FEVER WITH JAUNDICE
By
PBL 2
Supervised by
Dr. Raghda Farag
ILOS
Definition of
fever
Definition of
jaundice
Causes of
fever with
jaundice
Clinical
approach to
diagnose fever
with jaundice
FEVER
DEFINITION OF FEVER
Fever is an elevation of body temperature that
exceeds the normal daily variation, in conjunction with
an increase in hypothalamic set point.
θ in the anus ≥ 37.5-38.3ᵒC
in the mouth ≥ 37.7 ᵒC
axillary/otic ≥ 37.2 ᵒC
PATTERN OF FEVER
Sustained (Continuous) Fever
Intermittent Fever (Hectic Fever)
Remittent Fever
Relapsing Fever:
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Tertian Fever
Quartan Fever
Days of Fever Followed by a Several Days Afebrile
Pel Ebstein Fever
Fever Every 21 Day
JAUNDICE
JAUNDICE – IS IT A DISEASE OR A SIGN OF A
DISEASE?
Yellowish staining of the skin and sclerae
High levels of bilirubin in blood
CLINICAL ASPECTS OF JAUNDICE
Clinically detectable if SB is >2.0 mg%
With edema and dark skin – Jaundice may be masked
What is special about the sclera ? – Rich Elastin
Skin discoloration – Yellowish, - Carotinemia – Eyes N
Mucosa – hard palate (in dark skinned)
Greenish hue of skin and sclera - due Biliverdin – indicates long standing jaundice
Generalized Pruritus – Obstructive Jaundice – Why ?
JAUNDICE – CLASSIFICATION
Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg%
Jaundice may be due to:
Over production of Bilirubin (Hemolytic)
 From hemolysis of RBC
 Lysis of RBC precursors – Ineffective erythropoesis
Impaired hepatic function (Hepatitic)
 Hepatocellular dysfunction in handling bilirubin
 Uptake, Metabolism and Excretion of bilirubin
Obstruction to bile flow (Obstructive)
 Intrahepatic cholestasis
 Extrahepatic Obstruction (Surgical Jaundice)
CAUSES OF FEVER WITH JAUNDICE
oInfectious : viral causes
oViral Hepatitis A,B,C,D,E
oImmune deficiency , acquired (AIDS/HIV)
oInfectious mononucleosis
oViral haemorrhagic fevers:
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Ebola virus
Yellow fever
African hemorrhagic (Marburg) virus disease
Dengue fever
BACTERIAL
oBacterial overwhelming sepsis
oLeptospirosis Ictohemorrhagica (Leptospirosis):Leptospiral disease/severe (Weils)
type
oListeria hepatitis, newborn
oStreptococcus/toxic shock/type A strn
oToxic shock syndrome
oBacterial Relapsing fever (Borrelia)
oTyphiod fever
PARASITIC
oNewborn TORCH syndrome
oMalaria (Blackwater fever)
oAmebic abscess, liver
oBabesiosis
oCryptosporidiosis
oBiliary Ascariasis with ascending cholangitis
ALLERGIC, COLLAGEN, AUTO-IMMUNE
DISORDERS:
oAutoimmune hemolytic anemia
oTransfusion reaction, hemolytic
oEvan's syndrome (AHA/Immune TP)
oAutoimmune hepatitis
NEOPLASTIC DISORDERS
oCarcinoma, hepatocellular
oMetastatic liver disease
oAdenocarcinoma, pancreatic
oCarcinoma, gallbladder
oCarcinoma, biliary tree
HEREDITARY, FAMILIAL, GENETIC DISORDERS:
oSickle cell anemia
oCirrhosis/childhood Indian type
AN APPROACH TO JAUNDICE & FEVER
oIs it isolated elevation of serum bilirubin ?
oIf so, is the↑unconjugated or conjugated fraction?
oIs it accompanied by other liver test abnormalities ?
oIs the disorder hepatocellular or cholestatic?
oIf cholestatic, is it intra- or extrahepatic?
oThese can be answered with :
History and physical examination
Interpretation of laboratory tests and
Radiological tests and procedures.
o History
oPhysical examination
oBlood tests - laboratory
oUltrasonography
oCT
oMRI
oLiver biopsy
oERCP
oEndoscopic ultrasound
Diagnosis
CLINICAL HISTORY – IMP CLUES
o Duration of jaundice – Acute / Chronic
o Abdominal pain v/s painless jaundice
o Pruritus - obstructive
o Affect appetite – Hepatocellular infection / Malignancy
o Weight loss – Malignancy – CAH
o Colour of stools –chalky white –obstructive
o Family history – Hemolytic – Inherited dis.
o H/o transfusion, IDU
o Alcohol abuse, Medications.
LABORATORY TESTS
oBilirubin level in serum (total and direct)
oAminotransferase
oAlkaline phosphatase
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oU/A for bilirubin and urobilogen
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Complete blood count
Prothrombin time
Other laboratory tests pertinent to
history
Coombs test
Electrophoresis of hemoglobin
Viral hepatitis panel
FIRST STEP
Estimate Serum Bilirubin
Is it less than 1 mg % - Normal
Is it more than 1 mg % - Elevated
SECOND STEP : IF SB > 1.0 MG
Is it unconjugated bilirubin ?
Haemolytic Jaundice
Is it Conjugated Bilirubin ? (> 20%)
Hepatocellular jaundice
Obstructive jaundice
↑ IN UNCONJUGATED BILIRUBIN
Hemolytic Jaundice 1. Hemolytic Disorders + Anemia
2. Ineffective Erythropoesis –B12, Fe, F
3. Drugs – Rifampicin, Probenecid
4. Inherited –Crigler Najjar, Gilberts
THIRD STEP : IF CSB IS INCREASED
Do - AST and ALT (SGOT and SGPT)
Elevated AST and ALT
Hepatocellular jaundice
AKP, 5N, GGT will be normal
Do - Alkaline Phosphatase and GGT
AKP, GGT ↑↑ in Obstructive Jaundice
AST and ALT will be normal
FOURTH STEP : HEPATOCELLULAR
Hepatocellular – Features and D.D
Conjugated SB is increased
AST and ALT are increased
AKP, 5NS, GGT are normal
Hepititis – A,B,C,D,E, CMV,EBV
Toxic Hepatitis – Drugs, Alcohol
Malignancy – Primary Ca
Cirrhosis – ALD, NAFLD
TREATMENT
Treatment requires a precise diagnosis of the specific cause and should be directed
to the specific problem
PBL MEMBERS
Alif
Alia
Syafiq
Yasmin
Malisa
Deanna
Fatimah
Fadhillah
Mohamed
Shawameera