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Week 120 > Fever > Flashcards

Fever Flashcards

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1
Q

What is fever?

A

Elevated core temperature often as part of a defensive mechanism against invasion of microorganisms recognised as pathogenic by the host

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2
Q

What % of paediatric admissions are due to fever?

A

30%

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3
Q

How does termperature regulation work?

A

Heat sensitive receptors in skin and within hypothalamus are sensitive to changes inblood temperature

Signal frequency is increased if temperature increases above 37.1, increasing the signal which inhibits sympathetic stimulation causing sweating and vasodilation

Signal frequency is decreased if temperature drops below 37.1, preventing inhibition of the SNS and causing vasoconstriction, piloerection, shivering, behavioural changes.

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4
Q

Effects of a drop in blood temperature?

A

Decreased inhibition of the SNS:

  • piloerection
  • shivering
  • vasoconstriction
  • behavioural changes
  • NA release
  • TSH release
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5
Q

Pathophysiology of fever?

A

Exogenous pyrogen e.g. LPS

Stimulates release of endogenous pyrogens by MACROPHAGES and neutrophils, such as IL-1, IL-6, IFN-Y, TNF-alpha

As well as initiating inflammation, these cross the BBB and cause upregulation of COX2 enzyme which increases PGE2 via the arachidonic acid pathway.

PGE2 acts at the PGER3 in the preoptic area of the hypothalamus raising cAMP and causing sympathetic output.

PGE2 raises the set temperature until PGE2 is no longer present

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6
Q

How do NSAIDs work and how do they cause stomach ulcers?

A

Inhibit COX2 to reduce the inflammatory effects of PGE2 and to reduce the raising of the hypothalamic set temperature

Also inhibit COX1 which reduces basal PGE2 production which usually has a protective effect

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7
Q

What is the primary cytokine to best correlate with fever?

A

IL-6

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8
Q

What cytokine is an endogenous antipyretic factor?

A

IL-10

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9
Q

Which other endogenous antipyretic facotrs are there?

A

glucocorticoids e.g. cortisol

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10
Q

What resets the thermostat?

A

PGE2 (and cAMP)

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11
Q

How does malignancy cause fever?

A

Direct production of TNF-a, IL-1 and IL-6 by the tumour

or

Macrophage production of TNF-a, IL-1, IL-6, in response to the tumour

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12
Q

Describe the APR

A

Endogenous pyrogens are produced by macrophages and neutrophils in response to injury or infection (IL-1, IL-6, IFN-y, TNF-a)

These cause the liver to produce CRP, SAA, fibrinogen, complement factor (up to several hundred times their basal concentration)

CRP = opsonin activation
SAA = attracts leukocytes to site
fibrinogen = coagulation factor aids in trapping microbes in blood clots
CF = complement activation
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13
Q

What is raised ESR and what causes it?

A

Erythrocyte sedimentation rate; RBCs fall faster

Due to rouleaux formation

Due to fibrinogen (acute phase response)

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14
Q

What stimulates leukocytosis, and what is it?

A

IL-1 and TNF-a

First mechanism = release of cells from post-mitotic reserve pool in bone marrow = more immature cells (left shift)

Second = CSFs stimulate proliferation of precursor cells in bone marrow e.g. macrophage CSF

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15
Q

Why is fever potentially good?

A

IL-1 is critical for initation of innate immune system

Its evolutionarily conserved

It interfers with growth and virlence of pathogens (which grow best at normal body temp)

Small temperature elevations enhance immune function

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16
Q

What are the four types of fever and their example causes?

A

Remittent - Endocarditis, typhoid
Intermittent - malaria
Sustained - Pneumonia, UTI
Relapsing - tick-borne

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17
Q

What causes a fever which is always elevated but keeps spiking, and what type of fever is it?

A

Remittent fever

Endocarditis, typhoid fever

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18
Q

What causes a normal temp to keep spiking intermittently, within hours?

A

Intermittent fever

Malaria

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19
Q

Fever is always high, what’s it called and examples?

A

Sustained

UTI, pneumonia

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20
Q

Fever is low for a few days then spikes a while then low a few days

A

Relapsing

Tick borne disease

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21
Q

What are the four phases of fever?

A

Prodromal: “flu-like symptoms”, non specific

Chill: feeling cold, shivering etc as temperature is rising toward new set point e.g. vasoconstriction, piloerection, shivering, goose bumps, behavioural changes, feeling warm and shivering then stops.

Flush: cutaneous vasodilation causes red, warm and dry skin

Defervescence: sweating

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22
Q

What are rigors, and common cause?

A

Shivering to try to increase temperature

UTI

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23
Q

Night sweats common causee

A

Lymphoma, TB

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24
Q

Headache is due to? Red flag for? Also though?

A

Vasodilatation of cerebral vessels

Red flag for meningitis

Also common in non-specific fevers though

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25
Delirium
Temporary mental confusion
26
Who is delirium common in?
Children and elderly
27
Myalgia and athralgia
Viruses ++ e.g. flu Bacteraemia ++ e.g. meningococcal disease
28
Management of sepsis?
``` ABCDE Oxygen IV fluids ABx Blood cultures Serial lactates Hourly fluid output ```
29
Four conditions not to give antibiotics in?
Acute otitis media Acute conjunctivitis Acute URTI Acute sinusitis
30
When shoudl you give ABx for sinusitis?
Double acute sinusitis - typical bacterial
31
What is hyperthermia?
Raised core temperature without a change in set hypothalamic point Raised core temperature without sweating
32
What does hyperthermia look like?
Tachycardia / tachypnoea NO SWEATING Hypothermia Collapse/LOC/seizures
33
Which drugs have no effect in hyperthermia?
Antipyretics
34
What is malignant hyperthermia?
Autosomal dominant condition Triggered by exposure to halogenated anaestetic agents in GA or succinylcholine Drastic increase in oxidative metabolism of skeletal muscle causing muscle contraction and overwhelms bodys ability to produce O2 and remove CO2 - rapid t increase to 43... fast death
35
What is drug fever.?
Fever coinciding with drug administration and ending when drug is stopped
36
How do antihistamines and TCAs cause drug fever?
Impaired heat dissipation
37
How does cimetidine cause drug fever?
Direct blocking of hypothalamic receptors
38
How do anticancer drugs cause drug fever?
Direct pyrogens
39
What is neuroleptic malignant syndrome and what might cause it?
Rare but life threatening reaction to DA antagonist neuroleptic medications such as haloperidol and chlorpromazine.
40
How does NMS present?
Central dopamine blockae in the hypothalamus leads to increased mucular rigitiy, EPS and hyperthermia Onset 4-14d after start of therapy
41
How to treat NMS?
Discontinue the drugs May need to treat complication e.g. ITU
42
How does thyrotoxicosis cause hyperthermia?
Raised T3/T4 = raised BMR
43
Acute exacerbation of chronic bronchitis?
Amoxicillin
44
Low severity CAP
Amoxicillin PO
45
Moderate severity CAP
Amoxicillin PO and clarithroymycin PO Doxycyline if allergy to one
46
High severity CAP
Benpen + clarithromycin IV or co-amoxiclav + clarithromycin IV
47
HAP
Co-amoxiclav (broadspectrum) Tazocin (anti-pseudomonal) Ceftazidime (broad-spectrum ceph)
48
Gastroenteritis
Usually nothing as viral or self-limiting
49
Campylobacter
Clarithromycin if severe or immunocomprimised
50
Salmonella
Ciprofloxacin if severe
51
Shigellosis
Ciprofloxacin if severe
52
C diff
Oral metronidazole / vancomycin
53
Typhoid
cefotaxime
54
Pre-hospital meningitis tx
Benzylpenicillin as soon as possible Cefotaxime if pen allergic
55
Hospital meningitis tx
After initial dose of benpen/cefotaxime Cefotaxime up to 50y Add amoxicillin if >50y
56
Lower UTI
Trimethoprim or nitrofurantoin (quinolone)
57
Lower UTI in pregnancy
Cefalexin
58
Sepsis
Tazocin or timentin (broad-spectrum anti-pseudomonal) or Cefuroxime (broad-spectrum cephalosporin) Add vanc if suspected MRSA Add metronidazole if suspected GIT origin (anaerobe)
59
Purulent conjunctivitis
Chloramphenicol
60
Periodontitis
Metronidazole
61
Otitis externa
Flucloxacillin Clari if pen allergic
62
Otitis media
Nothing as usually caused by viruses If systemically unwell or high risk of complications e.g. immunosuppression, amoxicilin or clarithro
63
Throat infections
Pen V | but URTI usually self limiting
64
Cellulitis
Flucloxacillin
65
Biliary / gut
Cefuroxime + metronidazole
66
Malaria
Quinine + doxycycline
67
TB
Rifampicin Isoniazid Pyrazinamide Ethambutol
68
What is lysozyme?
Attaches onto PG layer of gram-positives
69
What is the definition of PUO?
> 38.3 for 3 weeks 3 days inpatient 3 outpatient consultations
70
Signs & symptoms of meningitis?
``` Unwell/drowsy STIFF NECK Purpuric haemorrhagic non blanching rash Bulging fontanelle Decreased consciousness Fever ```
71
Investigations of meningitis?
Bloods BLood cultures LP CSF culture
72
Treatment of meningitis in neonate?
Gentamicin
73
Viral infections signs and symptoms?
Prodromal symptoms | Cough
74
Signs and symptoms of roseola infantum?
Sixth disease High fever > generalised macular rash starting on trunk then face > FEVER SUBSIDES VERY QUICKLY ONCE RASH APPEARS and child becomes better
75
Complications of sixth disease?
Febrile convulsions, aseptic meningitis / encephalitis
76
Most common time for sixth disease?
9-12m
77
Pathophysiology of 6th disease?
HHV-6 infects CD4+ lymphocytes - remains latent Can affect many organs and CNS early
78
Treatment of 6th disease?
SUpportive Antivirals (ganciclovir) in immunocomprimised
79
Most common cause of seizures in childhood?
Febrile convulsions
80
What characterises simple febrile convulsons?
Up to 15m Tonic clonic Once in 24h Full recovery in 1h
81
What characterises complex febrile convulsons?
``` Usually tonic clonic Above 15m Partial seizure More thn 1 in 24h No full recovery in 1h ```
82
Risk of recurrence of febrile convulsions?
30-50%
83
Initial investigations for febrile convulsions?
Rule out meningitis / encepahlitis with LUMBAR PUNCTURE Glucose (hypoglycaemia = seizures) Ca/Mg (low = seizures) If all tests negative... maybe febrile convulsions
84
Symptomatic treatment of febrile convulsions
Rectal diazepam if above 5 minutes Antipyretics
85
S&S Elderly patient with UTI
``` Dysuria Haematuria Lower abdo pain Fever CLEAR CHEST ```
86
Ix Elderly patient with UTI
Bloods Urinalysis MCU (MC&S)
87
Infective endocarditis S&S
``` Heart murmur Night sweats Weight loss Myalgia Arthralgia Fever ```
88
Infective endocarditis investigations
Bloods Cultures CXR Echo
89
Sepsis
``` Rigors Hypotension Tachycardia Headache Fever Oliguria ```
90
Sepsis ix
``` Bloods Cultures CXR Urinalysis Sputum ```
91
Pneumonia ix
CXR Bloods Sputum Urine
92
Meningitis signs
``` Headache Confusion NECK STIFFNESS Non blanching rash Fever ```
93
Meningitis ix
Bloods | LUMBAR PUNCTURE + CSF culture
94
Most common cause of UTI?
E coli and other "coliforms" Proteus mirabilis Klebsiella
95
Risk factors for UTI?
Elderly because LOW FLOW AND INEFFECTIVE EMPTYING
96
What is a simple UTI versus complicatied?
``` Simple = just in bladder COmplicated = tracking up ```
97
Treatment of simple UTI?
3 days trimethoprim
98
Diagnosis of UTI?
MSU sample
99
Waht do you do with an existing catheter in a UTI?
REPLACE IT
100
Wide-ranging non-focussed line of quiestioning - searhing for a positive response. Gets a comprehensive but time consuming history
Inductive
101
Initial differential diagnosis formed from initial info and then specific lines of focussed questioning
Hypothetico-deductive
102
Experienced clinical recognises key symptoms and links them quickly
Pattern recognition process
103
Pattern recognition process strength and weakness?
Fast decision making but mental short cuts may lead to errors
104
Adverse effects of macrolides?
N&V Diarrhoea Prolonged QT Increased risk of statin-induced myopathy: withhold statin during treatment
105
Which class would you withhold statins during treatment for?
Macrolides
106
Which macrolide is particularly bad for causing diarrhoea?
Erythromycin (pro-motility)
107
Aminoglycosides A/Es?
Lots - dangerous (narrow window) - Nephrotoxicity > renal failure - Ototoxicity (irreversible damage to vestibular nerve) - NMJ breakdown - Headache, fever, dizziness
108
What drugs would you monitor serum levels of and why?
Aminoglycosides - narrow therapeutic window (monitor for accumulation)
109
Quinolones A/Es
Reduce seizure threshold | Tendon damage
110
Tetracyclines A/Es
Irritation of gastric mucosa - take with food but not milk (chelation) Phototoxicity reactions (like severe sunburn) DISCOLOURATION OF TEETH AND TEMPORARY GROWTH STUNTING DUE TO INCORPORATION INTO BONES - contraindicated in children and pregnancy/breast feeding
111
Trimethoprim A/Es
Rare Rarely causes depression of haematopoesis
112
Sulfamethoxazole AEs
Rare but serious side effects e.g. bone marrow depression Used rarely e.g. PJP pneumonia and other immunocompromised patients, and toxoplasmosis
113
Toxoplasmosis
Sulfamethoxazole
114
Metronidazole A/Es
``` Metallic taste Rashes Disulfram reaction with alcohol Dark urine Hepatitis/pancreatitis ```
115
Glycopeptides A/Es
``` Red man syndrome if infused too rapidly Phlebitis if not diluted sufficiently Nephrotoxicity (elderly++) Ototoxicity (elderly ++) Neutropenia after 1w or 25g ```
116
Monitor serum levels of..
Aminoglycosides Vancomycin (after 3-4 doses; less in renal impairment)
117
Rifampicin A/Es
Stain body secretions orange
118
Monitor what during rifampicin tx?
LFTs
119
Oxazolidinones A/Es
HAEMATOPOETIC DISORDERS e.g. thrombocytopenia, anaemia, leukopaenia, pancytopenia OPTIC NEUROPATHY (28d +++++)
120
Oxazolidonones monitoring?
FBC weekly
121
Oxazolidonones interactions?
MAOI so no tyramine rich foods, SSRIs, TCAs
122
Max course length linezolid?
28d
123
Penicillins AEs?
Few Hypersensitivity 10%/true = 0.2% Cholestatic jaundice
124
Which causes cholestatic jaundice?
Flucloxacillin
125
One of least toxic penicillins?
Benpen (pen G)
126
Cephalosporins A/Es
Hypersensitibity (about 10% of those pen allergic)
127
1st gen ceph use?
Skin / soft tissue (gram +ve)
128
2nd gen ceph use?
G-ve
129
3rd gen
G-ve ... bad for g +ve Good CSF for ceftriaxone so meninitis Ceftazidime for pseudomonas
130
Which bacteria are intracellular?
Legionella Listeria Chlamydia Mycobacterium Lets Live inside Cosy Membranes
131
Which antibiotics pass into mammalian cells?
Glycopeptides Macrolides Quinolones Tetracyclines Quick, There! Get Me in!
132
Which drugs are cautioned in liver diseae?
Rifampicin (liver elimination) Flucoxacillin (toxicity) Co-amoxiclav (toxicity)
133
Which antibiotics impair CYP enzymes?
Macrolides
134
Which drug wouldn't you use for UTI in renal impairment?
Nitrofurantoin Excretion insufficient to raise level in urinary tract enough
135
Mycoplasma / legionella treatment?
Macrolides Tetracyclines Quinolones (Quick, There, Get Me in!)
136
Which antibiotic would you give family planning advice with, to a fertile female?
Rifampicin | CYP enzyme induction = OCP level not high enough
137
Which antibiotic is highest linkage to peudomembranous colitis?
Clindamycin
138
Which type of antibiotics are most likely to cause c diff?
Broad spectrum | e.g. quinolones, 2nd/3rd gen cephs
139
If a patient is on methotrexate with a UTI, which drug would be given / not given?
Not trimethoprim as MTX toxicity likely as both reduce folate metabolism: liver toxicity, bone marrow suppression, neutropenia, ifnections NITROFURANTOIN?
140
Give these on an empty stomach
Erythromycin / azithromycin Penicillins Note clarithromycin should be with food
141
Which macrolide is OD?
Azithromycin
142
Which macrolide causes particularly bad N&V/diarrhoea
Erythromycin - increased gastric motility (used in gastroparesis)
143
What is the MOA of aminoglycosides?
Enter bacterial cell via O2-dependent transport system Then bind to 30s...
144
Which bacteria is gentamicin NOT active against?
Anaerobes - no o2-carrier system! - hence no use for abscesses, CSF
145
Which is the only currently available oral anti-pseudomonals?
Quinolones - ciprofloxacin VERY GOOD BIOAVAILABILITY! Good for serious infections with oral dosing.
146
Which drug class shouldn't be given with Ca/Al/Mg?
Quinolones
147
CYP inhibitor
SICKFACES.COM Sodium Valproate Isoniazid Cimetidine Ketoconazole & fluconazole ``` Fluoxetine Alcohol - acute consumption & cigarettes Cardiac failure and liver failure Erythromycin & clarithromycin Sulphonamides . Ciprofloxacin Omeprazole Metronidazole ```
148
Acne treatment
Tetracyclines
149
PJP w/ AIDS Toxoplasmosis Immunocompromised patients
Cotrimoxazole -Rare but serious side effects so rarely used
150
Aspiration pneumonia AB
Metronidazole
151
Caution in 1st trimester++ of pregnancy due to mutagenic activity
Metronidazole
152
Glycopeptide used once daily
Teicoplanin due to long half life - 50h
153
Glycopeptide given intraventricularly
Vanc - directly into CSF
154
Elimination of nasal carriage of neisseria meningiditis
Rifampicin
155
Not licensed for under18s
Linezolid
156
Which unusual bacteria aren't sensitive to penicillins, and why?
Mycoplasma - no cell wall
157
Which drugs are given with aminoglycosides?
Penicillins - synergism
158
Cephalosporins names and generations
1st gen... A - CephALOthin - CefAZOlin - CefADROxil 2nd gen... F - CeFURoxime - CeFOXitin - CeFAClor * ``` 3rd gen... T - CefoTAXIme - CefTIZOXIme - CefTAZIDIme Note also the "me"'s - CefTRIAXONE ``` 4th gen... EPIc QUEEN of PI&ROME - CefEPIme - CefQUINOme - CefPIROME
159
Which drugs don't cephs have action against?
LAME Listeria Atypicals (mycoplasma/chalmydia) MRSA (except 5th) Enterococci

Week 120 (3 decks)

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