ID Miscellany|physical Exam|Signs|Humanities #idmesh
๐™๐™€๐™‘๐™€๐™ ๐™‹๐˜ผ๐™๐™๐™€๐™๐™‰๐™Ž: ๐˜ผ ๐™‡๐™Š๐™Ž๐™ ๐˜ผ๐™๐™?

Great! Three quarters find inquiring about fever patterns still useful. We will review some of the most important fever patterns.


For centuries, physicians have relied upon meticulous observations to dx infections. For many years, observation of the fever pattern provided physicians w/ important diagnostic clues. However, the advent of abx & advanced dx & imaging has changed this landscape. #idmesh
Swift initiation of abx & antipyretics make it impossible to verify historical descriptions of certain fever patterns. Hence, inquiry into fever patterns loses its clinical significance
Fever: rise in temp 2/2 โฌ†๏ธ hypothal set point through humoral/neural paths & PE2๐Ÿ‘‡

The โฌ†๏ธ set point distinguishes it from hyperthermia.

Temp has diurnal (โฌ‡๏ธ am โฌ†๏ธ pm), anatomic (rectal>oral), & physiologic (older age, co-morb) variations. #idmesh
๐™๐™ƒ๐™€ ๐™๐™€๐™‘๐™€๐™ ๐™‹๐˜ผ๐™๐™๐™€๐™๐™‰๐™Ž

1โƒฃ Continuous/sustained fever: fever doesnโ€™t fluctuate >1 C, doesnโ€™t normalize

โ–ช๏ธ Classically a/w lobar pneumonia, rickettsial diseases, & typhoid. #idmesh
Typhoid has a peculiar pattern of continuous fever called:

2โƒฃ Step-ladder fever๐Ÿ‘‡ In tropical countries, this has been shown to be of immense value in typhoid fever diagnosis (LR 177.4)

3โƒฃ Intermittent fever (hectic, โ€œpicket fenceโ€): present only for several hrs during the day. Exemplified by the majority or pyogenic infections.

โ–ช๏ธ Classically a/w malaria, TB, lymphoma
Malarial intermittent fevers๐Ÿ‘‡
โ–ช๏ธ P. vivax & ovale: intermittent tertian
โ–ช๏ธ P. falciparum: intermittent subtertian
โ–ช๏ธ P. knowlesi: quotidian (daily) #idmesh
4โƒฃ Pel-Epstein fever๐Ÿ‘‡: characterized by 3-10 days fever w/ subsequent afebrile period of 3-10 days.

โ–ช๏ธ Thought to be characteristic of lymphoma. #idmesh
There are also Pel-Ebstein-like patterns that are characteristic of:

5โƒฃ Relapsing fever: tick- or louse-borne: Fever for 3 days (2-7 days), afebrile period of 7 days (Fig 1๐Ÿ‘‡)
6โƒฃ Undulant fever a/w some cases of brucellosis (Fig 2๐Ÿ‘‡)
7โƒฃ Double quotidian fever: 2 distinct daily peaks of fever; seen only in a few conditions๐Ÿ‘‡

โ–ช๏ธ Adult Stillโ€™s: most cited in literature @alhkim @LisaZickuhr
โ–ช๏ธ Gonococcal endocarditis
โ–ช๏ธ Visceral leishmaniasis
8โƒฃ Biphasic (saddleback, dromedary) fever: not truly relapsing; course marked by onset of fever for a few days, followed by an afebrile phase

โ–ช๏ธ Exemplified by dengue, Colorado tick fever, leptospirosis #idmesh

Refer to our prior discussion
9โƒฃ Typhus inversus: reversal of diurnal fever pattern (highest temp in the AM rather than PM)

โ–ช๏ธ Thought to be seen in military TB, hepatic abscess, endocarditis
An aspect of fever that is most useful is the degree. Hyperpyrexia (>106.7 F), can be seen in infections but more commonly w/ hyperthermia (set point unchanged, inability to lose heat from excess production or exogenous exposure). #idmesh
@grepmeded @DxRxEdu @rabihmgeha
We talked about some of the causes of hyperpyrexia (in the setting of rigidity) here before: #idmesh
Knowledge of fever patterns is also helpful in differentiating the major causes of periodic fever syndromes๐Ÿ‘‡:
โ–ช๏ธ FMF: <2d + serositis/arthritis/rash
โ–ช๏ธ Hyper-IgD: <4-6d + LAD/rash/localized myalgia
โ–ช๏ธ TRAPS: >2wks + rash/conjunctivitis
A closely related topic is the temperature-pulse dissociation (Fagetโ€™s sign) which weโ€™ve discussed previously on #idmesh
Fever patterns are not pathognomonic. Should not bias one into a dx. The most important aspect of fever is appraising it in a/w the patientsโ€™ SSx, lab & imaging. This is at the โค๏ธ of clinical reasoning. @CPSolvers @thecurbsiders @MedEdPGH @MohitHarshMD @Maximal_Change
I would like to also refer you to the master @tony_breu's recent tweetorial on fever. #idmesh

Rounding out this #idmesh tweetorial.

Please share stories on how you used fever patterns in diagnosing patients. @PaulSaxMD @CarlosdelRio7 @DxRxEdu @rabihmgeha @GermHunterMD @FungalDoc @tosh_taniguc @NNolanMD @JonathanRyderMD @TxID_Edu @swinndong @LeMiguelChavez

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Geography matters!

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Standard, contact, droplet, eye protection, airborne (N95) in aerosol-generating procedures, until Sx resolve & 2 (-) swabs 24H apart

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98% develop Sx within 12 days

Everyone, regardless of age, is SUSCEPTIBLE and can be a vector of infection๐Ÿ‘‡ >50% of cases are in people <50 yrs.
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48F, bitten by a monkey at a zoo. She calls her primary who then calls you for advice.

What Qs should you ask? What infections should you be worried about? @TxID_Edu @Cortes_Penfield @BradCutrellMD @jdcooperid

Have you had a consult on monkey bite before?
@TxID_Edu @Cortes_Penfield @BradCutrellMD @jdcooperid 1/15
Great! Thank you for ALL your responses. Speical thanks to @TxID_Edu @vivax74 @VarunPhadke2 @10minus6cosm for referencing additional resources.

Hope this tweetorial helps, especially those who may get consulted on monkey bite/exposure in the future.

Follow the thread ๐Ÿ‘‡
๐–๐ก๐š๐ญ ๐ข๐ง๐Ÿ๐ž๐œ๐ญ๐ข๐จ๐ง๐ฌ ๐ฌ๐ก๐จ๐ฎ๐ฅ๐ ๐ฒ๐จ๐ฎ ๐›๐ž ๐ฐ๐จ๐ซ๐ซ๐ข๐ž๐ ๐š๐›๐จ๐ฎ๐ญ?
A LOT, but the most important ones are:

1โƒฃ Herpes B
2โƒฃ Rabies
3โƒฃ Tetanus

Let's talk a little bit more about Herpes B and rabies ๐Ÿ‘‡
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61M ESRD s/p kidney transplant 2016 (CMV D-/R-), on tac/pred, 6 mos progressive memory loss, falls, headache, blurred vision. No fever.
Traveled to southwest US, Malaysia, Thailand >10 yrs ago. Monogamous relationship.
@BradCutrellMD @Cortes_Penfield
Exam: disoriented, poor memory, โฌ‡๏ธ proprioreception, supple neck.
Labs: macrocytic anemia
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Prior to transfer, managed in the dementia clinic.
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Case presentation:
1/3 | 18/M CC: "most severe headache"

Late summer in IL. 1 wk ago, +fever, myalgia, leg rash. SSX resolved after 4 d. 3 d later, fever recurred (low grade) but now w/ headache. Day of admission, "worse headache" & delirium. Hospital admission.
2/3 Case presentation:

UTD w/ immunization. No PMH/meds. Not sexually active. Works in Walmart. Reported hiking 1 wk prior, +tick/mosquito bites, +swimming in man-made lake. Has dogs, cats, pet lizard. No sick contacts.
3/3 Case presentation:

Exam: supple neck, confused.

WBC 14, Plt 610. CMP n/l. CSF: WBC 320 (78%L), n/l gluc/TP. CSF HSV/VZV/enterovirus/bacterial Cx (-). RPR/HIV(-). Resp viral panel(-).

Diagnosis? Differentials?
@TxID_Edu @DocWoc71 @BradCutrellMD @Cortes_Penfield @jdcooperid
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19 Nov 19
35F, from St. Louis, woke up w/ a mildly painful bruise L arm, the next day, +diffuse erythematous rash, fever, abdominal pain. Unremarkable VS/labs. Representative pics of rashes ๐Ÿ‘‡.

Diagnosis? Differentials? @TxID_Edu @BradCutrellMD @Cortes_Penfield @DocWoc71
@TxID_Edu @BradCutrellMD @Cortes_Penfield @DocWoc71 1/9
Case continued:
Bruise evolved into an ulcer. On further questioning, reported seeing spider close to her bed prior

Acute generalized exanthematous pustulosis (AGEP) 2/2 spider bite

Pics in MCQ:โ€ฆโ€ฆ
The rash a/w AGEP is characteristic:

โ–ช๏ธ Diffuse erythema
โ–ช๏ธ Innumerable, pinhead-sized pustules

@TxID_Edu @rloganjonesmd @PVishnuRao1 @alxpenguin @npowah @dschless immediately suspected AGEP! Nice job!
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