age are more likely to develop serious symptoms.
A positive IgM antibody test of serum or cerebral spinal fluid
is needed to confirm the disease. The test is positive in most
patients within 8 days of onset of symptoms.
Could exposure to animals explain the fever?
Key Questions
l
Has a cat scratched you recently?
l
Do you have any pets or have you been around other
animals?
Cat-Scratch Disease
Cat-scratch disease, or toxoplasmosis, is a bacterial
infection transmitted by cats. The etiological agent is a
gram-negative bacillus. Exposure may occur when
changing kitty litter boxes. Single-node or regional
adenopathy is the dominant clinical feature. A lowgrade fever is also present.
Animal Exposure
Also possible are brucellosis and leptospirosis from
dogs; tularemia from rabbits; ornithosis, histoplasmosis,
or psittacosis from birds; and lymphocytic choriomeningitis from hamsters or cats. Exposure to infected animals
can produce infection and fever in humans. Occupational exposure to pathogens, such as brucellosis, should
be investigated in patients who work with animals or
animal products.
Could this be the result of a recent immunization?
Key Question
l
What immunizations have you had recently?
Immunization Reactions
Adverse effects of immunization are rare but do occur.
History of recent immunization followed by 4 hours of
high temperature (39.5° C [103° F]) may indicate such
an adverse reaction. Measles/mumps/rubella (MMR)
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