Rigors

Description
A rigor is an episode of shaking or exaggerated shivering which can occur with a high fever. It is an extreme reflex
response which occurs for a variety of reasons. It should not be ignored, as it is often a marker for significant and
sometimes serious infections (most often bacterial). It is important to recognise the patient's description of a
rigor, as the episode is unlikely to be witnessed outside hospital, and to be aware of the possible significance of
this important symptom.
Pathophysiology
[1]
Shivering is a reflex which occurs when someone feels cold and, physiologically, it serves to raise body
temperature. The trigger point at which this reflex occurs is set in the anterior hypothalamus. This has been
likened to an internal thermostat.
[1]
With infection or inflammation, pyrogens (probably cytokines and
prostaglandins) 'reset' the trigger temperature so that the body feels cold and shaking occurs to raise
temperature to the new hypothalamic 'temperature point'. The body's attempts to raise temperature are
accompanied by other familiar reflex responses including contraction of erector pilae muscles ('goose bumps')
and peripheral vasoconstriction. Peripheral vasoconstriction causes cold extremities and pallor. Most of the work
done on various pyrogens responsible for mediating this response has been done on animals.
[1]
Epidemiology
Rigors are a common accompaniment of high fever.
They occur more commonly in children.
[2]
They are less likely to occur in the elderly.
[3]
However, they are a predictor of bacteraemia and bacterial infection in young and old.
[2] [3]
Presentation
History:
The sudden attack of severe shivering accompanied by a feeling of coldness ('the chills') is
called a rigor and is associated often with a marked rise in body temperature. It may be
described by patients as an attack of uncontrollable shaking.
A history of rigors should raise suspicion of infection, particularly bacterial infection. Enquiry
should be made about:
Symptoms suggestive of local infection, particularly respiratory infections,
urinary infections, biliary disease, and gastrointestinal (GI) infections.
Recent surgical procedures.
Any relevant past medical history such as rheumatic heart disease.
Recent foreign travel.
Medication and allergies.
Examination:
This should be performed according to the history.
Care should be taken in children where even an otitis media or upper respiratory infection
may have triggered a rigor.
It should be remembered that rigors can be an early symptom in septicaemia, particularly
meningococcal septicaemia.
[4]
Appropriate care should be taken to examine for rashes as
well as signs of meningism, especially in children.
A history of rigors in the night may be followed by signs of a pneumonia the next day.
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Differential diagnosis
The classic differential diagnosis for rigors includes:
Biliary sepsis (part of Charcot's triad)
[5]
Pyelonephritis
Visceral abscess (including lung, liver and paracolic)
Malaria
It is important in children to differentiate a rigor from a febrile convulsion. In adults care should be taken to
differentiate from a fit or convulsion.
A review of the recent literature demonstrates the range of conditions associated with rigors. These may be:
Cardiac:
Infective endocarditis
Pericarditis
Lemierre's syndrome
[6] [7]
Dressler's syndrome
[8]
Pulmonary:
Pneumonia
[9] [10] [11]
Severe acute respiratory syndrome (SARS)
[12] [13]
Genitourinary:
Urinary tract infections
Pyelonephritis
Prostatitis
Prostate cancer
[14]
Obstetric:
[15]
Over half of parturients experience shaking rigors
Epidurals and fever seem to be associated with the rigors
Rheumatological:
Septic arthritis
[16]
Rheumatic fever
Infectious diseases:
Meningococcal septicaemia
[4]
Malaria
[17]
Rat bite fever
[18]
Filariasis
[19]
Brucellosis
[20] [21] [22]
Tuberculosis (miliary)
[23] [24] [25]
Lyme disease
[26]
Louse-borne relapsing fever (endemic in Ethiopia)
[27]
GI:
Gastroenteritis
Acute cholangitis
[5]
Ulcerative colitis
[28]
Drug reactions (usually intravenous)
[29] [30]
:
Jarisch-Herxheimer reaction
[29] [31]
Gentamicin
Vancomycin
Interleukin II
Amphotericin B
Anti-TNF alpha drugs
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Transfusion reactions:
30% of transfusion reactions are associated with rigors
[32]
Many types of blood product transfusions
Dermatological:
Generalised pustular psoriasis
[33]
Any severe generalised rash, especially in children
Iatrogenic:
Haemodialysis
[34]
After radiotherapy
[35]
After bone marrow transplant
Catheterisation
[3] [36]
Postoperative infections
Investigations
This will depend on the clinical assessment and likely cause. Very often history and examination will reveal a
source of infection, and treatment can be commenced without extensive investigation. However, in children,
extreme care should be taken and hospital admission will usually be indicated particularly when the child remains
febrile and no source of infection is found (the pyrexia of unknown origin (PUO)).
The following list is not exhaustive. In particular, an ill child investigation is likely to include:
Screening for infection, and basic blood tests:
Full blood count, urea and electrolytes, erythrocyte sedimentation rate, C-reactive protein,
and liver function tests
Blood cultures
Urine for microscopy and culture
Lumbar puncture and cerebrospinal fluid analysis
Imaging:
Chest X-ray
CT scan
MRI scan
Management
Temperature-lowering measures, particularly in children, are important.
It is important to find and treat the source of infection.
It is likely that hospitalisation will be required for diagnosis and treatment if the patient remains unwell
and febrile. Admission to hospital is more likely to be required in children and in the elderly.
Further reading & references
1. McCabe WR, Treadwell TL, De Maria AJr ; Pathophysiology of bacteremia. Am J Med. 1983 Jul 28;75(1B):7-18.
2. Tal Y, Even L, Kugelman A, et al ; The clinical significance of rigors in febrile children. Eur J Pediatr. 1997 Jun;156(6):457-9.
3. Pfitzenmeyer P, Decrey H, Auckenthaler R, et al ; Predicting bacteremia in older patients. J Am Geriatr Soc. 1995
Mar;43(3):230-5.
4. Yung AP, McDonald MI; Early clinical clues to meningococcaemia. Med J Aust. 2003 Feb 3;178(3):134-7.
5. Rahman SH, Larvin M, McMahon MJ, et al; Clinical presentation and delayed treatment of cholangitis in older people. Dig
Dis Sci. 2005 Dec;50(12):2207-10.
6. Leugers CM, Clover R; Lemierre syndrome: postanginal sepsis. J Am Board Fam Pract. 1995 Sep-Oct;8(5):384-91.
7. Koay CB, Heyworth T, Burden P; Lemierre syndrome--a forgotten complication of acute tonsillitis. J Laryngol Otol. 1995
Jul;109(7):657-61.
8. Payne CM, Winwood RS; Rigors in Dressler's syndrome. J R Soc Med. 1982 Aug;75(8):672-3.
9. Falagas ME, Siempos II, Tsakoumis I; Cure of persistent, post-appendectomy Klebsiella pneumoniae septicaemia with
continuous intravenous administration of meropenem. Scand J Infect Dis. 2006;38(9):807-10.
10. Musgrave T, Verghese A; Clinical features of pneumonia in the elderly. Semin Respir Infect. 1990 Dec;5(4):269-75.
11. Cockcroft DW, Stilwell GA; Lobar pneumonia caused by Mycoplasma pneumoniae. Can Med Assoc J. 1981 Jun
1;124(11):1463-8.
12. Bhaskar G, Lodha R, Kabra SK; Severe acute respiratory syndrome (SARS). Indian J Pediatr. 2003 May;70(5):401-5.
Page 3 of 4
13. Lee N, Hui D, Wu A, et al ; Amajor outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003 May
15;348(20):1986-94. Epub 2003 Apr 7.
14. Le BH, Rosenthal MA; Prostate cancer presenting with fever and rigors. Intern Med J. 2005 Oct;35(10):638.
15. Benson MD, Haney E, Dinsmoor M, et al; Shaking rigors in parturients. J Reprod Med. 2008 Sep;53(9):685-90.
16. Margaretten ME, Kohlwes J, Moore D, et al; Does this adult patient have septic arthritis? JAMA. 2007 Apr 4;297(13):1478-
88.
17. Mendiratta DK, Bhutada K, Narang R, et al; Evaluation of different methods for diagnosis of P. falciparum malaria. Indian J
Med Microbiol. 2006 Jan;24(1):49-51.
18. Elliott SP; Rat bite fever and Streptobacillus moniliformis. Clin Microbiol Rev. 2007 Jan;20(1):13-22.
19. Wijeyaratne SM, Sheriffdeen AH; The swollen leg: is it deep vein thrombosis? The experience of a tertiary referral center in
Sri Lanka. Ceylon Med J. 2002 Mar;47(1):16-8.
20. Memish ZA, Alazzawi M, Bannatyne R; Unusual complication of breast implants: Brucella infection. Infection. 2001
Oct;29(5):291-2.
21. Memish ZA, Bannatyne RM, Alshaalan M; Endophlebitis of the leg caused by brucella infection. J Infect. 2001
May;42(4):281-3.
22. Memish ZA, Mah MW; Brucellosis in laboratory workers at a Saudi Arabian hospital. Am J Infect Control. 2001 Feb;29(1):48-
52.
23. Lowry KJ, Stephan KT, Davis CE; Miliary tuberculosis presenting with rigors and developing unusual cutaneous
manifestations. Cutis. 1999 Jul;64(1):23-8.
24. al Attia HM, Shanaa ZA, al Ahmad YM; Prolonged fever and rigors in disseminated tuberculosis. Postgrad Med J. 1994
May;70(823):383.
25. Harvey C, Eykyn S, Davidson C; Rigors in tuberculosis. Postgrad Med J. 1993 Sep;69(815):724-5.
26. Maloy AL, Black RD, Segurola RJ Jr; Lyme disease complicated by the Jarisch-Herxheimer reaction. J Emerg Med. 1998
May-Jun;16(3):437-8.
27. Daniel E, Beyene H, Tessema T; Relapsing fever in children--demographic, social and clinical features. Ethiop Med J.
1992 Oct;30(4):207-14.
28. Hawkes ND, Mutimer D, Thomas GA; Intermittent jaundice and rigors in a patient with longstanding ulcerative colitis.
Postgrad Med J. 2001 Jun;77(908):406-7, 412-3.
29. Greenberger PA; 8. Drug allergy. J Allergy Clin Immunol. 2006 Feb;117(2 Suppl Mini-Primer):S464-70.
30. Smak Gregoor PJ, van Saase JL, Weimar W, et al; Fever and rigors as sole symptoms of azathioprine hypersensitivity.
Neth J Med. 1995 Dec;47(6):288-90.
31. See S, Scott EK, Levin MW; Penicillin-induced Jarisch-Herxheimer reaction. Ann Pharmacother. 2005 Dec;39(12):2128-30.
Epub 2005 Nov 15.
32. Henderson RA, Pinder L; Acute transfusion reactions. N Z Med J. 1990 Oct 24;103(900):509-11.
33. Iizuka H, Takahashi H, Ishida-Yamamoto A; Pathophysiology of generalized pustular psoriasis. Arch Dermatol Res. 2003
Apr;295 Suppl 1:S55-9. Epub 2003 Jan 25.
34. Archibald LK, Khoi NN, Jarvis WR, et al; Pyrogenic reactions in hemodialysis patients, Hanoi, Vietnam. Infect Control Hosp
Epidemiol. 2006 Apr;27(4):424-6. Epub 2006 Mar 29.
35. Devereux S, Hatton MQ, Macbeth FR; Immediate side effects of large fraction radiotherapy. Clin Oncol (R Coll Radiol).
1997;9(2):96-9.
36. Singh B, Depner TA; Catheter related bacterial infections mimic reactions to exogenous pyrogens during hemodialysis.
ASAIO J. 1994 Jul-Sep;40(3):M674-7.
Original Author: Dr Richard Draper Current Version: Dr Richard Draper
Last Checked: 22/03/2010 Document ID: 2737 Version: 21 EMIS
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