Types of fever...Really!

Performance of the various types of fever
a) Fever continues
b) Fever continues to abrupt onset and remission
c) Fever remittent
d) Intermittent fever
e) Undulant fever
f) Relapsing fever

The pattern of temperature and diagnosis:

• Continuous fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis, ortyphus. Typhoid fever may show a specific fever pattern (Wunderlich curve of typhoid fever), with a slow stepwise increase and a high plateau. (Drops due to fever-reducing drugs are excluded.)
• Intermittent fever: The temperature elevation is present only for a certain period, later cycling back to normal, e.g. malaria, kala-azar, pyaemia, or septicemia. Following are its types 
  • Quotidian fever, with a periodicity of 24 hours, typical of Plasmodium falciparum
  • Tertian fever (48 hour periodicity), typical of Plasmodium vivax and Plasmodium ovale
  • Quartan fever (72 hour periodicity), typical of Plasmodium malariae.
• Remittent fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g., infective endocarditis.
• Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma, being high for one week and low for the next week and so on. However, there is some debate as to whether this pattern truly exists.

A neutropenic fever, also called febrile neutropenia, is a fever in the absence of normal immune system function. Because of the lack of infection-fighting neutrophils, a bacterial infection can spread rapidly; this fever is, therefore, usually considered to require urgent medical attention. This kind of fever is more commonly seen in people receiving immune-suppressing chemotherapy than in apparently healthy people.

Febricula is an old term for a low-grade fever, especially if the cause is unknown, no other symptoms are present, and the patient recovers fully in less than a week.

I possibly know everything about fever!

Temperature Classification
	Core (rectal, esophageal, etc.)
Normal	36.5–37.5 °C (97.7–99.5 °F)
Hypothermia	<35.0 °C (95.0 °F)
Fever	>37.5–38.3 °C (99.5–100.9 °F)
Hyperthermia	>37.5–38.3 °C (99.5–100.9 °F)
Hyperpyrexia	>40.0–41.5 °C (104–106.7 °F)
Note: The difference between fever and hyperthermia is the mechanism.

 A raised temperature is not always a fever. For example, the temperature of a healthy person rises when he or she exercises, but this is not considered a fever, as the set-point is normal. On the other hand, a "normal" temperature may be a fever, if it is unusually high for that person. For example, medically frail elderly people have a decreased ability to generate body heat, so a "normal" temperature of 37.3 °C (99.1 °F) may represent a clinically significant fever.

Hyperthermia: Characterized on the left. Normal body temperature (thermoregulatory set-point) is shown in green, while the hyperthermic temperature is shown in red. As can be seen, hyperthermia can be conceptualized as an increase above the thermoregulatory set-point.
Hypothermia: Characterized in the center: Normal body temperature is shown in green, while the hypothermic temperature is shown in blue. As can be seen, hypothermia can be conceptualized as a decrease below the thermoregulatory set-point.
Fever: Characterized on the right: Normal body temperature is shown in green. It reads "New Normal" because the thermoregulatory set-point has risen. This has caused what was the normal body temperature (in blue) to be considered hypothermic.

A wide range for normal temperatures has been found.Fever is generally agreed to be present if the elevated temperature is caused by a raised set point and:

• Temperature in the anus (rectum/rectal) is at or over 37.5–38.3 °C (99.5–100.9 °F)
• Temperature in the mouth (oral) is at or over 37.7 °C (99.9 °F)
• Temperature under the arm (axillary) or in the ear (otic) is at or over 37.2 °C (99.0 °F)

Hyperthermia

Hyperthermia is an example of a high temperature that is not a fever. It occurs from a number of causes including heatstroke, neuroleptic malignant syndrome, malignant hyperthermia, stimulants such as amphetamines and cocaine,idiosyncratic drug reactions, and serotonin syndrome.

Acid Reflux - Why this Kola Eri? - can lifestyle changes make a difference?

What Causes GERD?

Gastroesophageal Reflux Disease, or GERD, is a chronic, often progressive condition resulting from a weak Lower Esophageal Sphincter (LES). When left untreated, serious complications can result, including: esophagitis, stricture, Barrett's esophagus, and esophageal cancer.

The LES is a muscle at the junction of the esophagus and stomach that functions as the body's natural barrier to reflux. The LES acts like a valve, allowing food and liquid to pass through to the stomach. Normally, the LES closes immediately after swallowing, preventing reflux. (Fig. 1) However, in people with GERD, the LES is weak, allowing acid and bile to reflux from the stomach into the esophagus. (Fig. 2)

• 
  Figure 1: A competent LES prevents chronic reflux into the esophagus
• 
  Figure 2: A weak LES allows reflux into the esophagus

Symptoms of GERD

People experience symptoms of GERD in a variety of ways. The most common symptom of GERD is heartburn.
Other symptoms may include:

• Regurgitation
• Sore throat
• Cough
• Chest pain

Treatment Options - NON MEDICAL OPTIONS

Treatment options for people who suffer from GERD vary widely depending on the severity and symptoms of their disease, however, there are currently three primary means of treating GERD: lifestyle changes, medical therapy and surgical intervention. Always consult your physician when considering treatment options.

Lifestyle Changes

Infrequent heartburn may be controlled by lifestyle changes such as weight loss, smoking cessation and eating modifications.

Taking the following steps may aid in reducing the frequency and severity of reflux episodes:

• Eating smaller meals
• Avoiding spicy foods, alcohol, coffee and chocolate
• Remaining upright after meals
• Eating evening meals several hours before going to bed
• Sleeping with the head of the mattress elevated

Taking steps such as these may help to reduce the symptoms associated with infrequent reflux, however, for patients who have moderate to severe GERD, lifestyle changes alone may not completely relieve symptoms.

Courtesy: http://www.toraxmedical.com/linx/understandingGERD.php

Chalazion Meibomian gland lipogranuloma

A chalazion is a small bump in the eyelid caused by a blockage of a tiny oil gland.

A chalazion develops in the glands that produce the fluid that lubricates the eye. These are called Meibomian glands. The eyelid has approximately 100 of these glands, which are located near the eyelashes.

A chalazion is caused by a blockage of the duct that drains one of these glands

• Eyelid tenderness
• Increased tearing
• Painful swelling on the eyelid
• Sensitivity to light
  
  Chalazions are non-infections inflammations of the meibomian glands. This is different from a stye, which is an infection of a sweat-gland or hair follicle, similar to a pimple.
  Image courtesy: Opthobook
  
  
  

  A chalazion will often disappear without treatment in a month or so.

  The primary treatment is to apply warm compresses for 10-15 minutes at least four times a day. This may soften the hardened oils blocking the duct, and promote drainage and healing.

  If the chalazion continues to get bigger, it may need to be removed with surgery. This is usually done from underneath the eyelid to avoid a scar on the skin.

  Antibiotic eye drops are usually used several days before and after the cyst is removed. However, they are not much use otherwise in treating a chalazion.

  Steroid injection is another treatment option.

  

  
  
  Chalazia usually heal on their own. The outcome with treatment is usually excellent.
  A large chalazion can cause astigmatism due to pressure on the cornea. This will get better when the chalazion is treated.

Meningococcal Vaccine: for high risk children (9months to 10 years)

The meningococcal conjugate vaccine (MCV4) is recommended for certain high risk children from ages 9 months through 10 years.

The high risk children for whom this vaccine is recommended include 

1. children who travel to, and United States citizens who reside in, countries where meningococcal meningitis is hyperendemic or epidemic (e.g. the African Meningitis Belt), 

2.persons with persistent complement component deficiencies (e.g., C5-C9, properdin, factor H, or factor D), 

3. persons with functional or anatomic asplenia, and children who are in a defined risk group during a community or institutional meningococcal disease outbreak. However, 9 through 23 month old children with functional or anatomic asplenia are NOT recommended to receive the vaccine.

A 2-dose primary series is recommended for any child with the risk factors described above whose first dose was received before their second birthday. 

Persons at increased risk because of complement component deficiencies and persons with functional or anatomic asplenia should receive a two dose primary series 2 months apart and then get a booster dose every 5 years. Children aged 9 months-6 years at increased risk are recommended to be revaccinated 3 years after their primary series, and then at 5 year intervals if they remain at risk.

In October 2010, ACIP voted to recommend a two-dose primary series of MCV4 given 2 months apart for 2 through 54 year olds with medical risk factors (complement component deficiency, functional or anatomic asplenia). 

In April 2011, ACIP voted to recommend MCV4 for children 9 through 23 months of age with certain medical risk factors (complement component deficiency).

Meningococcal Vaccine: Who Needs to be Vaccinated?

here are two meningococcal vaccines available in the United States:

• Meningococcal polysaccharide vaccine (MPSV4)
• Meningococcal conjugate vaccine (MCV4)

Courtesy: http://mommy-mall.com/health-and-nutrition/the-meningococcal-vaccine

In adolescents, those ages 16 through 21 years have the highest rates of meningococcal disease.

All 11-12 years olds should be vaccinated with meningococcal conjugate vaccine (MCV4). 

Now, a booster dose should be given at age 16 years. 

For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before the peak in increased risk. 

Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.

When MCV4 was first recommended for adolescents in 2005, the expectation was that protection would last for 10 years; however, currently available data suggest it wanes in most adolescents within 5 years. Based on that information, a single dose at the recommended age of 11 or 12 years may not offer protection through the adolescent years at which risk for meningococcal infection is highest (16 though 21 years of age). 

Meningococcal vaccination is required to attend many colleges. The Advisory Committee on Immunization Practices (ACIP) suggests that your child receive the vaccine less than 5 years before starting school.

Adolescents age 16 through 18 years can get the booster dose at any time. The minimum interval between doses is 8 weeks.

The meningococcal conjugate vaccine (MCV4) is recommended for certain high risk children from ages 9 months through 10 years.

We will talk about that age group tomorrow....

Inflammation vs. Infection - what is the difference?

Inflammation (Latin, īnflammō, "I ignite, set alight") is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants.
Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process. Inflammation is not a synonym for infection, even in cases where inflammation is caused by infection. 


Although infection is caused by a microorganism, inflammation is one of the responses of the organism to the pathogen. 


However, inflammation is a stereotyped response, and therefore it is considered as a mechanism of innate immunity, as compared to adaptive immunity, which is specific for each pathogen


Without inflammation, wounds and infections would never heal. Similarly, progressive destruction of the tissue would compromise the survival of the organism. However, chronic inflammation can also lead to a host of diseases, such as hay fever, periodontitis, atherosclerosis, rheumatoid arthritis, and even cancer (e.g., gallbladder carcinoma). It is for that reason that inflammation is normally closely regulated by the body.


Inflammation can be classified as either acute or chronic. 

Acute inflammation is the initial response of the body to harmful stimuli and is achieved by the increased movement of plasma and white blood cells from the blood into the injured tissues. A cascade of biochemical events propagates and matures the inflammatory response, involving the local vascular system, the immune system, and various cells within the injured tissue. 

Micrograph showing acute inflammation of the prostate gland with the characteristic neutrophilic infiltrate. H&E stain.

Prolonged inflammation, known as chronic inflammation, leads to a progressive shift in the type of cells present at the site of inflammation and is characterized by simultaneous destruction and healing of the tissue from the inflammatory process.

Mosquito bites and treatment

Visible, irritating bites are due to an immune response from the binding of IgG and IgE antibodies to antigens in the mosquito's saliva. Some of the sensitizing antigens are common to all mosquito species, whereas others are specific to certain species. 

There are both immediate hypersensitivity reactions (types I and III) and delayed hypersensitivity reactions (type IV) to mosquito bites.Both reactions result in itching, redness and swelling. Immediate reactions develop within a few minutes of the bite and last for a few hours. Delayed reactions take around a day to develop, and last for up to a week.

Several anti-itch medications are commercially available, including those taken orally, such as Benadryl, or topically applied antihistamines and, for more severe cases, corticosteroids. 

Using a brush to scratch the area surrounding the bite and running hot water (around 49 °C or 120 °F) over it can alleviate itching for several hours by reducing histamine-induced skin blood flow. 

Tea tree oil has been shown to be an effective anti-inflammatory, reducing itching

(Tea tree oil, or melaleuca oil, is a pale yellow colour to nearly colorless and clear essential oil with a fresh camphoraceous odor. It is taken from the leaves of the Melaleuca alternifolia, which is native to the northeast coast of New South Wales, Australia. Tea tree oil should not be confused with tea oil, the sweet seasoning and cooking oil from pressed seeds of the tea plant Camellia sinensis (beverage tea), or the tea oil plant Camellia oleifera.)

Jod-Basedow effect vs. Wolff-Chaikoff effect

The Jod-Basedow effect is hyperthyroidism following administration of iodine or iodide either as a dietary supplement or as contrast medium.

This phenomenon is an iodine-induced hyperthyroidism, typically presenting in a patient with endemic goiter who then relocates to an iodine-abundant geographical area.

It is named for Karl Adolph von Basedow, a German physician and the German word for iodine, "jod". It is the opposite of the Wolff-Chaikoff effect.

Carl Adolph von Basedow (1799 – 1854)

The Wolff–Chaikoff effect is a reduction in thyroid hormone levels caused by ingestion of a large amount of iodine.

It is an autoregulatory phenomenon that inhibits organification (oxidation of iodide) in the thyroid gland, the formation of thyroid hormones inside the thyroid follicle, and the release of thyroid hormones into the bloodstream.

This becomes evident secondary to elevated levels of circulating iodide. The Wolff–Chaikoff effect lasts several days (around 10 days), after which it is followed by an "escape phenomenon" which is described by resumption of normal organification of iodine and normal thyroid peroxidase function.

The Wolff–Chaikoff effect can be used as a treatment principle against hyperthyroidism (especially thyroid storm) by infusion of a large amount of iodine to suppress the thyroid gland. 

Iodide was used to treat hyperthyroidism before antithyroid drugs such as propylthiouracil and methimazole were developed. Hyperthyroid subjects given iodide may experience a decrease in basal metabolic rate within 24 hours that is comparable to that seen after thyroidectomy. The Wolff–Chaikoff effect also explains the hypothyroidism produced in some patients by several iodine-containing drugs, including amiodarone.

Iodine Intake - the official recommendations

The daily Dietary Reference Intake recommended by the United States Institute of Medicine is 

1. between 110 and 130 µg for infants up to 12 months, 

2. 90 µg for children up to eight years, 

3. 130 µg for children up to 13 years, 

4. 150 µg for adults, 

5. 220 µg for pregnant women and 

6. 290 µg for lactating mothers.

Electron shell diagram for Iodine, the 53rd element in the periodic table of elements.

The Tolerable Upper Intake Level (UL) for adults is 1,100 μg/day (1.1 mg/day).

 The tolerable upper limit was assessed by analyzing the effect of supplementation on thyroid-stimulating hormone.

The thyroid gland needs no more than 70 micrograms /day to synthesize the requisite daily amounts of T4 and T3. The higher recommended daily allowance levels of iodine seem necessary for optimal function of a number of body systems, including lactating breast, gastric mucosa, salivary glands, oral mucosa, thymus, epidermis, choroid plexus, etc. 

The high iodide-concentration of thymus tissue in particular suggests an anatomical rationale for this role of iodine in the immune system.

The trophic, antioxidant and apoptosis-inductor actions and the presumed anti-tumour activity of iodides has been suggested to also be important for prevention of oral and salivary glands diseases.

Natural sources of iodine include sea life, such as kelp and certain seafood, as well as plants grown on iodine-rich soil. 

Iodized salt is fortified with iodine.

As of 2000, the median intake of iodine from food in the United States was 240 to 300 μg/day for men and 190 to 210 μg/day for women.

 In Japan, consumption is much higher, owing to the frequent consumption of seaweed or kombukelp.

It should also be noted that information processing, fine motor skills, and visual problem solving are improved by iodine repletion in moderately iodine-deficient children. 

"PRISH"- Some interesting facts!

Neutrophils migrate from blood vessels to the inflamed tissue via chemotaxis, where they remove pathogens through phagocytosis and degranulation

Acute inflammation is a short-term process, usually appearing within a few minutes or hours and ceasing upon the removal of the injurious stimulus. It is characterized by five cardinal signs:

The acronym that may be used for this is "PRISH" for Pain, Redness, Immobility (loss of function), Swelling and Heat

The first four (classical signs) were described by Celsus (ca 30 BC–38 AD), while loss of function was added later by Galen


Redness and heat are due to increased blood flow at body core temperature to the inflamed site; swelling is caused by accumulation of fluid; pain is due to release of chemicals that stimulate nerve endings. Loss of function has multiple causes 

The classic signs and symptoms of acute inflammation:

English	Latin
Redness	Rubor
Swelling	Tumor
Heat	Calor
Pain	Dolor
Loss of function	Functio laesa
All the above signs may be observed in specific instances, but no single sign must, as a matter of course, be present. These are the original, or "cardinal signs" of inflammation. Functio laesa is an apocryphal notion, as it is not unique to inflammation and is a characteristic of many disease states.