FEVER

Normal Thermoregulatory Mechanisms

Under normal conditions body temperature is controlled around a specific "set-point" temperature by neuronal regulatory mechanisms within the hypothalamus. The preoptic area and adjacent regions of the anterior hypothalamus contain heat sensitive receptors and neurons which are capable of altering physiologic processes to increase heat loss and decrease heat production in response to hyperthermia. In contrast, when cold receptors in the posterior hypothalamus are stimulated, signals are transmitted to the hypothalamic temperature control center to increase heat production and decrease heat dissipation.

Normal Thermoregulatory Mechanisms

Although the terms fever and hyperthermia have been used interchangeably in the past, recently they have been differentiated into distinct pathophysiologic entities. Fever is defined as an elevated set point temperature to which physiologic processes are altered to increase body temperature. Hyperthermia describes a condition whereby the patient's set point is normal but abnormal physiologic processes exist to produce an elevated body temperature.

Hyperthermia
Pathophysiology Hyperthermia results from increased heat production and/or decreased heat dissipation under conditions where the set point temperature is normal. Body temperature may be elevated by conditions that
1) increase the hypothalamic set point temperature 2) increase heat production, and/or 3) decrease heat dissipation.

Hyperthermia
Etiologies Several acute and chronic diseases, neuroleptic drugs, excessive doses of sympathetic drugs may increase the set point temperature through direct stimulation of the hypothalamus or disruption of normal feedback mechanisms. Hypothalamic lesions secondary to stroke, neurosurgical procedures, or tumors may impair thermoregulation. The illicit use of drugs, particularly those with significant adrenergic activity, may produce dramatic elevations in body temperature through centrally mediated effects and increased muscular activity. Catecholamine secreting tumors, such as pheochromocytoma and neuroblastoma may alter body temperature in a similar manner. Prolonged seizures, certain psychiatric illnesses, and malignant hyperthermia may increase body temperature secondary to sustained skeletal muscle activity.

Hyperthermia .
Other mechanisms whereby heat production can rise include increased metabolic rate secondary to excessive thyroid hormone activity and uncoupled oxidative phosphorylation secondary to excessive salicylate ingestion. Even in usual pharmacologic doses, drugs with significant sympatholytic activity may reduce cutaneous blood flow and sweat gland secretions, thereby decreasing the amount of heat that can be dissipated. Decreased heat exchange due to environmental conditions is an important factor in the pathogenesis of heat stroke. Heat stroke is an example of hyperthermia in which overexertion in an excessively hot and humid environment results in increased heat production under conditions where heat dissipation cannot occur.

Fever
Pathophysiology While exogenous pyrogens, such as live viruses, bacterial endotoxins, and antigen-antibody complexes may act directly to increase body temperature, most experimental evidence suggests that these substances produce fever through the action of intermediary substances. Other initiating events may include tissue injury or inflammatory processes

Clinical Assessment
From the previous definitions and examples of altered thermoregulatory mechanisms, it is apparent that an elevated body temperature requires a careful history, physical examination, and diagnostic evaluation to determine the underlying cause and the most appropriate form of management.

Diurnal Temperature Variations

In all normal persons there exists a diurnal temperature variation; the peak occurs in the late afternoon or early evening and the nadir occurs in the early morning between three and five o'clock. This variation in body temperature appears to be independent of sleep habits and eating or working patterns.

Clinical Definition of Fever

The average oral temperature is 37 C, although the normal range may vary between 36.5 and 37.5 C in older children and adults, and may even be higher in infants. Properly recorded rectal temperatures are generally 0.5 "C higher than oral temperatures, whereas axillary temperatures are usually 0.5 C lower than oral readings. Therefore, the clinical definition of fever is determined by method of measurement and is generally accepted to be any temperature above the normal range

Methods of Measurement
Several methods for measuring body temperature are available. The most commonly employed methods are oral, rectal, and axillary. Axillary temperatures may be less accurate although safer and easier to measure in infants and small children. Axillary temperatures are recorded by placing the thermometer tip in the armpit and holding the elbow against the chest to stabilize it. The thermometer should be left in place for three to five minutes For the patient who is fully cooperative and does not have a respiratory illness, oral temperatures are preferred.

Efficacy of Skin Thermometers.

Plastic strip thermometers which are held across the forehead for one minute have been marketed as a quick and gentle means of measuring body temperature. The reliability of these devices to detect fever has been examined in two large studies. In comparison with an electronic thermometer in 152 patients and a standard glass thermometer in 613 patients, the plastic strip thermometer had an overall sensitivity and reliability of about 0.8. Although the skin thermometer performed better in patients with high fevers, the authors expressed concern that serious illness may be underestimated if this temperature measuring device is the only method used.

Temperature Assessment by Palpation

Palpations of the forehead, face, abdomen, torso, neck, and arms are common methods to detect the presence or absence of fever. In some instances this subjective method may even be used in lieu of a thermometer. Subjective assessment of body temperature by palpation is not a substitute for using a rectal or oral thermometer; however, it may provide useful historical information in the evaluation of pediatric illnesses

Factors Affecting Treatment Decisions

Although the role of fever during infections has been studied extensively, it is not well established whether fever is an essential host defense mechanism or not. In vitro, elevated temperatures have been shown to produce unfavorable growth conditions for certain bacteria and viruses; however, there is no solid evidence, in vivo, that fever enhances host defenses against infection. Therefore, the decision to treat fever is often based on attitudes of the patient and prescriber; the patient's age, past medical history, and concurrent symptoms; and the diagnostic and treatment plans.