Common Symptoms---Fever and Edema
The First Affiliated Hospital of Liaoning
Medical College
Nephropathy Deparment
Zhou HongLi
Fever
1 Introduction
2 Pathlogeny and sort
3 Occurrence Mechanism
4 Clinical occurrence
5 Patterns of fever
6 FUO
Intruduction
1 normal rang: 36-37℃
2 higher: late afternoon, evening
maximum 8:00-10:00 pm
lower: morning
minimum 3:00-4:00 am
3measure pathway：rectum (higher 0.3-0.5)
mouth
axillia (lower 0.2-0.4)
Pathlogeny and sort
1 Infective fever-------most common cause
①bacterial
②viral
③rickettsial
④fungal
⑤parasitic
Pathlogeny and sort
2 Noninfective fever
①aseptic necrosis mass absorption : tissue
ischemia and infarction,vascularitis,
subarachnoid hemorrage
②antigen-antibody reaction: acute rheumatic
fever, still disease ,serum sickness,
systemic lupus erythematosus
③familal fever: congenital familial
mediterranean fever
④endocrine disease: endocrine hyperthyroidism
⑤tissue damage:myocardial infarction,
pullmonary infarction
⑥drug reaction and gout
⑦tumor: lymphomas,solid tumors
⑧neuroleptic seizures
⑨psychosocial factitious
Occurrence Mechanism

physiologic temperature elevated----fever
(elevation of hypothalamic set point)
Pathologic temperature elevated-- hyperthermia
( unregulated heat generation, impaired heat
exchange)

Occurrence Mechanism--physiologic
set point (hypothalamus)
regulate
Internal temperature
maintain
cellular function
Deviation >4 ℃
cellular dysfunction
Occurrence Mechanism
increased heat production
decreased heat dissipation
failure of regulating system
Set point change
Temperature deviation
fever
exogenous pyrogen (bacterial, viral)
activate
neutrophil, eosinophil, mononuclear
macrophage
release
endogenous pyrogen(interleukin-1(IL-1),TNF, interferon）
hypothalamus Set point
heat production heat dissipation
fever
Occurrence Mechanism
Specific patients:
 elderly patients
 renal failure patients
 high doses of corticosteriods



unable to mount
fever
immunocompromised hosts fever
HIV-infected fever
nosocomial fever
require special consideration
Clinical occurrence
low-grade fever:37.3-38℃
Grade
(oral reading)
middle-grade fever:38.1-39℃
high-grade fever:39.1-41℃
hyperthemia:﹥41℃
Clinical occurrence
effervescence（heat production ,heat loss ）
(chill,rigor,vasoconstriction)
clinical features
altithermal
(reach new set point)
(warm,moist,flushed,tarchycardia)
defervescence (heat production heat loss )
sweat
Patterns of fever







Continuous fever
Remittent fever
Intermittent fever
Undulant fever
Relapsing fever
Episodic fever
Pel-Epstein fever
Continuous fever
①temperature: 39-40 ℃,days or weeks;diurnal
variation 0.5-1.0 ℃
②disease: typhoid, acute pneumonia
Continuous fever
Remittent fever
①temperature ＞38 ℃, diurnal variation＞2 ℃
（no normal temeratrue）
②disease: sapraemia,acute rheumatic fever,
acute infectious endocarditis
Remittent
fever
Intermittent fever
① suddenly reach climax, continue several
hours, suddenly fall to normal,
intermission 1-several days
②disease: malaria, acute pyelonephritis
Intermittent fever
Undulant fever
①slowly reach ＞ 39 ℃,slowly return to
normal. (repeate the rhythm)
②disease: brucellosis,tumor
Undulant fever
Relapsing fever
①suddenly reach 39 ℃ , continue several
days, suddenly drop to normal. bout every
5-7days
②disease: spirochetes infection
Relapsing fever
Episodic fever
①last for days or longer, then without fever
for at least 2 weeks
②disease: familial periodic fever
Pel-Epstein fever
①continuous or remittent fever bouts
several days
②disease: Hodgkin disease
FUO—fever of unknown origin
Diagnosis criteria:
①the illness last at least 3 weeks;
②38.3 ℃ repeatedly;
③no diagnosis after 1 week hospitalization
Causes:
①noninfectious inflammatory disease;
②infections;
③malignancies (hematologic);
④50% unexplained
Edema
Pathophysiology
Clinical
occurrence
Idiopathic edema
Tropical edema
angioedema
Pathophysiology
hydrostatic and oncotic pressure
A
fluid
fluid
filter
out
interstitial tissues
Keep in balance
V
resorption
equilibrating factors
filtration
resorption
capillary hydrostatic pressure
interstitial fluid colloid osmotic pressure
serum colloid osmotic pressure
interstitial tissues pressure
Filtration > resorption
edema
Factors leading to edema





retention of sodium and water
capillary filtration pressure（right heart failure）
capillary permeability
（acute nephritis）
serum colloid osmotic pressure (serum albumin )
lymphatic return disturbance (filariasis)
pitting edema detectable:4.5kg fluid accumulate
identify method :
press thumb into the skin against a bony
surface (anterior tibia, fibula,dorsum of foot,
sacrum) to demonstrate the presence of edema
when the thumb is withdrawn, an indention
persist for a short time.
Site of edema:





walking patient--feet, ankles
gravity
supine patient--posterior calves, sacrum
both legs and symmetric—in the pelvis or
more proximally
arms and head---superior vena cava
limited one extremity-vascular channels, local
inflammation
Brawny edema:
chronic edema of the legs leads to
fibrosis of the subcutaneous tissues and
skin, so they no longer pit on pressure.
Clinical occurrence
Localized edema
 cause: local vein or lymphatic return,soft
tissues disturbance or capillary permeability
 disease: Inflammation infection
insufficiency of the venous valves
chemical or physical injuries
arteriovenous fistulas

site: above the diaphragm--superior
vena cava obstruction
below the diaphragm—jugular
venous press ,portal vein hypertension,
loss of venous tone drugs
Generalized edema:
 cardiac edema
 renal edema
 hepatic edema
 nutritional edema (protein losing conditions)
 Drug (corticosteroid, NSAID)
 Systemic inflammatory response syndrome(SIRS)
Cardic edema



Symptoms: chest distress, short breath,
dyspnea
Site: lower limbs
Disease： right heart failure
renal edema



Symptoms：hematuria，proteinuria
Site: eyelid，legs
Disease: nephrotic syndrome
hepatic edema



Symptoms: anorexia, vomitting,liver
function test abnormal
Site: first lower limbs, then spread all over
the body, ascites is most common
Disease：cirrhosis, chronic liver disease
Protein losing conditions



Enteropathy
Burns
fistulas
Idiopathic edema


women in 30-50years old without disease,affective
disorders and obesity may coexist
Mechanism :upright posture --capillary leakage
inappropriate chronic diuretic administration
activate
-----peripheral edema
hormones involved in
salt and water retention
Tropical edema



Normal adults
condition:48h after traveled from temperate
climate to tropics or from cool and dry to warm
and humid
resolve quickly in a few days of acclimatization
Angioedema
Site: face,lips,tongue, larynx----life-threatening
Subcutaneous soft-tissue edema ;Erythema is not prominent.


Causes: hereditary absence of C1 esterase
exposure to allergen
angiotensin-converting enzyme inhibitors
1Reasons of infective fever
2Grades of fever.
3Patterns of fever.
4cause of generaliz edema
5How to distinguish cardiac edema from
renal edema?