During our Post graduate training we had been under the impression that Fever is the Most difficult symptom to solve and fever does not kill the patients but it can kill a Doctors reputation, But here the story comes : In early 2k, I was on duty as Assistant Professor in Medical wards of a reputed Medical college - Govt. Stanley Medical College, in Chennai - India. At about 4 pm my Post graduate in Medicine admitted an Young 27 years old female with an history of fever since 2 days. She delivered a baby about a week ago ( Full term natural delivery and smooth ante-natal history). She was breast feeding the baby. History and physical examination were unremarkable. I was angry with the post graduate for hospitalising a recent puerperal mother for a short acute febrile illness without any significant physical findings. About an hour later I received a call from the post graduate that She became seriously ill gasping for breath and rapidly desaturating in the ECG room while an ECG was recorded . I became very furious towards the attitude of that postgraduate for sending the patient for an ECG, which I thought was an unwarranted test in a febrile patient. She was shifted to M-ICU intubated and cardiac resuscitation was attempted. In vain. She succumbed to the undiagnosed Acute short febrile illness. But the ECG was very diagnostic in determining the cause of death. Following this experience until now, I order an ECG for every febrile patients.
Dear Muralidharan R.s.,
It is really a very sad story.
Since the topic is so interesting I have copied some important text to shed light on this kind of illness:
Acute febrile illness is the medical term used to describe a sudden fever or elevation in body temperature. This happens when the body is invaded by a pathogen and the immune system is activated to fight it off. Read more to learn about the symptoms and treatment options.
What Is Acute Febrile Illness?
When the body is invaded by a foreign pathogen like a virus or bacteria, the immune system kicks into gear and tries to fight the infection before it has a chance to spread. When this happens, the body's temperature is elevated to try to kill off the pathogen, and this results in what we call a fever. Acute febrile illness is when a fever develops suddenly; specifically, the body temperature rises above 37.5 degrees Celsius (99.5 degrees Fahrenheit).
Causes
If you've ever been sick, you've probably experienced having a fever, and you know how hard it can be to determine the underlying cause. Acute febrile illness can occur whenever the body is invaded by some type of infectious disease, but it is especially worrisome in tropical and sub-tropical regions where serious diseases loom. These can include malaria, dengue, typhoid, chikungunya, Leptospirosis, scrub typhus, influenza, encephalitis, histoplasmosis, enteric fever, rickettsiosis, Hantavirus, and many, many others. Specifically, the hypothalamus is the part of the brain responsible for regulating body temperature, and it may 'decide' to elevate body temperature in response to an infection.
Symptoms
In addition to causing elevated body temperature, acute febrile illness can be accompanied by headaches, dizziness, sweats, chills, muscle pain, joint pain, and weakness. Sometimes it's also affiliated with respiratory symptoms like coughing or wheezing. A fever in itself isn't necessarily cause for alarm; however, it becomes problematic when the body temperature gets too high or lasts for an extended amount of time.
In infants or very young children, fever may be accompanied by seizures (called febrile seizures). These are generally harmless (although they can be very scary to witness), though it's recommended to take children to the doctor the first time they experience a febrile seizure. They can be recurring, so it's best to make sure they aren't indicative of a more serious cause.
http://study.com/academy/lesson/acute-febrile-illness-symptoms-treatment.html
Rafik
I am disclosing the answer. This patient had a Typical Brugada syndrome - Type 1 revealed in the ECG. Fever ( of any aetiology ) can unmask this Brugada syndrome making the patient vulnerable for Ventricular tachycardia and Sudden Cardiac Death.
The term “ FEVER” is well defined and has a very sound scientific basis. Every doctor must know the land mark article authorized even as early as 1960 by Petersdorf RG, Beeson PB; Fever of unexplained origin: report on 100 cases in the Journal Medicine (Baltimore). 1960 Feb; vol : 40, p 1-33. The body temperature > 101 degree F is defined as fever is best suited even today. The duration of fever, the degree of fever, the pattern of fever, circadian variation and associated symptoms like Chills, Rigor, Head ache, nausea, vomiting, malaise, arthralgia, fatigue, insomnia, rashes - all help in understanding the aetiology of fever. Cough, headache, vomiting, altered bowel movements ( either constipation or diarrhea ), dysuria, nocturia, urgency, hesitancy, precipitancy, hematuria, LOC, Convulsions, altered sensorium - all help in understanding which compartment of the human body is affected ( eg. Pulmonary, cerebral, Gastro-intestinal, genitor urinary… ).
2. Broadly the concepts in approaching a patient with a febrile illness are :
- To know the aetiology of Fever
- To compartmentalize the disease
3. It is well understood that the entire ‘fever scenario’ is completely scientific. Broadly the aetiological aspects of fever is considered to be due to :
a) 1/3 rd cases are to due to infection
b) 1/3 rd cases are due to inflammatory
c) 1/3 rd cases are due to malignancy.
d) Rest of the cases include Drug fever, Familial Mediterranean fever, inherited disorders, endocrine disorders, Factitious fever, kikuchi disease, Peripheral pulmonary embolism, Cyclical Hyperthermia, Catamonial fever, F.U.O. are all rare causes of fever.
4. When we approach the fever patient, each symptom we ask and each physical finding ( positive and negative ) we elicit has a following scientific basis to arrive at a diagnosis before embarking on battery of tests that are now available.
o Chills and rigor at one end in adults and convulsions ( febrile ) in children at the other end have a common scientific basis. When the Hypothalamic core temperature ( thermostat ) raises due to the febrile illness ( mediated by chemical mediators - Interleukin 1, Histamine, Kinins, Leukotrines and Prostaglandins ) patient feels uncomfortable and the external body raises to level with the hypothalamic thermostat. Chills when the rate of raise of body temperature is slow and the peaking of fever is intermediary grade, Rigor when the rate of body temperature is fast and peaking of fever is high grade in adults. In children convulsions is the fastest mechanism of raising the body temperature to level with high set hypothalamic thermostat.
o Similarly when the fever remits either spontaneously or anti pyretic mediated - is associated with profuse defervescence sweating.
o Head ache represents the intracellular nature of the pathogen / vasodilatation phenomenon of inflammatory origin.
o Evening raise of temperature, chills, nocturnal sweats, fatigue, anorexia and weight loss over a prolonged period - the constitutional symptoms of Tuberculosis - irrespective of Tuberculous compartment ( Pulmonary, Extra Pulmonary )
o Nausea, vomiting, malaise, arthralgia, fatigue, insomnia are induced by the Chemical mediators indicating acute febrile illness of shorter duration. Either infective or inflammatory origin.
o Rashes indicative of Viral infective aetiology / Drug fever.
5. Compatmental symptoms :
- Cough, sputum, chest pain sometimes breathlessness of - respiratory compartment
- Nausea, vomiting, anorexia and altered bowel movements - of Gastro-intestinal system
- Dysuria, haematuria, poikilouria, nocturia, hesitancy, precipitancy, urgency - of Genito – urinary system
- Head ache, nausea. Vomiting, convulsions and altered sensorium - of CNS system.
So in a nut shell, when we approach a febrile patients, we should be well aware of these scientific basis. It is mandatory first to obtain a detailed history and perform a thorough physical examination before ordering wide variety of tests. Man fist, scientific mind second and last but not the least the relevant tests, takes us to a very high degree of perfection in managing the fever patient.
This was a very interesting case , in which death occurred due to a non infectious cardiac cause . The ECG was probably taken as the patient deteriorated rapidly . If the ECG was not available , the debate would have been the cause of mortality in a young post natal mother . Rafik Karaman has discussed the various causes of tropical acute febrile illness & some of these can cause serious complications , such as ARDS or myocarditis with fatal consequences . The other possibility if ECG was not available , would have been Pulmonary Embolism , as part of a differential diagnosis .
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