Management of Fever in Rural Areas

What is fever?

In simple terms Fever is elevation of body temperature. Although 98.6 degrees F or 37 degrees C is considered normal temperature, the normal temperature is the lowest in the morning and highest in the late afternoon sometimes reaching 99.9 F. Sometimes temperature peaks every day and then returns to normal and this is called intermittent fever. If the temperature varies but does not return to normal it is called remittent fever. Some fevers can have step ladder pattern. These patterns were relevant at a time when people did not take medication on their own.

What are the consequences of fever?

Although many people worry that fever can cause harm, the typical temporary elevations in body temperature to 100.4° to 104° F (38° to 40° C) are very well tolerated and do not cause any harm. They are caused by short-lived (acute) illnesses and are mostly of viral origin. However, a moderate fever may be slightly dangerous for adults with a heart or lung disorder because fever causes heart rate and breathing rate to increase. Fever can also worsen mental status in people with dementia.

Fever is good because it allows the people to rest and recover from the minor infections that cause the rise in temperature.

However extreme fever [> 105.8 F or > 41 C] can cause lot of damage to most organs and can even lead to failure of these organs.

What are the causes of fever?

Fever is caused by presence of what is called pyrogens in the blood. The toxins produced by bacteria and virus are from outside the body while body cells called monocytes and macrophages produce endogenous pyrogens from inside the body. Pyrogens from outside also cause release of endogenous pyrogens.

Infection is not the only cause of fever. There are other causes like inflammation, reactions to medicines, allergic reactions, autoimmune diseases and sometimes cancers cause fever. Inflammatory disorders include joint, connective tissue, and blood vessel disorders such as rheumatoid arthritis, systemic lupus erythematosus (lupus), and giant cell arteritis.

What are the common causes of fever?

The most common causes are infections of the upper and lower respiratory tract, gastrointestinal tract, urinary tract and skin. Most of these are self limiting and occur when the general resistance is low due to a variety of causes.

If the fever persist for a long time and is of high grade it could be due to more serious causes. These may be due to tuberculosis, abdominal or pelvic abscesses, and perforated hollow viscus like appendix, diverticulitis, malignancy or trauma. Malignancies that sometimes are difficult to diagnose, such as chronic leukemia, lymphomas, renal cell carcinomas, and metastatic cancers, often are found in patients with such long term fevers.

What are the symptoms of fever?

Those with fever can also have the following:

• Sweating
• Shivering (chills)
• Headache
• Muscle pains
• Anorexia
• Rashes
• Restlessness
• Feeling weak
• A very high fever can cause confusion, extreme sleepiness, irritability, and seizures

Are there any warning signs that one should look for?

There are few signs that could mean that fever is not due to ordinary self limiting causes. They are:

• A change in mental function, such as confusion
• A headache, stiff neck, or both
• Flat, small, purplish red spots on the skin (petechiae), which indicate bleeding under the skin
• Low blood pressure
• Rapid heart rate or rapid breathing
• Shortness of breath (dyspnea)
• A temperature of >104° F (40° C) or < 95° F (35° C)
• Recent travel to an area where malaria is common (endemic)
• Recent use of drugs that suppress the immune system (immunosuppressant’s)

What should be done when there is fever?

For the first two days conservative measures should suffice. The most important thing is having sufficient rest.

The other measures include the following:

• Drinking plenty of fluids to prevent dehydration
• Eating easy to digest light food
• Having warm bath
• Light dress even if feeling chill
• Having over the counter medicines like Paracetamol or Brufen

What are the common investigations that are necessary?

If the fever persists for over 3 days then some investigations are necessary.

1. Total and differential blood counts: If the count is more than 14,000 and there is the so called shift to the left it means that there is significant infection and further tests might be necessary to find out where this infection is present. It will also warrant usage of antibiotics for treatment
2. Urine analysis and urine cultures are necessary if urinary tract infections are suspected or just to rule out these infections
3. Chest x-rays might be necessary if lung infections are suspected

If fever persists for over a week then gastrointestinal infections and infections like typhoid should be considered and tested.

If fever is present for more than two weeks then extensive investigations to find out the cause are necessary. The tests would be carried out one by one to ascertain the cause. Some of the tests that might be used are: various scans starting with ultrasound examinations, tests for tuberculosis, immunosuppression or malignancies.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

Image: A medical/clinical thermometer. Source/Author: Menchi. Date: 2005-01-30. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Clinical_thermometer_38.7.JPG