ID Miscellany|physical Exam|Signs|Humanities #idmesh
1/20
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.

@ID_fellows

2/20
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
3/20
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 bit.ly/33iXCLs.
4/20
Fever: rise in temp 2/2 โฌ†๏ธ hypothal set point through humoral/neural paths & PE2๐Ÿ‘‡bit.ly/2E09nhm

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
5/20
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
6/20
Typhoid has a peculiar pattern of continuous fever called:

2โƒฃ Step-ladder fever๐Ÿ‘‡bit.ly/2E09nhm. In tropical countries, this has been shown to be of immense value in typhoid fever diagnosis (LR 177.4) bit.ly/3mcuo9T

#idmesh
7/20
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
#idmesh
8/20
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
bit.ly/3kdxjxa
9/20
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. bit.ly/3hpsUp3 #idmesh
10/20
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‘‡) bit.ly/33mUMoF
#idmesh
11/20
7โƒฃ Double quotidian fever: 2 distinct daily peaks of fever; seen only in a few conditions๐Ÿ‘‡bit.ly/3hrm1Ub

โ–ช๏ธ Adult Stillโ€™s: most cited in literature
bit.ly/3hrm1Ub @alhkim @LisaZickuhr
โ–ช๏ธ Gonococcal endocarditis
โ–ช๏ธ Visceral leishmaniasis
#idmesh
12/20
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
13/20
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 bit.ly/3iubhWl
14/20
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
15/20
We talked about some of the causes of hyperpyrexia (in the setting of rigidity) here before: #idmesh
16/20
Knowledge of fever patterns is also helpful in differentiating the major causes of periodic fever syndromes๐Ÿ‘‡: bit.ly/3hweu6t
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
#idmesh
17/20
A closely related topic is the temperature-pulse dissociation (Fagetโ€™s sign) which weโ€™ve discussed previously on #idmesh
18/20
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
19/20
I would like to also refer you to the master @tony_breu's recent tweetorial on fever. #idmesh

20/20
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

โ€ข โ€ข โ€ข

Missing some Tweet in this thread? You can try to force a refresh
ใ€€

Keep Current with WuidQ: Washington University ID Questions

WuidQ: Washington University ID Questions Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @WuidQ

12 Jul
๐—œ๐—— ๐—–๐—ผ๐—ฟ๐—ฒ ๐—ง๐—ผ๐—ฝ๐—ถ๐—ฐ๐˜€ ๐Ÿญ #idcoretopics
1/20

TICKBORNE INFECTIONS (TBI)

Itโ€™s summer (= tick bites ๐Ÿž) and we have new faculty, fellows, residents, interns, & students coming from different places.
@grepmeded

This tweetorial is an overview of TBI mainly in the US.
2/20

โ–ช๏ธClimate change is expanding the seasonal/geographic distribution of TBI.
โ–ช๏ธLack of tick bite in H/P should not dissuade you from considering TBI. In fact, only ยผ with Lyme remember a tick bite.
โ–ช๏ธNo perfect test.
โ–ช๏ธEarly Abx is important.

#idcoretopics
3/20

Geography matters!

An effective way of learning about TBI is learning it according to its geography.

@MohitHarshMD @TxID_Edu @rabihmgeha @DxRxEdu @Anirban63395569 @k_vaishnani @VarunPhadke2 @NNolanMD @Jncherabie @LeMiguelChavez @LParraRod @CGhaznavi

#idcoretopics
Read 21 tweets
18 Mar
๐—–๐—ผ๐˜ƒ๐—ถ๐—ฑ-๐Ÿญ๐Ÿต: ๐—ป๐—ผ๐˜๐—ฒ๐˜€ ๐—ผ๐—ป ๐—ฎ ๐—ฝ๐—ฎ๐—ป๐—ฑ๐—ฒ๐—บ๐—ถ๐—ฐ

1/17 1๏ธโƒฃ Prevention: healthcare

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

CDC: bit.ly/2Wb0VCy
WHO: bit.ly/2UcMwTA
2/17 1๏ธโƒฃ Prevention: community

Vaccine development ongoing
5 things you can do to protect yourself ๐Ÿ‘‡ [Fig 1]

Flattening the curve is not just a mathematical modeling; history has shown its importance ๐Ÿ‘‡[Fig 2] wapo.st/2WeypQp

CDC: bit.ly/2QiCTSj
3/17 2๏ธโƒฃ Clinical features

Incubation: median 4 days (2-7 days ); up to 14 days

98% develop Sx within 12 days bit.ly/2w3dzJi

Everyone, regardless of age, is SUSCEPTIBLE and can be a vector of infection๐Ÿ‘‡ >50% of cases are in people <50 yrs. bit.ly/38UbRY2
Read 19 tweets
18 Feb
#idgrandrounds
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‘‡
2/15
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‘‡
Read 16 tweets
14 Jan
#idgrandrounds
1/2
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
2/2
Exam: disoriented, poor memory, โฌ‡๏ธ proprioreception, supple neck.
Labs: macrocytic anemia
CXR: nonspecific small nodule
MRI: mild periventricular hyperintensity, panventriculomegaly

What are you DDX and suggested work-up? @TxID_Edu @jdcooperid @MohitHarshMD @k_vaishnani
@TxID_Edu @jdcooperid @MohitHarshMD @k_vaishnani 1/11
CASE RESOLUTION
Prior to transfer, managed in the dementia clinic.
LP was only done late: lymphocytic pleocytosis, elevated TP, glucose <20. Serum/CSF CrAg +, CSF +Cryptococcus neoformans.

Excellent work @Cortes_Penfield @jdcooperid @TxID_Edu @ShohamTxID @PVishnuRao1
Read 14 tweets
3 Dec 19
#idgrandrounds
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
Read 13 tweets
19 Nov 19
#IDgrandrounds
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

CASE RESOLUTION:
Acute generalized exanthematous pustulosis (AGEP) 2/2 spider bite

Pics in MCQ:
medicaljournals.se/acta/content/hโ€ฆ
flickr.com/photos/1448153โ€ฆ
2/9
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!
Read 11 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!