High fever

Introduction High fever does not mean that the body temperature exceeds 39.1 °C. Hyperthermia is divided into acute hyperthermia and long-term hyperthermia. Acute hyperthermia is more common in infectious and allergic inductive diseases, while long-term hyperthermia can be seen in sepsis, Salmonella infection, tuberculosis, rheumatic fever, and juvenile rheumatism.

Cause

(1) Acute high fever

Infectious disease

Early acute infectious diseases, acute infectious diseases of various systems.

2. Non-infectious diseases

Heat syndrome, neonatal dehydration fever, intracranial injury, convulsions and epileptic seizures.

3. Allergic reaction

Allergies, allogeneic serum, vaccination response, infusion, transfusion reactions, etc.

(2) Long-term high fever

Common disease

Sepsis, Salmonella infection, tuberculosis, rheumatic fever, juvenile rheumatism, etc.

2. Rare disease

Malignant tumors (leukemia, malignant lymphoma, malignant histiocytosis), connective tissue disease.

an examination

Related inspection

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(1) Medical history inquiry points

Ask the medical history in detail, pay attention to:

1. Inducement: There is no skin trauma and sputum history within 2 to 3 weeks before fever; there is no history of epidemic disease in the past 1 to 3 weeks; there is no history of contact with schistosomiasis in 1 month. Skin trauma and paralysis are clues to the diagnosis of sepsis. Have a history of infectious disease epidemic areas, consider acute infectious diseases; abdominal surgery after fever should consider abdominal cavity, pelvic infections such as underarm abscess, intestinal gap abscess, hollow organs and so on.

2. The onset season: the onset of winter and spring, more common in measles, epidemic cerebrospinal meningitis; summer and autumn, the incidence of more common in Japanese encephalitis, malaria, typhoid, dysentery, heat stroke.

3. Body temperature lifting method:

Sudden-type fever is seen in malaria, acute pyelonephritis, lobar pneumonia, sepsis, infusion reaction, etc.; slow-lift fever is seen in the early stage of typhoid fever, tuberculosis, brucellosis, etc.; sudden drop in malaria, acute pyelonephritis, large leaves Pneumonia, infusion reaction and taking antipyretics; the descending type is seen in the typhoid remission period, rheumatic fever and infectious diseases when antibiotic treatment is effective.

4. Accompanying symptoms

(1) fever with cold war, more common in sepsis, lobar pneumonia, acute cholecystitis, acute pyelonephritis, epidemic cerebrospinal meningitis, malaria, drug fever, acute hemolysis and infusion reaction, epidemic typhus, parrot Heat, smallpox, epidemic hemorrhagic fever, infectious mononucleosis.

(2) with sore throat, more common in upper respiratory tract infection, suppurative tonsillitis; with cough, cough, found in acute respiratory infections and lung infections.

(3) with chest pain, seen in pneumonia, pleurisy, myocardial infarction, lung abscess and so on.

(4) with abdominal pain, nausea, vomiting, seen in acute bacterial dysentery, acute cholecystitis, acute pyelonephritis, acute mesenteric lymphadenitis, acute hemorrhagic necrotic enteritis, acute pancreatitis, acute gastroenteritis.

(5) with headache, seen in encephalitis, meningitis, brain abscess and so on.

(6) with muscle pain seen in myositis, dermatomyositis, trichinosis, Legionnaires' disease, leptospirosis, drug fever.

(7) Systemic joint pain, seen in connective tissue disease, gout, psoriatic arthritis, etc.

(8) with neurological disorders, found in encephalitis, meningitis, infectious toxic encephalopathy, cerebral hemorrhage, heat stroke, temporal arteritis, lupus encephalopathy and so on.

(9) fever with obvious symptoms of poisoning found in serious infections, especially sepsis.

(10) Whether it is accompanied by rash and rash time: fever on the 1st appears rash found in chickenpox; rash on the 2nd, seen in scarlet fever; rash on the 3rd, found in smallpox; rash on the 4th, seen in measles; rash on the 5th Rash typhoid; rash on the 6th is seen in typhoid fever.

(two), physical examination

A full physical examination should be done, but it should be noted that:

1. General condition and systemic skin mucosa examination, pay attention to systemic nutritional status. Cachexia suggests severe tuberculosis and malignant tumors. Pay attention to the type of rash and rash: plague is seen in erysipelas and typhus; facial erythema, fingertips and periorbital erythema suggest systemic lupus erythematosus (SLE); ring erythema is found in rheumatic fever; papules and maculopapular rash are found in scarlet fever, Drug fever; rose rash is seen in typhoid fever and paratyphoid fever. The sputum conjunctiva and the skin are slightly stagnant, and the osler nodules with tenderness on the fingertips, toes, and large and small fish muscles are found in infective endocarditis. Soft palate, underarms have a cord-like or scratch-like bleeding point, found in epidemic hemorrhagic fever. Skin scattered in the spots, ecchymosis, purpura found in aplastic anemia, acute leukemia and malignant connective tissue disease. Large plaques suggest diffuse intravascular coagulation; those with cutaneous swelling should consider sepsis and sepsis. 2. Pay attention to the swelling of the whole body lymph nodes. Local lymph nodes are swollen, soft and tender, considering inflammation in the corresponding drainage area. Local lymph nodes are enlarged, hard, no tenderness, and may be cancer metastasis or lymphoma. Systemic lymphadenopathy is seen in lymphoma, acute and chronic leukemia, infectious mononucleosis, systemic lupus erythematosus, and the like.

3. Head and neck examination: conjunctival hyperemia is more common in measles, hemorrhagic fever, typhus; tonsil enlargement, with yellow-white exudate attached to it, considering suppurative tonsillitis; purulent discharge from the external auditory canal is suppurative otitis media The mastoid swelling and tenderness is mastoiditis; the neck stiffness is seen in meningitis and meningoencephalitis; the goiter is associated with hyperopia and hyperthermia in the hyperthyroidism crisis.

4. Heart condition: The heart expands and new systolic murmurs indicate rheumatic fever. In the case of valvular heart disease, the nature of the noise changes, and infective endocarditis should be considered.

5. Pulmonary examination: one side of the lungs with localized dullness, increased vocal fibrillation, wet rales, suggesting lobar pneumonia; fixed or repeated wet rales in the lower chest or back, seen in bronchiectasis with secondary infection; The percussion of the lower part of the lung was voiced, and the breath sounds and tremors were reduced, suggesting pleural effusion.

6. Abdominal examination: gallbladder point tenderness, Murphy sign positive with skin, sclera yellow staining, suggesting cholecystitis, cholelithiasis fever. Apparent tenderness in the upper abdomen, gray-purple spots on the ribs (Grey-Turner sign) or umbilical skin cyanosis (Gullen sign), found in hemorrhagic necrotizing pancreatitis. Right lower abdomen or full abdomen tenderness, sometimes with abdominal mass, abdominal wall or perineum with fistula, poor systemic nutrition, considering Crohn's disease (Crohn's disease). Hepatomegaly, hard, with nodules or giant pieces on the surface, suggesting liver cancer fever. Liver and spleen are enlarged at the same time, which can be found in leukemia, lymphoma, malignant histiocytosis, systemic lupus erythematosus and the like. Seasonal ribs tenderness, sputum pain in the kidney area, suggesting upper urinary tract infection.

7. Limbs and nervous system examination: clubbing with fever, found in lung cancer, lung abscess, bronchiectasis, infective endocarditis. Joint swelling and tenderness are seen in rheumatic fever, lupus erythematosus or rheumatoid arthritis. Positive Klinefelter or Brinell signs are seen in central nervous system infections.

(three), laboratory inspection

Because of the many causes of fever, a targeted examination should be made according to the cause, but the following routine examinations should be made:

1. Blood routine, urine routine, and fecal routine. Neutrophil increased with fever, common in bacterial infection, major bleeding, tissue damage; neutropenia, seen in typhoid fever, paratyphoid fever, acute viral infection, malaria, kala-azar, acute aplastic anemia, malignant histiocytosis, Systemic lupus erythematosus, acute disseminated tuberculosis, acute non-leukocytic leukemia, acute neutropenia, etc. Eosinophils increase, common in drug fever, serum disease; eosinophilia is seen in typhoid fever. Hyperthermia with anemia is seen in acute hemolysis, acute aplastic anemia, and acute non-leukocytic leukemia.

2. Blood culture should be done during chills and high fever, blood smear examination. Blood smear examination: helpful for the diagnosis of malaria, regression fever, leukemia, systemic lupus erythematosus, leptospirosis, etc.

3. If the heat is more than 1 week, it should be used for the fat reaction, the external reaction, and the Brucella agglutination test.

4. Suspected respiratory diseases, should be chest fluoroscopy or chest X-ray examination, sputum culture, sputum smear examination.

5. Suspected liver disease, liver function and abdominal B-ultrasound should be done.

6. There is a tendency to hemorrhage, clotting time, platelet, prothrombin time should be determined.

7. If you suspect urinary tract infection, you should do urine culture.

8. For those who have painkillers, anti-streptolysin "O" test and C-reactive protein, anti-nuclear antibody, erythrocyte sedimentation rate, serum protein electrophoresis, immunoglobulin and other tests should be performed.

9. The cause of high fever is unknown. If it is not effective with antibiotics, it is necessary to perform lymph node biopsy and bone marrow biopsy.

10. Serological examination: positive for fata, found in typhoid fever, paratyphoid fever; positive for Faji, considering typhus; positive for Brucella agglutination test, considering brucellosis; positive for eosinophilic agglutination test, considering infectious single Nuclear cell hyperplasia; positive condensing test, considering mycoplasmal pneumonia.

Differential diagnosis

Disease identification:

(1) Infectious diseases

Septicemia

Common are Staphylococcus aureus sepsis and Gram-negative septicemia. The former has an acute onset, sudden chills, high fever, and hot type. It is characterized by pleomorphic rash, skin mucosal bleeding, joint swelling and pain, endocarditis and migraine lesions. Peripheral blood leukocytes and neutrophils were significantly elevated. Gram-negative septicemia is often a relaxation heat, intermittent heat or bimodal fever, which may be associated with relatively slow pulse, necrotic rash, hepatosplenomegaly and septic shock. In some patients, peripheral blood leukocytes may not be high. Multiple blood cultures and bone marrow cultures are helpful for the detection of pathogenic bacteria. It is generally believed that the best time to take blood should be before the use of antibiotics and when chills and high fever occur. A positive lysate test (LLT) indicates the presence of Gram-negative bacilli endotoxin, but also false positives and false negatives.

2. Tuberculosis

(1) Miliary tuberculosis

There may be symptoms of high fever, chills, shortness of breath and systemic poisoning, and chest radiographs show diffuse nodules.

(2) invasive pulmonary tuberculosis

May have fever, cough, hemoptysis, fatigue, reduction, weight loss, night sweats, sputum tuberculosis culture can be positive, chest radiograph shows one or both sides of the lung patch or spotted shadow, and can have fibrosis and calcification .

(3) Extrapulmonary tuberculosis

Including tuberculous meningitis, tuberculous pleurisy, peritoneal tuberculosis, lymph node tuberculosis, kidney tuberculosis and so on. Clinical symptoms of systemic poisoning and associated symptoms. The white blood cells are generally normal or slightly elevated, and may have an increase in erythrocyte sedimentation rate, and the tuberculin test is positive. Diagnostic treatment is effective.

Typhoid fever

The onset is slow, the body temperature rises in a trapezoidal shape, and the retention type continues to be hot, accompanied by apathy, relatively slow pulse, and rose rash. Typical cases may have splenomegaly and hepatomegaly at 1 week of the disease. The white blood cell count was reduced, the fatda reaction was positive, and the typhoid bacillus was isolated from the blood culture. In recent years, due to the widespread use of antibiotics, atypical cases of typhoid fever have increased, complications have increased, and types are complex, which should be taken seriously.

4. Epidemic hemorrhagic fever

Rats are a source of infection and can be popular in spring and summer and autumn and winter. The clinical classification is divided into fever, hypotension, oliguria, polyuria, and recovery. The onset of fever is rapid, the body temperature is generally between 39 °C ~ 40 °C, the heat type is more relaxation heat, accompanied by headache, eye pain, eyelid pain, blurred vision, thirst, nausea, vomiting, abdominal pain, diarrhea, etc. The face and eyelid area are congested, the upper chest is flushed, and the underarm is visible at the bleeding point. Leukocytosis, lymphocytosis, and decreased platelet count. Diffuse exudative changes can occur in chest radiographs.

5. Malaria

The incidence rate is high in summer and autumn, and there is obvious chill before high fever. The body temperature can reach above 40 °C, accompanied by a lot of sweating, splenomegaly and anemia, and the white blood cell count is low. For patients suspected of malaria, such as multiple blood smears or bone marrow smears have not found malaria parasites, try chloroquine for diagnostic treatment.

6. Infective endocarditis

In patients with congenital heart disease or rheumatic heart valve disease, or after cardiac surgery, unexplained high fever accompanied by generalized fatigue, progressive anemia and embolism, physical examination of bleeding spots on the skin, mucous membrane, nail bed, etc. Cardiac auscultation has new murmurs or changes in the nature of the original murmur, or accompanied by arrhythmia, the possibility of considering this disease, repeated blood culture helps to confirm the diagnosis.

7. AIDS

If there are two or more of the following high-risk groups, the AIDS may be considered:

(1) intermittent or continuous fever for more than 1 month;

(2) generalized lymphadenopathy;

(3) Chronic cough or diarrhea for more than 1 month;

(4) Weight loss of more than 10%;

(5) Repeated herpes zoster or herpes simplex infection;

(6) Oropharyngeal Candida infection.

Further diagnosis requires HIV antibody and HIV RNA detection as well as CD4+ T lymphocyte counts.

8. Influenza

Good winter and spring, easy to outbreak. More often with high fever, accompanied by headache, fatigue, body aches, body temperature can reach 39 ° C ~ 40 ° C, for 2 to 3 days, retreat, nasal congestion, runny nose, sore throat, cough, blood stasis or combined bacterial infection Pus, a small number of patients may have difficulty breathing or gastrointestinal symptoms. The white blood cell count is normal, reduced or slightly increased, and the proportion of lymphocytes can be increased.

9. SARS/Severe Acute Respiratory Syndrome (SARS)

The pathogen may be a new type of coronavirus, the source of infection for its patients and carriers of latent pathogens, with close air droplets and close contact as a means of transmission. The clinical process is rapid, and fever is the first symptom. The body temperature is generally above 38 °C, which may be accompanied by headache, general malaise or muscle pain. It may have dry cough, and severe cases may have shortness of breath or even respiratory distress. White blood cell counts generally do not increase or decrease, often with reduced lymphocyte counts. Chest X-rays showed varying degrees of patchy, patchy infiltrating shadows or reticular changes. This type of "atypical pneumonia" is different from atypical pneumonia known to be caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella and common respiratory viruses. It is highly contagious, aggregating, has a strong clinical manifestation, and its disease progresses rapidly and is harmful. And other characteristics, especially those older than 50 years old or with a combination of underlying diseases have a poor prognosis.

10. Legionnaires' disease

It is an acute respiratory infection caused by Legionella. The mode of transmission is mainly inhaled by water supply system, air conditioning and atomized inhalation. People who are older and have low immunity are prone to develop. Onset is characterized by high fever, chills, fatigue, myalgia, dry cough, diarrhea, and severe cases may have difficulty breathing and neuropsychiatric symptoms. The white blood cell count is increased, and the neutrophil nucleus is shifted to the left, which may be associated with renal dysfunction. In the early stage of chest radiograph, peripheral plaque-like alveolar infiltration, followed by lung consolidation, the lower lobe is more common.

11. Acute bacterial pneumonia

It is inflammation of the lungs caused by bacterial infection. According to the extent of lesion involvement, it is divided into lobar pneumonia and bronchial pneumonia. The patient has fever, cough, sputum and purulent sputum, chest radiograph showing inflammatory infiltrative shadow in the lung, white blood cell count or neutrophil increase, or qualified sputum culture can isolate meaningful pathogens.

12. Local infection

Liver abscess, biliary tract and acute genital tract infection, intra-abdominal abscess are more common, acute infection can cause high fever, fatigue, backache, abdominal pain, nausea, vomiting and other accompanying symptoms, should be observed changes in physical signs, and repeated laboratory Inspection and auxiliary examinations are of great value for the discovery of lesions.

13. Fungal infections

Patients with long-term use of antibiotics, glucocorticoids or immunosuppressive agents are prone to opportunistic fungal infections. Clinical manifestations of fever can continue, with chills, night sweats, anorexia, weight loss, general malaise or cough, hemoptysis, etc., should consider the possibility of oropharynx or deep fungal infection, conditional fungal culture or antifungal drug observation treatment.

(2) Non-infectious diseases

1. Systemic lupus erythematosus (SLE)

More common in young women, fever has a longer duration. Acute exacerbation has high fever, body temperature can be as high as 39 ° C ~ 40 ° C, more with joint pain, skin lesions, facial butterfly erythema, sun allergy, anemia, fatigue, limb arterial spasm, bleeding points. Clinical and laboratory tests showed liver, kidney, heart, lung and other multiple organ damage, hemolytic anemia, white blood cells, thrombocytopenia, increased erythrocyte sedimentation rate, positive antinuclear antibody (highest positive rate), anti-smooth muscle antibody positive (specific Highest), found lupus cells in the bone marrow and peripheral blood, or positive for skin biopsy. 2. Rheumatic fever often invades adolescents, and often has a history of acute pharyngitis or tonsillitis before onset. It is a systemic allergy caused by infection with hemolytic streptococcus. Most patients have fever, most of them are irregular heat, often accompanied by migratory joint pain, increased heart rate, and arrhythmia. Some patients have ring erythema on the trunk and inside the limbs. Subcutaneous nodules can be seen in the affected joint area, which is hard and painless and does not adhere to the skin. Laboratory tests for accelerated erythrocyte sedimentation rate, increased mucin, and increased anti-streptolysin "O" titer.

3. Dermatomyositis

The clinical manifestations are high fever, with general discomfort, extreme fatigue and symmetry of muscle pain and tenderness. Patients cannot sit and stretch.

4. Adult Still's disease

The old name "variant subsepticemia" is characterized by intermittent high fever, rash and joint symptoms. In addition, there are lymphadenopathy, hepatosplenomegaly, white blood cell count, erythrocyte sedimentation rate, rheumatoid factor and anti-nuclear antibody are negative, repeated blood culture negative, antibiotic treatment is invalid, glucocorticoid treatment is effective.

5. Blood disease

Acute leukemia, malignant lymphoma, malignant histiocytosis, myelodysplastic syndrome, acute aplastic anemia, multiple myeloma and other blood diseases can be characterized by long-term fever, and the fever is mostly relaxation, intermittent or periodic. The course of fever can be delayed from several weeks to several months. Patients with varying degrees of pale, bleeding tendency, hepatosplenomegaly or lymphadenopathy often require bone marrow aspiration, lymph node biopsy, etc. Can be diagnosed.

6. Various malignant tumors

Tumor patients may have moderate or moderate fever, such as digestive tract, respiratory malignant tumor, osteosarcoma, renal cancer, adrenal cancer, and patients with progressive wasting, loss of appetite and symptoms of diseased organs .

7. Drug fever

Patients with fever use antipyretic analgesics, sulfonamides, certain antibiotics or sleeping pills, etc., but the fever continues to rise or rise again, or if there is no fever before, there is no new evidence of infection, accompanied by pleomorphic rash. Joint pain, lymphadenopathy and eosinophilia, patients generally good condition, no symptoms of poisoning, should consider the possibility of drug fever. Suspected drugs can be stopped under close observation. If the body temperature drops to normal within a few days, a diagnosis of drug fever can be made.

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