THE DECISION TO TREAT FEVER

 

Most fevers are associated with self-limited infections, most commonly of viral origin. In these cases, the general cause of the fever is easily identified. The routine use of antipyretics given automatically as “standing,” “routine,” or “prn” orders to treat low-grade fevers in adult patients on hospital wards is entirely unacceptable. This practice masks not only fever but also other important clinical indicators of a patient’s course. For example, the daily highs and lows of normal temperature are exaggerated in most fevers, but the usual times of peak and trough temperatures may be reversed in typhoid fever and disseminated tuberculosis. Temperature-pulse dissociation (relative bradycardia) occurs in typhoid fever, brucellosis, leptospirosis, some drug-induced fevers, and factitious fever. In newborns, the elderly, patients with chronic renal failure, and patients taking glucocorticoids, fever may not be present despite infection, or core temperature may be hypothermic. Hypothermia is observed in patients with septic shock.

Some febrile diseases have characteristic patterns. With relapsing fevers, febrile episodes are separated by intervals of normal temperature; when paroxysms occur on the first and third days, the fever is called tertian. Plasmodium vivax causes tertian fevers. Quartan fevers are associated with paroxysms on the first and fourth days and are seen with P. malariae. Other relapsing fevers are related to Borrelia infections and rat-bite fever, which are both associated with days of fever followed by a several-day afebrile period and then a relapse of days of fever. Pel-Ebstein fever, with fevers lasting 3 to 10 days followed by afebrile periods of 3 to 10 days, is classic for Hodgkin’s disease and other lymphomas. Another characteristic fever is that of cyclic neutropenia, in which fevers occur every 21 days and accompany the neutropenia. There is no periodicity of fever in patients with familial Mediterranean fever.
Source: Harrison_s_Principles_of_Internal_Medicine_16th_Edition