Fever

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Fever is a common complaint, which is usually related to an infection of viral, bacterial or parasitic origin. It may be a valuable guide to the diagnosis and severity of infections.

Fever is defined as an axillary temperature above 37.5 °C (read after keeping the thermometer in place for 3 minutes). Fever above 38°C in children and adults often needs urgent attention, especially if the patient is restless or delirious. Not every fever is due to malaria or typhoid. Every fever should be investigated and treated appropriately. A thorough history, physical examination and appropriate investigation would usually reveal the cause of the fever.

In neonates and the elderly, severe infections may not be accompanied by a fever. In infants and young children, fever may be associated with convulsions, collapse or coma. (See table below for possible differential diagnoses and appropriate action)

Causes

  • Viral infection
  • Bacterial infection
  • Fungal infections
  • Parasitic infestations
  • Haematological malignancies e.g. lymphoma, leukaemia
  • Connective tissue disease
  • Medicine-related

Symptoms

  • Chills, rigors
  • Body aches

Signs

  • Temperature > 37.5°C
  • Evidence of dehydration e.g. sunken eyes
  • Evidence of underlying conditions (refer guidelines below)
  • Tachypnoea
  • Tachycardia

Investigations

  • FBC
  • Blood film for malaria parasites
  • Rapid diagnostic test for malaria
  • Cultures of urine, blood, sputum, ear discharge, throat swab, wound swab, cerebrospinal fluid depending on presentation

Treatment

Treatment objectives

  • To reduce body temperature to normal
  • To relieve symptoms
  • To identify and treat the underlying cause of the fever (see guidelines below)

Non-pharmacological treatment

  • Keep the patient well hydrated with fluids e.g. water, fruit juices, light porridge, “rice-water” or coconut milk
  • Maintain nutrition, continue breast-feeding in babies
  • Tepid sponge the child. (Wet a towel with lukewarm water and apply to the body starting from the extremities and gradually work your way upwards to the head. Leave a film of water on the body to dry on the skin. Repeat the process as often as needed)

Pharmacological treatment

Evidence Rating: [A]

  • Paracetamol, oral,
    Adults: 1g 6-8 hourly
    Children: 10-15 mg/kg/dose. May repeat dose 6-8 hourly as necessary
    Or
  • Paracetamol, rectal suppository,
    Adults: 1g 6-8 hourly
    Children: 125-250 mg 6-8 hourly
    Or
  • Ibuprofen, oral,
    Adults: 200-400 mg 6-8 hourly
    Children
    • 7-18 years; 200 mg 6-8 hourly
    • 2-7 years; 100 mg 8 hourly
    • 6 months-2 years; 50 mg 8 hourly
    • 1-6 months; 5 mg/kg 6-8 hourly

Treat the cause of the fever appropriately (See appropriate section)

DO NOT give Aspirin to children under the age of 16 years. Control convulsions with diazepam (See section on ‘Seizure Disorders’ in full STG)

Referral Criteria Fever persisting for more than 10 days in spite of treatment should be considered as pyrexia of unknown origin (PUO) and should be referred for further investigation.

 
Complaints  Diagnosis Action
  (See appropriate section) (See appropriate section)
Rigors, fever (occasionally periodic), sweating, general malaise, joint pains Malaria Take a blood film or perform rapid diagnostic test for malaria parasites and treat appropriately
Rigors, fever, sweating, general malaise, altered sensorium Cerebral Malaria Take a blood film or perform rapid diagnostic test for malaria parasites and treat appropriately
Headache, vomiting, drowsiness, stiff neck, seizures Meningitis Do not delay treatment while awaiting results of lumbar puncture
Cough, brown sputum, rapid  breathing, pain on deep breathing Pneumonia Give appropriate antibiotic
Increased frequency of urination and/or painful micturition, loin pain Urinary tract infection Do urine examination plus culture and sensitivity; Give appropriate antibiotic
Fever, constipation or diarrhoea (may be with blood), headache, abdominal pain, general malaise Typhoid Start appropriate treatment
Warm, swollen, painful, reddish looking limb Cellulitis, Erysipelas or impetigo Give appropriate antibiotic
Fever in a child with cough, sore throat and red ear drums Otitis media Give appropriate antibiotic
Fever during pregnancy with loin pain Pyelonephritis Take sample for urine culture and sensitivity and give appropriate antibiotic
Pain in a bone (usually a limb bone), painful to touch Osteomyelitis X-ray the affected part; treat as for osteomyelitis
Jaundice preceded by feeling unwell, anorexia, low grade fever Viral hepatitis Do liver function tests, Hepatitis B surface antigen; treat conservatively, bed rest
Headache, body ache, runny nose, sneezing Common cold or influenza Give paracetamol if required
Long standing fever, weight loss, chronic diarrhoea, lymphadenopathy Acquired immunodeficiency syndrome Manage as appropriate
Sore throat or pain on swallowing Tonsillitis and pharyngitis Manage as appropriate
Abrupt fever, chills and malaise; weakness, muscle pain, rash, diarrhoea, bleeding Viral haemorrhagic fever e.g. Ebola virus disease Manage according to standard protocol