Very useful points about fever

1. Recurrent rigors are most likely to be caused by bacterial infections.

2. Severe muscle pain may be a symptom of sepsis, even in the absence of fever.

3. Fever in the elderly is rarely caused by a viral illness.

4. Sepsis in the elderly may not present with a fever. “The older the colder!”

5. Hypothermia in a septic patient is a medical emergency that carries a worse

prognosis than a high fever.

6. “When a patient has a fever post operatively, it is usually related to the surgical procedure”. (Petersdorf’s Law)

7. Jaundice in a febrile patient is rarely caused by viral hepatitis.

8. Early meningococcaemic rash may resemble a non-specific viral rash.

9. Generalized rashes that also involve the palms and soles are likely to be caused by drugs, viral infections, rickettsial infections or syphilis.

10. Malaria (falciparum in particular), must be excluded on presentation of a

febrile traveller returning from a malaria endemic area.

11. An elderly patient from a tuberculosis endemic setting with fever and multisystem disease has disseminated tuberculosis until proven otherwise.

12. Staphylococcus aureus in the urine is a sign of staphylococcal bacteraemia until proven otherwise.

13. Never underestimate staphylococcal bacteraemia: look into the heart and at the bone.

14. Staphylococcus aureus meningitis without preceding central nervous system instrumentation indicates the presence of endocarditis until proven otherwise

15. A moveable joint does not exclude septic arthritis.

16. More than one infection may be present in a patient, particularly in the elderly, the immunosuppressed, and the returned traveller. (Occam’s razor is an instrument with which many clinicians eventually slit their own throats!)

17. Think of acute bacterial epiglottitis in an adult patient with a normal looking throat who is complaining of acute sore throat, pain on swallowing and/ or hoarse voice.

18. Infection in the diabetic patient will flourish until the diabetes is controlled.

19. Think of vertebral osteomyelitis and epidural abscess in a patient with fever

and back pain.

20. Consider common bacterial infections, and not just opportunistic infections in febrile patients with HIV.

21. Specific IgM antibodies are a useful but unreliable marker of primary infections in pregnancy, thus clinical decisions should not be based solely on a positive IgM.

22. Not everyone with aseptic meningitis has viral meningitis; unless confirmed by PCR, viral meningitis is a diagnosis made after the patient has recovered.

23. Avoid the term “atypical pneumonia” in children, adults over the age of 50 years, the immunocompromised, the severely ill, or patients with diffuse bilateral interstitial pulmonary infiltrates.

24. Remember that Listeria monocytogenes meningoencephalitis can masquerade clinically as herpes simplex encephalitis.

25. Bacterial aortitis needs to be excluded in a patient who develops abdominal pain or back pain within weeks of an episode of diarrhoea.

26. In patients with unexplained neurological features, think of the five great infective mimics: HIV, syphilis, tuberculosis, Lyme disease (with epidemiological history), Whipple’s disease.

27. When you suspect bacteraemia, do not wait for the patient’s temperature to go up before doing blood cultures.

28. In community-acquired infection, resistant organisms do not cause more severe illness than their sensitive counterparts. The only reason for using broader than usual therapy is when you (and the patient) cannot afford to be wrong.

29.Always investigate source control before looking towards drug failure.

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