Acute Febrile Illness

[Music] hi i'm sushant and welcome to this online tutorial by quest one of the commonest presentations to us in our opd or emergency departments are patients presenting with fever such acute febrile illnesses would have seasonal peaks around the months of monsoons in this tutorial let's study an approach to these patients with acute febrile illness and our focus would be on four important diseases that are found across india namely malaria dengue chikungunya and leptospirosis what is common to all of them is of course fever very often this is going to be high grade fever lasting for days to weeks patients can have associated chills and can have associated complications like rashes bleeding disorders or systemic involvement in form of renal liver or cns involved let's first understand malaria because that's a big problem in india patients who have malaria before they have fever would start mounting chills these chills would last for around a period of 20 to 60 minutes and following that the temperature would start rising the fever is very often going to be high grade fever lasting for us and following fever patients would have episodes of sweating or diaphoresis which would last for around half an hour now the fever that occurs in malaria is associated with the rupture of erythrocytic resonance which occurs every third to fourth day so patients would have fever which would typically if left untreated repeat every third to fourth day along with fever malaria can get complicated and have involvement of other organs classically patients can have neurologic involvement and that is known as cerebral malaria here patients can present with altereds and sodium and sometimes can present with seizures acute kidney injury is a very dreaded complication of malaria patients can have renal injury because of dehydration because of associated shock and there can also be sequestration of the parasite within the renal tissue which contributes to the renal injury one parallel thing that these patients are having is they can have severe hemolysis remember these rbcs are bursting open because of the parasite and such hemolysis can lead to dark colored urine giving malaria its name black water fever another dreaded complication which we see very commonly in our urban scenarios is patients coming with acute respiratory distress syndrome this is commoner with wi-wax malaria than with falsifera malaria jaundice can be another important complication and this could be because of either direct liver injury or because of the hemolysis that we have mentioned apart from these major complications patients can also present with hypoglycemia very commonly in malaria patients can have hemolytic anemias which could be very severe and patients can present with metabolic acidosis if you compare malaria with dengue dengue again comes with high grade fever but patients of dengue can have a triphasic course to begin with patients would have fever and this fever would be associated with severe headache myalgias arthralgias and a typical rash patients would also complain during this time of fever of retrovital pain this stage of fever would typically last for three days or sometimes up to a week and characteristically during this period patients who present to us with a low wbc count might have a slightly normal to low normal platelet count and very often would have elevated liver enzymes as this phase passes off as the fever settles down patients would enter into the second phase which is a more critical phase this is the time when vascular leak phenomena starts and as the vascular leakage starts patients start manifesting hemo concentration in the lab parameters this is reflected by an increase in hematocrit remember when i am seeing a patient of dengue one of the very important tests for me more important than platelets is the hematocrit value also due to vascular leak patients are also coming with hypoproteinemia together this vascular leak would lead to pleural effusions a scientist patients would also complain of abdominal pain and this is also the time when the platelet count is drastically dropping down this is going to be manifested with bleeding in form of mucosal bleeding particular rashes and sometimes gi bleeding this critical phase is also marked by the onset of arts we need to watch out for these patients along with plural efficient whether there are pulmonary infiltrates this is also the time when patients of dengue are predisposed to myocarditis now in some cases the vascular leak would be so severe that patients rapidly deteriorate into a hypovolemic shock this is marked by onset of tachycardia a weak pulse and of course a low blood pressure a very poor sign at this moment could be a poor mental status multi-organ dysfunction can set in and these patients can rapidly deteriorate and suffer cardiac arrest mortality is highest during this phase of dengue of course there are patients who recover out of this space of shock these are patients where the vascular leak has stopped and as a result of this patients are out of the danger phase so if you look at the complications of dengue the neurologic complications the renal complication ards and hepatitis all of this look very similar to what malaria patients could present with there are some typical complications which are more likely dengue these could be patients can have gbs now this is rare but it is associated with dengue more than malaria similarly a common finding which might not be symptomatic is patients can have a calculus cholecystitis this could be a finding to watch out for on a sonography if done patients as i've already said can have myocarditis but can also have myocytis which can lead to myalgias and sometimes elevated muscle enzymes and of course the bleeding disorder is much likely in dengue than in malaria now a disease very similar to dengue in presentation is chikungunya the febrile stage is in fact very similar to dengue the patient would have fever would have rash which can be difficult to differentiate from dengue would have headache backache retrovital pain as well as abdominal pain but what really marks chicken vineyard separate from dengue is that these patients have arthritis this arthritis is very often in the small joints of the hands but can involve multiple large joints as well and not only is this arthritis in the acute stage of fever it can last later on chronically for months or sometimes for years together now the good news for chikungunya is that systemic involvement and complications are much less likely than with dengue or with malaria now apart from this vector-borne diseases of malaria dengue and chikungunya there is one more disease that comes very often with monsoons especially in the urban slums and in those areas which have suffered from floods and have low hygiene this is leptospirosis leptospirosis again comes with fever with chills patients can have headaches very often have myalgias they can also have renal involvement and liver involvement which is in fact classical presentation of leptospirosis but a thing which can differentiate them early on is the conjunctival involvement they very often have conjunctival subfusion or swelling and can present with conjunctival hemorrhages remember this does not separate them completely from malaria or dengue even those patients can have hemorrhages but the conjunctival swelling is more common in patients of leptospirosis patients can also present with meningitis-like picture this is aseptic meningitis that means if i do a lumbar puncture i wouldn't find any bacteria but patient still has features clinical features of meningitis but the classical presentation is a patient of fever presenting with jaundice and worsening renal outcomes such a presentation of fever jaundice and renal involvement gives together the triad of what is known as wheels disease wheels disease is the most severe form of leptospirosis remember not everybody needs to develop these diseases patients might have fever without wealth disease but the classical triad is of fever jaundice and acute kidney injury just like other conditions that we have seen leptospirosis also puts the patient at risk of ards patients can have alveolar hemorrhages and that really increases the risk of mortality and clinically it might look very similar to a rds except that the patient has severe hemoptysis and similarly patients can have gi bleeding now we have seen the clinical profile of malaria dengue chikungunya and leptospirosis now let's go to the source where are these diseases emerging from well the easiest to understand is leptospirosis that's a zoonotic disease it's a spirochete known as leptospira enteroguns and it is the rat urine which is the most common source for us in humans this rat urine would contaminate the flood waters and from flood waters it would enter into the human skin but the other three are vector-borne diseases malaria for instance is a protozoan parasite known as plasmodia plasmodium falciparum and why wax are the most common in india around six percent of total global burden of malaria is found in india and of these two thirds are falsified and one third is y wax we all know that it is the infected female anaphylese mosquito which inoculates sporozoites within the human beings the parasite then travels to the liver from the liver towards the rbcs and it matches within the rpcs after maturation in the rbc it causes rupture of rbcs and at this stage patients have coinciding fever from the rbc it further goes on to become the gametocyte and from here the mosquito will take it back again the sexual phase of the parasite happens within the mosquito while the asexual phase happens within human beings but as it infects the rbcs the rbcs tend to adhere to each other and cause blockages of the microvascular system leading to microvascular hypoxia and most of the clinical features of malaria the parasite also activates cytokines leading to a pro-inflammatory state and a sepsis like phenomena now one good part about this is since it requires the rbcs to survive variants of hemoglobin like sickle cell or hbc or hbe tend to have a protective effect against malaria the remaining two dengue and chikungunya these are viruses both of them have similarity in that both of them are rna viruses and both of them require the same kind of mosquito dengue is a flavivirus and it has four serotypes namely one to four and the mosquito that is required for its transmission is the aedes egypti mosquito typically this is a mosquito found in the urban scenario and it's a mosquito that bites during the daytime now if a patient has an infection with any one given serotype of dengue that leads only to the features of fever and very often that is a self-resolving fever the good part is if i get infected with any one zero type of dengue i would have a lifelong immunity against it but unfortunately if i get the second infection with dengue with some other zero type now my immune response is going to be associated with vascular leakage the non-structural one or ns1 antigen of this virus is especially responsible for activation of the immune system and associated endothelial damage and vascular leakage so patients who have the second infection are the ones who enter into the shock syndrome that we saw or will enter into the bleeding manifestations of dengue chikungunya on the other hand is an herbal virus it also spreads through the aedes egyptian mosquito as well as the aedes albopictus chikungunya causes endothelial cell damage it survives in the macrophages and more importantly it causes damage to the synovial cells and that is how it contributes to the features of arthritis now let's focus on how do you evaluate these patients and how do you manage them when we are examining these patients we are of course looking out for signs of fever looking out for shock any bleeding manifestations we are looking for hepatosplenomegaly we are looking for any lymphadenopathy we are examining the chest for any competitions or crackles to look for features of ards we are of course looking for any finding of fluid or loading form of pleural effusions or hcvp investigation wise we very often need to hurry up especially if the patient has been hospitalized so there are going to be some general investigations i'll need like complete blood count here i am looking for presence of anemia i am looking for the wbc count which is very often going to be normal except in dengue where it is going to be leukopenia and of course i am looking at the platelet ground platelet count remember can be low in all of them from dengue malaria leptospirosis as well as chikungunya but dengue and malaria of course are the ones which will have the worst hit of platelet count i am also looking at hematograd especially because hemoconcentration is a feature of dengue i am looking for the renal functions that is shrimp retinol and the liver functions that is bilirubin and the sut hgpt levels because malaria dengue and reptospirosis very commonly can have renal as well as hepatic complications i'm going to monitor the patient's urine output and i'm looking for any signs of hematuria for patients of malaria as well as dengue it's a good idea to have the coagulation profile done especially when i'm looking for evidence of bleeding i would do an ecg to look for myocarditis and i'll do a chest x-ray to look for associated pleural effusions or arts of course i would do an x-ray to rule out pneumonia as well an important test for these patients is going to be imaging of the abdomen using an ultrasound this will not only show me patosphenomygally but in cases of dengue it might show me a calculus cholecystitis and it might also sometimes show me features of pancreatitis as seen in malaria or dengue apart from the general investigations of course we need specific investigations targeted towards malaria dengue chikungunya and leptospirosis we would very often know what kind of epidemic our region has and we might be able to tailor this test and sometimes if we do not have an idea we might have to do one test from each of them for malaria of course the primary test is a peripheral smear we can do both a thick as well as a thin smear and nowadays there are rapid diagnostic tests available these are strip test and they test for two types of antigen first is ldh ldh is present in all parasites and therefore can help me to diagnose malaria and we can also have the histidine rich protein which is present only in the falciparum one so it will help me to differentiate whether this is falciferum or the otherwise which is 5x dengue can be diagnosed using ns1 antigen test this is an elisa based test and the limitation here is this is positive only in the first five days after first five days of fever are over i would typically look for an igm capture realizer and this is positive from the 5th day onwards right up to the second month there are other tests for dengue known as the rt pcr or the culture test and both of these are not usually done coming to chikungunya the most specific test is rtpcr for viral rna but again not very commonly done what is commonly available and done is the serology igm antibody via eliza for chicken gournia virus isolation can also be done but again this is predominantly for research purposes rather than routine clinical practices for leptospirosis rapid card tests are easily available this would again test for the igm antibody against leptospirosis the gold standard test is microscopic agglutination test or mat but this test is not easily available we can do an elisa for igm that is available and sometimes we can do an rtpcr or culture of leptospirosis but again it would have a limited availability in the community once we have sent the basic investigations and some specific investigations even before we get back the reports we need to start the therapy and while starting the therapy the first question in our mind is where do we need to treat is this an opd-based management or do we need to hospitalize remember any patient who is appearing sick should be hospitalized now what would that mean that would typically be a patient who is hemodynamically unstable we need to look at the heart rate patient in shock or a patient having ards a patient who has poor oral intake could be because of nausea or vomiting a patient who has an altered neurological status a patient who has renal injury or sometimes simply because the patient has a poor social support now the first line of management for all febrile illnesses is fluid management if the patient has been managed on opd basis and can have oral intake we should advise for good oral intake of fluid typically this would mean around two to three liters of oral fluids per day but if the patient has been hospitalized or has less fluid intake then we should consider iv fluids typically normal saline while i am giving normal saline i need to be watching out for blood pressure i need to watch out for the heart rate urine output and jvp and i do not want the hematocrit to change beyond 20 because that could be a marker of hemoconcentration i am also watching out for the chest for repetitions to look for fluid overload we typically would start with five to seven ml per kg per hour of iv fluids that would be roughly around one point of ns in the first star and then we would gradually lower down the rate monitoring the patient to one point given over four to five hours patients have come to us with fever and the drug of choice for this is paracetamol we need to be liberal in our use of paracetamol at least for the first one to two days and that would mean giving a 500 milligram tablet around four times a day patients can have associated gastritis and proton pump inhibitors are the drug of choice we need to be careful about avoiding two drugs over here first we need to avoid aspirin and second we need to definitely avoid steroids in all such acute fibroid illnesses we need to monitor the patient for his platelet count and we need to consider transfusions appropriately now it's important to remember that if the patient does not have any signs of bleeding there is no one cut off for transmission of platelets especially in dengue on a safer side we tend to transfuse once the platelet count up below 10 000 but again that's not a guideline that's more of a practical thing that we do what is the guideline is we need to transfuse any patient who has any signs of bleeding we need to of course consider supportive care in form of requirement of mechanical ventilators for rds or requirement of dialysis if the patient has acute renal injury moving towards specific therapy if our diagnosis is malaria for false phylum malaria we need to give artisonate plus sp combination or arty method plus lumifantrin combination both of them are given for a period of three days and if it is y wax malaria we need to give chloroquine for three days and along with that to prevent a relapse we need to give prima queen for 14 days remember prima queen before we give that we have to test the patient for any deficiency of g6pd enzyme for leptospirosis depending on where the patient is in the community that is opd-based we could give doxycycline or if the patient has been hospitalized we can use either iv ceptraxone or sometimes penicillin management of acute febrile illness is not complete without thinking of the preventive measures and all patients should be educated so that they do not have relapse of this and their family members do not suffer from similar consequences this has been a long tutorial i am sure there are going to be questions if there are any questions feel free to reach out to me till then thank you so much and giant [Music]