Fever PDF

261 Fever Classification of infections depend on the system involved: Classification of infections  RS depend on type...

261 Fever Classification of infections depend on the system involved: Classification of infections  RS depend on type of  GIT microbes:  GUT  Viral  CNS  Bacterial  MSS  Parasitic  Fungal Causes of fever in children:  Autoimmune disease  Malignant disease  Infectious disease Advantages of fever:  Protective role in the immune system  It inhibits growth& replication of microbes  It aids in body’s acute phase reaction  It enhances functions of WBCs:  lymphocytes  production of interferon  bactericidal activity of neutrophils  It enhances monocyte maturation into macrophage  Promotion of lymphocyte production of antibodies  Decreased availability of free iron for bacterial replication Normal temperature: 36.5-37.2 C Sites of temp. measurement:  Oral  Rectal  Axillary  Tympanic  262 Fever classification Temperature classification Grade C Grade C Normal 36.5-37.2 Hypothermia < 35 Low grade 37.3-37.8 Hyperthermia > 37.5 Moderate 37.9-39.4 Hyperpyrexia > 40.5 High grade 39.5- 40.5 Hyperpyrexia > 40.5 Important definitions: Bacteremia: +ve blood culture Mechanism of fever Sepsis: systemic response Septicemia: CNS, CVS& DIC Fever without a focus: Exogenous Child < 3 years old and Hx & Ex fail to establish a cause pyrogens Fever of unknown origin: Fever>14 days without etiology despite Hx, Ex, Inv Endogenous Bacterial infections: pyrogens  Gram +ve  Gram –ve  Anaerobic Prostaglandin E 2  Chlamydia  Mycoplasma  Mycobacterial Organism causes fever in infants < 3 months old: Hypothalamus  UTI: E. coli  Pneumonia: GBS, S. pneumonia, S. aureus  Meningitis: S. pneumoniae, H.infleunzae, GBS  Septic arthritis: S. aureus, GBS Fever  Bactermeia: GBS, E.coli, L. monocytogens Evaluation of the cause of fever causes: Upper respiratory tract: Hx: Rhinorrhea, sore throat, cough, drooling, stridor, trismus, sinus pain, tooth pain, hoarse voice, ear pain. Ex: Nasal congestion, pharyngeal erythema, enlarged tonsils with exudate, swollen red epiglottis, regional lymphadenopathy, red tympanic membrane or pus. Lower respiratory tract: Hx: Cough, chest pain, dyspnea, sputum production, cyanosis. Ex: Tachypnea, crackles, wheezing, localized diminished breath sounds, intercostal retractions. Cardiovascular: Hx: Dyspnea, palpitations, fatigue, exercise intolerance, chest pain. Ex: Tachycardia, hypotension, cardiomegaly, hepatomegaly, splenomegaly, crackles, petechiae, Osler nodes, Janeway lesions, Roth spots, new or change in murmur, distended neck veins, pericardial friction rub, muffled heart sounds  263 Gastrointestinal: Hx: Nausea, vomiting, diarrhea, abdominal pain, anorexia. Ex: Hypoactive or hyperactive bowel sounds, abdominal tenderness (generalized or focal), hematochezia. Liver: Hx: Anorexia, vomiting, dark urine, light stools. Ex: Jaundice, hepatomegaly, hepatic tenderness, bleeding diatheses, coma. Genitourinary: Hx: Dysuria, frequency, urgency, flank or suprapubic pain, vaginal discharge. Ex: Costovertebral angle or suprapubic tenderness, cervical motion and adnexal tenderness. Central nervous system: Hx: Lethargy, irritability, headache, neck stiffness, seizures. Ex: Nuchal rigidity, Kernig sign, Brudzinski sign, bulging fontanel, altered mental status, focal neurologic deficits, coma. Musculoskeletal: Hx: Limp, bone pain, limited function (pseudoparalysis). Ex: Local swelling, erythema, warmth, limited range of motion, point bone tenderness, joint line tenderness. Hemoatological: Hx: Fever, pallor& bleeding tendency Ex: Temp., pallor, petechial, ecchymosis& hepatosplenomegaly. N.B. Empirical antibiotics often are begun before a definitive diagnosis is established, which complicates the ability to rely on cultures for microbiologic diagnosis. Bacterial infection patients’ are usually toxic has no rash, no petechial, no LNE, High WBCs, PMN, CRP, Blood cultures are sensitive and specific for bacteremia. CXR, bone& joint X-ray or Abd. U/S Brain C-T scan or MRI to diagnose or follow the severity. Treatment:  According to site& severity  According to patient G.C.  According to AB guidelines  Susceptible microorganism  264 Bacterial infection  History& examination are the cornerstone of diagnosis.  Investigations often are confirmative or for follow up.  Empirical antibiotics often are begun before the definitive diagnosis is established, that complicates the ability to rely on cultures for microbiologic diagnosis.  Bacterial infection patients' are usually toxic has no rash, no petechial, no LNE,  Investigations usually show high WBCs, PMN& CRP.  Blood cultures are sensitive and specific for bacteremia.  Biochemistry to look for organ involvement by infection.  Serology to find the possible cause if possible.  CXR, bone& joint X-ray or Abd. U/S  Brain C-T scan or MRI to diagnose or follow the severity.  Treatment:  According to patient condition.  According to site& severity.  According to AB guidelines.  Susceptible mico-organism.  Complications of bacterial infections:  Life loss  Organ loss  Septicemia  Septic shock  Disseminated intravascular coagulopathy Common bacterial infections in children:  TB  Boils  Tetanus  Diphtheria  Osteomyelitis  Septic arthritis  Bacterial meningitis  Bronchopneumonia N.B. T.B., diphtheria, bronchopneumonia& bacterial meningitis, are mentioned before.  265 Boils: It is painful infection of hair follicle surrounding skin. It is caused by Staphylococcus aureus. Types of boils:  Carbuncle: is a group of boils together.  Cystic acne: infection of acne vulgaris.  Armpit& groin: is pus filled lump in axilla.  Pilonidal abscess: infection of pilonidal sinus.  Stye in the eye: follicle of an eyelash Treatment: Home care, warm compresses, open& drain. Antibiotic ointment +/- oral antibiotic if recurrent. Tetanus: rigid Lockjaw caused by Clostridium tetani. It enters by a break in the skin. Muscle spasm starts in the jaw then spread to whole body. It is associated with headache, fever& seizures. Increased by external stimuli lie light& sound. It lasts 3-4 weeks, but may lasts for months. It is usually fatal. Prevention: Vaccination by tetanus toxoid Treatment: Tetanus immunoglobulin, baclofen, diazepam+/- SIMV Osteomyelitis: Infection of the bone& Caused mainly by Staphylococcus aureus. It can affect any bone but mainly long bones. The patient has fever, bone pain, tenderness& limitation of movement. Risk factors: Diabetes, SCA, splenectomy or trauma. Treatment: IV antibiotics for weeks or even months. Surgery in complicated cases as debridement or amputation. Septic arthritis is similar to osteomyelitis.  266 Viral infections Viruses that can cause GLNE: EBV, HIV, HBV, HCV, CMV, Varicella, Robeola, Rubella , Adenovirus Viruses that can cause encephalitis: Focal or disseminated Herpes simplex virus, Varicella-zoster virus, Influenza virus, Adenovirus EBV, CMV, MMR, Rabies Viruses that can cause rhinosinusitis: Rhinoviruses and, less commonly, coronaviruses, respiratory syncytial virus. Less commonly, influenza, parainfluenza, and adenoviruses. Viruses that cause croup: Parainfluenza virus& respiratory syncytial virus Viruses that cause Pertusis syndrome: Parapertussis& adenovirus Viruses that cause bronchiolitis: Respiratory syncytial virus followed in frequency by human metapneumovirus, parainfluenza viruses, influenza viruses, adenoviruses, rhinoviruses. Viruses that cause Pneumonia: RSV, parainfluenza viruses, influenza viruses, adenoviruses Viruses cause severe acute respiratory syndrome: (SARS) is due to SARS-associated coronavirus (SARS-CoV). Avian influenza, also known as bird flu. Viruses cause acute gastroenteritis: Rotaviruses, caliciviruses, noroviruses, astroviruses, and enteric adenoviruses. Viruses that cause Hepatitis: Hepatitis A virus (HAV), Hepatitis B virus (HBV) , Hepatitis C virus (HCV) , Hepatitis D virus (HDV) Hepatitis E virus (HEV) & Hepatitis G virus (HGV) and others. Viruses cause immune deficiency: HIV (human immunodeficiency virus, Human T-lymphocyte virus. Viruses that cause parotitis: Mumps  267 Fever& Rash Fever with rash: Rashes are a common manifestation of many infections. The characteristic distribution and appearance provide important clues to the clinical diagnosis without investigations. Types of Rash:  Macular rash: Change color of skin  Pupuric rash: RBCs accumulation  Urticarial rash: Large area of wheals  Maculopapular rash: Discolored elevation of skin  Vesiculobullous rash: Bulla filled with fluid Viral causes of fever with macular rash:  Ebola  Rubella  Measles  Echovirus  Adenovirus  Hepatitis B Virus  Epstein Barr Virus  Roseola infantum  Erythema infectiosum  Human Immunodeficiency Virus Bacterial causes of fever with macular rash:  Typhus  Erysipelas  Scarlet fever  Drug reaction  Salmonella typhi  Rheumatoid arthritis  Meningococcal infection  Mycoplasma pneumonia  Rocky Mountain spotted fever  268 Macular rash: Measles (Rubeola)  Transmitted by droplet  Infective 5 days before& after rash  High grade fever& ill appearance  Then 3 C: cough, coryza, conjunctivitis  Koplik spot: pathognomonic enanthema  It is white dots opposite lower molar teeth  Followed by G. macular rash spread over 3 days  Disappear in 3 days with desquamation which still for 3 months Complications:  Otitis media  Keratitis& corneal ulcer  Laryngeotracheobronchitis  Severe &deep mouth ulcers  2ry bacterial bronchopneumonia  Diarrhea& secondary bacterial dysentery  Secondary malnutrition due to chronic diarrhea  CNS complications: Viral encephalitis, aseptic meningitis, encephalomyelitis, GBS, transverse myelitis, subacute sclerosing panencephalitis SSPE 5 years later  Rare: myocarditis, disseminated intravascular coagulopathy& ITP  Destroy humeral& cellular immunity& past immunity immune amnesia Prevention:  Vaccine at 9 months  Booster at 18 months  Booster at 36 months  Isolation from contacts Management:  No specific  Supportive  Ribavirin PO  Vitamin A capsules  Hydration with oral or IVF  Antipyretic for high grade fever  Eye& mouth care with local antibiotic  Treat secondary bacterial infection in hospital  Ribavirin capsules for all complicated cases in some studies  269 Rubella (German measles): 3 days measles 3 stages, 3 days, 3 parts Transmitted by droplet Infective 7 days before& after rash Clinical picture:  Has 3 stages:  Fever, coryza, LNE  Fever& rash which ends in 3 days  Disappear without any desquamation Complications:  Congenital rubella syndrome      Rare: encephalitis, arthritis, ITP Management:  Supportive, no specific ttt Prevention:  MMR vaccine Erythema infectiosum: Human parvovirus 19 Transmitted by droplet Incubation 5-15 days in children Clinical picture:  Mild fever& malaise  Affects the age: 5-7years old  Livid erythema of face (slapped cheeks)  Followed by rash appears in extensor of limbs& trunk  Fad with lacy or reticular appearance: raised& central clearing Complications:  Arthritis/ Arthralgia  Rash recurrence by sun exposure, exercise, fever& stress Management:  Symptomatic, no specific ttt  270 Roseola infantum: Human herpes type 6 Transmitted by droplet Incubation 5-15 days in infants Clinical picture:  It affects 6 months- 3 years  High fever 40 C +/- febrile seizures  Followed by rash appears at 3rd day  When rash starts, the fever disappears  Small maculopapular all over the body  Fade in 2 days without desquamation Management:  Gancyclovir in complicated cases Infectious mononucleosis: Epestin barr virus Transmitted by droplet Incubation 1-2 months in children Clinical picture:  Mild fever, fatigue& sore throat  Tonsillits with white spots *  Lymphadenopathy 90% *  Splenomegaly 50% *  Hepatomegaly 10%  Rash 15%* Complications:  Upper airway obstruction  Rupture of spleen  Myocarditis  Blood:  Burkitt’s lymphoma  Aplastic anemia  AIHA  ITP Management:  Supportive, no specific  Steroids for:  UAO, AIHA& seizures.  271 Scarlet fever: Erythematous rash. It ends with desquamation. It follows Group A- B-hemolytic. Characterized by high-grade fever. The patient appears ill, high fever, sore throat, headache, chills& rash. This rash begins in trunk followed by spread to extremities There is antecubital & axillary skin folds (Pastia’s lines). It is like sandpaper with circumoral pallor. The tongue is white strawberry. Then it gets red strawberry. Clinical picture: 6 S  Strept.  Sore throat  Swollen tonsils  Sandpaper rash  Strawberry tongue  Sudamina vesicles in hands& feet Management:  Antipyretic  Penicillin orally for 10 days Prevention: Treatment of tonsillitis Toxic shock syndrome: Life threatening complication of toxins from:  Staph. aureus  Group B strept  Chemotherapy Clinical picture:  Fever  Skin peeling  Hypotension, vomiting or diarrhea& sudden high fever (Toxic syndrome) Management:  Supportive: treat the shock  Specific: antibiotics(vancomycin), incision & drain abscess +/- immunoglobulins IV  272 Urticarial rash: Caused by leakage of serum from blood vessels to the skin. Causes:  Anaphylaxis  Leukemia  EBV  HBV  HIV  GAS Clinical picture: According to the cause as anaphlaxis due to ingested or injected or inhaled allergens with progression to anaphylactic shock. Anaphylactic shock: life threatening allergic reaction that develop very rapidly. Skin rash, swellen face& lips, hypotension, narrow airways& SOB. Stages of anaphlactic shock: sensitization& exposure, early allergic reaction, systemic reaction& anaphylactic shock& organ failure Management:  Epinephrine IM, hydrocortisone IV or IM followed by oral H1 blockers e.g. chlorphinarmine Purpuric rash: It is leakage of RBCs from blood vessels to the skin. Petechial =1-3 mm & Purpura = 4-10 mm Causes:  Sepsis  Vasculitis  Bleeding  Severe sepsis as: meningococcemia& DIC in critical cases  Vasculitis as: HSP : arthritis, rash on extensor surface of limbs +/- abdominal pain or hematuria or hematochesia  Bleeding as: causes of low platelets in ALL, ITP& aplastic anemia& dengue fever N.B. DIC= disseminated intravascular coagulopathy HSP= henoch schonleen purpura ALL= aculte lymphoblastic leukemia ITP= immune thrombocytopenia purpura  273 Vesiculobullous rash: It is accumulation of serous fluid in small vacuole (vesicle) or large vacuole (bulla) Causes:  Varicella zoster  Herpes simplex  Coxsacki virus  Staph. Bullous Imptigo  Stevens-Johnson syndrome  Toxic epidermal necrolysis TEN  Staphylococcal scalded skin syndrome SSSS Chicken pox: varicella Caused by human herpes virus 3 Clinical picture:  Droplet transmission  Contact from skin lesions  Infectivity 2 days before rash  It continue till the rash crusted  Fever, anorexia, sore throat& malaise  Different types of rash started& spread 2 after the infection  Rash is very itchy and mainly in the face& trunk +/- oral lesions Complications:  Encephalitis  Myocarditis  Mild hepatitis  Reye’s syndrome  Bronchopneumonia  Heomorrhagic varicella  Mesenteric lymphadenitis  Immune thrombocytopenia  Congenital varicella zoster in neonate  Recurrence in adults as shingles (fire built)  Herpes zoster (shingles) at old age reactivates& cause pain along the dermatome Management:  Supportive& specific in some cases.  Antiprurtic, antipyretic& antibiotic for secondary bacterial infection  Anti varicella zoster immunoglobulin& acyclovir for newborns& immune-compromised.  274 Herpes simplex Gingivostomatitis: Clinical picture:  High fever  Sore throat  Gum edema& pain  Ulcerated mouth lesions Management:  Supportive:  Analgesic antipyretic  Local antiseptic mouth lotion  Specific:  Oral acyclovir Hand-Foot-Mouth Disease: Caused by coxsackievirus A one of enteroviruses. Coxsackievirus B is responsible for carditis& encephalitis Hand, foot and mouth disease in children < 10 years old. Transmitted by droplet, direct touch of blisters& fecal spread Clinical picture:  Fever  Coryza  Sore throat  Followed by blisters in mouth, hands& feet Management:  Supportive, no specific ttt  Acyclovir can be used for its antiviral effect Staphylococcal Bullous Impetigo: Secondary bacterial infection of injured skin tissues Honey color Management:  Oral penicillin or amoxicillin  275 Toxic epidermal necrolysis=TEN: It is due to hypersensitivity to drug. Either penicillin, sulphonamide, antiepileptic It is a fatal illness. Complications:  Fluid& electrolytes disturbances  Secondary bacterial sepsis Staphylococcal scalded skin syndrome=SSSS: Severe systemic reaction to staph infection Clinical picture:  Fever& malaise  Crust around the mouth and fine erythema in face& neck  Followed by blister at any areas touched in the neonates Management:  High dose systemic IV antibiotics Stevens-Johnson syndrome: Clinical picture:  Rash  Mucosal necrosis  Systemic symptoms as:  Ill, fever, cough, vomiting& diarrhea.  It is a fatal disease due to reactions to drugs e.g. antibiotics& antiepileptic drugs. Management:  Supportive& no specific ttt  Steroids Drugs precipitate SJS: SANA  Sulfonamides  Anticonvulsants  NSAIDs  Allopurinol  276 Day of rash appearance Very Sick Patient Must Take Double Tablets Day 1 Varicella Day 2 Scarlet fever Day 3 Pox small Day 4 Measles Day 5 Typhus Day 6 Dengue Day 7 Typhoid Droplet precaution diseases: SPIDERMAN  Sepsis/Scarlet fever/Step. Pharyngitis  Pneumonia/Pertussis/Parvo virus  Influenza  Diphtheria  Epiglottitis  Rubella  Mumps/Meningitis/Meningeal pneumonia/Mycoplasma  Adenovirus Air borne: MTV  Measles  Tuberculosis  Varicella Skin infection: V-CHIPS  Varicella  Cutaneous deiphtheria  Herpes simplex  Impetigo  Pediculosis  Scabies Contact precautions: Mrs Wee  Multidrug resistant organism  Respiratory infections  Skin infections  Wound infections  Enteric (clostridium difficile)  Eye infections (conjunctivitis)  277 Endemic diseases in Yemen  Malaria  Leishmania  Dengue fever  Chikungunea Malaria: Epidemiology: It means bad air. It is the cause of 1000.000 deaths annually. It is wide spread in Taiz, Hajjah, Alhodiadah& Dhamar, Aden, Lahj& Shabwah Causative organism: P. falciparum, P. malariae, P. ovale, P. vivax& P. Knowlesi. Carrier insect: female anopheles mosquito Host: human being Life cycle: Sexual phase (sporogony) in mosquitoes Asexual phase (schizogony) in humans Mosquito Sporozoyte Merozyte Schizont Trophozoite Gametocyte Human Clinical picture: Ranging from asymptomatic infection to fulminant illness& death. Depending on the virulence of the infecting malaria species and the host immune response. Acute:  Fever  Rigor  Anemia  Jaundice  Sweating  Vomiting  Headache  +/- red urine  Others: sore throat, cough, abdominal pain Chronic:  Fever  Anemia +/- jaundice  Hepatosplenomegaly  (Tropical splenomegaly syndrome)  278 Acute Chronic Relapsing Recurrent Complicated Severe or complicated malaria:  Heart failure  Renal failure  Algid malaria Malaria stages in human:  Cerebral malaria From mosquito to human  Pulmonary edema Sporozoyte P.Malriea usually causes nephrotic syndrome Mitosis inside hepatocytes P. viva& P. ovale usually cause relapsing malaria Merozyte P.Falciparum usually causes severe malaria& Merozoite in RBCs  Gametocyte Merozoite in RBCs  Ring form nephritis Ring form in RBCs Trophozoite Classic clinical picture: In RBCs transform to Schizont  Fever paroxysms Hepatocyte release Schizont  Chills& sweating To mosquito Gametocyte  Headache& myalgia  Nausea& vomiting  Pallor& splenomegaly Fever paroxysms occurs during RBCs rupture& schizonts release !!! Every other day P. ovale& vivax Every third day P. malariae Every fourth day P. falciparum Congenital malaria can cause: Abortion, stillbirth, IUGR& premature. P.Falciparum usually causes complicated malaria P.Malriea usually causes nephrotic syndrome P. ovale usually cause relapsing malaria P. vivax usually cause relapsing malaria It is due to inhabiting hepatocytes as hypnozoite stage (hypnozoite reactivation) Recurrent malaria can occur !!! Investigations:  Blood: CBC, ESR, blood film, morphology Thick smear& thin smear LFT, KFT, S. electrolytes Rapid test for malaria  Radiology: CXR, Abdominal U/S  Invasive procedures: Bone marrow aspiration& Splenic aspiration  279 Management: Supportive& treatment of complications: Fever, anemia, hypoglycemia, heart failure, renal failure, cerebral malaria, algid malaria, pulmonary edema or shock. Specific: Antimalarial: Chloroquine is the treatment of choice. Except for chloroquine-resistant P. falciparum areas like in Yemen. Quinine sulfate plus tetracycline for severe or complicated malaria. Severe malaria: Quinine Classic malaria: Chloroquine Resistant malaria: Artesunate & Arthemether in Yemen Relapsing malaria: Primaquine Prophylaxis: Malaria vaccine that is derived from sporozoyte protein with hybrid construct of HBs Ag. Prevention: Stop mosquito life cycle. Prevention of relapses in vivax& ovale: Proguanil or Mefloquin Prophylaxis for travelers: Proguanil or Chloroquine or Deoxycyclin or Mefloquin or Primaquine Transmission from person to person by: Any blood products Contaminated needles Pregnant women to fetus Infected organ transplantation Malaria complications: Falciparum  Fever (blackwater)  ARDS  Low blood sugar  Infections  Pulmonary edema  Anemia  Relapses  Urine output decreased  Metabolic acidosis  280 Aims of malaria treatment Aim Cause Therapy Drug Treat By blood Schizonticidal Chloroquine, S&S parasites drug quinine, pyrimethamine, sulfadoxine Prevent Hypnozoites Schizonticidal Primauine relapses of P.vivax& drug P.ovale Prevent By gametes Gametocidal Primaquine spread drug Pyrimethamine, sulfadoxine Initial parenteral treatment in 1st 48 hrs Artesunate 2.4 mg/kg/dose IV or IM at time 0 then at 12,24 hr Artemether 3.2 mg/kg/dose IM at time 0 then 1.6 mg/kg at 12& 24 hrs Quinine 20mg/kg/dose loading. 12 hrs later 10mg/kg/dose then repeated 8  281 Leishmania: It is called also Kala Azar Which means the black sickness Life cycle: Promostigote in the sand fly (sexual cycle) Amastigote in human (asexual cycle) It inhabitates the monocytes which migrate to the tissues and called macrophages Clinical picture:  Visceral, Cutaneous& Mucocutaneous Cutaneous leishmaniasis:  Ulcer or nodule  Persists for weeks  Resistant to antibiotic Visceral leishmaniasis  Fever  Anorexia  Vomiting  Dark skin  Weight loss  Lymphadenopathy  Hepatosplenomegaly Investigations:  Blood: CBC, ESR, morphology LFT, KFT, S. Electrolytes Formal gel test  282  Radiology: CXR, Abdominal U/S  Invasive procedures: Bone marrow aspiration 70% & splenic aspiration 90% Complications:  Jaundice  Dysentery  Stomatitis  Anemia& heart failure  Leukopenia& secondary infection  Thrombocytopenia& bleeding tendency  Malnutrition due to prolonged anorexia  Pancytopenia due to huge splenomegaly  Pancytopenia due to bone marrow invasion Management: Supportive:  Fever: AP  Anemia: blood  Infections: antibiotics  Malnutrition: SAM protocol  Bleeding tendency: platelets Specific: Antileishmaniasis:  Stibogluconate for 28 days  Amphotricin B for 5 days You can repeat BMA after finishing treatment to be sure of complete cure.  283 Hemorrhagic fever Responsible viruses: Dengue fever, chikungunya, Zika and West Nile fever infections. The mechanism of bleeding in dengue hemorrhagic fever is not known. However, a mild degree of disseminated intravascular coagulopathy, liver damage& thrombocytopenia may operate synergistically. Pathogenesis: Capillary damage allows fluid, electrolytes, small proteins& RBCs to leak into extravascular spaces. This internal redistribution of fluid. In addition, fasting, thirsting, and vomiting, results in hem-concentration& hypovolemia. Increased cardiac work, tissue hypoxia, metabolic acidosis, and hyponatremia. Dengue fever Types of virus: DEVV1, DENV2, DENV3& DENV4 Virus: Flavirideae Carrier: Aedes egypti mosquito Types of illness: It range from mild flu to shock WHO classification:  DF: dengue fever: flu like symptoms  DHF: dengue hemorrhagic fever: DF + hemorrhagic rash  DSS: dengue shock syndrome: DHF + hypotension & LOC Clinical picture:  Headache  Fever > 39.4-41 C.  Nausea& vomiting  Macular, generalized rash  Frontal or retro-orbital pain  Generalized lymphadenopathy.  Myalgia and arthralgia but mainly muscle pain. Investigations:  CBC, PT & PTT  S. electrolytes  PCR & Dengue Abs: IgM +ve Management: Supportive only  Fluid, Sedation, Analgesic, Contraindication of aspirin& Plasma for shock& bleeding  284 Chikungunya: it is also called breakbone fever Transmitted by mosquito infected by the virus Virus: Togavirideae Carrier: Aedes aegypti Aedes albopictus Stages:  Acute phase: resolves  Post acute phase: lasting for 3 weeks  Chronic phase: symptoms for more than 3 months Clinical picture:  Back-break fever.  Fever > 39.4-41 C.  Macular, generalized rash  Frontal or retro-orbital pain  Cutaneous hyperesthesia or hyperalgesia  Myalgia and arthralgia increase in severity.  Joint symptoms severe in patients with chikungunya  Severe anorexia, nausea, vomiting& Taste aberrations. Investigations:  PCR +ve  Clinical suspicion  Chikungunya Abs b ELISA Management:  Treatment of joint pain by:  NSAIDs, ibuprofen, naproxen& aspirin For confirmed cases of synovitis: You can use Predenisolone or hydroxychloroquine or methotrexate or sulfasalazine