PENATALAKSANAAN DEMAM

( Approach to Fever )

Dr. Paul.N. Harijanto, Sp.PD-KPTI

Divisi Penyakit Tropik & Infeksi
Departemen Penyakit Dalam ,
RSU Bethesda Tomohon/ FK UNSRAT
Manado
Fever is one of the most common
reason for caregivers to seek medical
attention
Up to 22% of the visits to the
emergency department by children
are for 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
VARIATION IN TEMPERATURE
Anatomic variation
Physiologic variation:
Age
Sex
Exercise
Circadian rhythm
Underlying disorders
NORMAL BODY TEMPERATURE

Maximum normal oral temperature

At 6 AM : 37.2
At 4 PM : 37.7
PHYSIOLOGY OF FEVER
Pyrogens:
Exogenous pyrogens:
Bacteria, Virus, Fungus, Allergen,
Endogenous pyrogen
Immune complex, lymphokine,
Major EPs: IL1, TNF, IL6
PHYSIOLOGY OF FEVER

Exogenous pyrogen Activated leukocytes

Endogenous pyrogen(IL1,TNF,)
Acute Phase Response
Preoptic area of anterior hypothalamus (PGE2)
increase of set point =>
Brain cortex
Vasoconstriction heat conservation
Muscle contraction heat production FEVER
 Method of Temperature Measurement
Rectal gold standard
Oral reflect core
temperature in older child
able to cooperate; is
altered by ingestion of
hot or cold food or liquids
Axillary reflects surface
temp ; low sensitivity
Tympanic accurate;
commonly used
Definition of fever
Normal - 98.6 F (37 C) with a diurnal
fluctuation between 97 and 100.4
Mild Fever- 100.5 to 101.2F (38-38.5C)
Moderate Fever 101.2 to 105F (39-40.5C)
High Fever - > 105F (40.5C)
Harmful Fever - > 107F
Effects of Fever
The effects of fever in otherwise healthy
children include discomfort,dehydration
and seizures. Usually fever is non-harmful
and self-limited.
Children with underlying medical
problems are more likely to experience
complications of fever.
Normal Temperatur Tubuh
Di ukur secara ORAL
Paling rendah jam 6.00 pagi, 37,2C (98,9F)
Paling tinggi jam 18.00 sore, 37.7 C (99,9F)
Normal variasi 0,5 C 1 C
Rectal temperatur lebih Tinggi 0,4 C
Di urnal variation
Wanita lebih tingi pria
DEFINISI

Demam/ Fever : > 37,7 C

Hyperpyrexia : > 41.1 C
Malaria :
Temp > 41C Malaria Berat
PASIEN DENGAN DEMAM
Brapa lama Demam ?

Demam
Akut Infeksi kronik :
< 14 hari TBC, Endokarditis, HIV/AIDS
Lepra
DEMAM
Malignancy :
Leukemia, Limfoma
Demam
Kronik
> 14 hari Imunologik :
SLE, RA,
Duration of Fever ( Lama
Demam )
1 3 days 3 - 7 days 8 14days > 14 days ( 2 weeks )

Simple fever Most of Infection :

Viral infec.: Bacterial Infection : Chronic Infection
Resp. Typhoid fever TBC
Epstein Bar Pneumonia Endocarditis
Influenzae Pyelonephritis Lepra
GIT Sepsis HIV
Exercises Parasitic : Imunological Dis :
Dehydration Malaria SLE
Injury/ Trauma Viral systemic: RA
Allergic Dengue/ DHF Sarcoidosis
J-Encephalitis Malignancy :
Myocarditis Leucaemia
Lymphoma
 TIPE DEMAM
Tipe Karakter Contoh

Kontinyu Terus menerus tinggi Tifoid, DHF, drug fever

beda 0,5-1 C
Intermiten Temp turun sampai Infeksi piogenik,
normal setiap hari limfoma, TBC,
Remiten Fluktuasi harian > 2C, Malaria
tapi tak pernah normal
Berulang Suhu turun sampai Malaria
(Relaps) normal bbrp hari
meningkat lagi
 CONSEQUENCES OF THE GENERAL CLINICAL RESPONSES TO INFECTION AND INFLAMMATION
Sign/symptom Metabolic effect Benefit for host
Increased energy consumption is required to
cause and maintain body temperature above Beneficial effect on survival at moderate increases
Fever normal (102104F (3940C)). May be detrimental with
more marked increases (e.g. >107F (>42C))
Enzyme reactions are accelerated
Decreased nutrient intake requires
catabolism of body stores for new protein No apparent benefit in infection
Anorexia synthesis
Amino acids are converted to glucose by May permit survival during the healing process after
way of hepatic gluconeogenesis trauma

Benefits of rest documented in some infections

Decreased voluntary activity reduces energy
(poliovirus, Coxsackie B4 virus) in which exercise
needs
Lethargy increases severity of clinical manifestations

Allows metabolic support to be directed to host

defense responses
Result of muscle activity and muscle
catabolism to breakdown muscle protein Generates heat to elevate body temperature
releases amino acids into the circulation
Myalgia
Provides source of amino acids for increased protein
synthesis of host defense molecules and cells
PENYEBAB DEMAM NO
DIMANA INFEKSINYA ?
INFEKSI :
BAKTERI ORGAN/SYSTEM TERLIBAT
VIRUS -Respiratory MALARIA
PARASIT -Gastro-intestinal
JAMUR DENGUE
MALIGNANCY -Uro-genital
IMMUNOLOGIK -Upper respiratory YES
-Ear-nose-throat TETES
TEBAL/
-Eyes RDT
-CNS
PENYEBAB ?
Differential Leukosit Hb, Leuko ,
Trombo, Ht
Eos : parasit
Neutro : bakteri
LEUKO GRAM +
Limfo : gram -; virus
Mono : virus
GRAM ve; VIRUS, PARASIT
Tatalaksana pada Pasien
1. Anamnesa : Lama & keluhan lainnya
Obat, tindakan bedah/dental
Prostetic material/ implanted device
Riwayat pekerjaan : kontak dgn binatang,
bahan toxic, antigen/ agent infectious
Tempat tinggal/ riwayat perjalanan
Riwayat imunisasi/ obat prophylaktis
Hobby, kebiasaan, perilaku tertentu
Riwayat keluarga/ lingkungan
Ethic tertentu
Clinical History
HISTORY
Travel history - Bioterrorism & fever
Occupational
PHYSICAL EXAMINATION :
Temperature - Spleen
Mouth - Lymph nodes
Eyes
Making a decission : - Is the patient ill ?
Laboratory Investigation
MANAGEMENT : Isolation & Treatment
 Fever in Returning Travellers

COMMON UNCOMMON
Malaria Dengue
No Diagnosis made Thyphoid
Tuberculosis
Respiratory Infection
Acute HIV Infection
Diarrheal Disease Acute Schistosomiasis
Urinary Tract Infection Rickettial infec.
Viral Hepatitis Amoebiasis
 Pemeriksaan Fisik :
Tanda vital
Pengukuran temperatur aksiler tidak akurat
Skin ( rash)
Kelenjar limfe
Mata
Kardiovaskuler & respiratory
Abdomen : Hepar & Lien, ascites,
Muskuloskeletal( Artritis), saraf
Rectal Examination
Penis, prostate, scrotum, testes
Wanita : pem.gynaecologik
 LABORATORIUM :
Leukosit & Differential
Hb, Trombosit, PCV,LED
Malaria smear
Urinalisis
Bacterial smear
Tes Antigen
Tes Serologik
Microskopic tinja
Kimia Darah :
Elektrolit, gula darah, ureum, kreatinin,
LFT
Mikrobiologik :
Radiologik
DANGER POINT IN ACUTE FEVER

Petechial/ purpuric rash

Travel (risk of malaria)
Chills/ rigors
Extreme of age
Neurologic sign
Asplenia
Hypogammaglobinaemia
Post bone marrow transplant
 TREATMENT OF FEVER

Most fevers are associated with

self-limited infections, most

commonly of viral origin.

TREATMENT OF FEVER
Reasons not to treat fever:
The growth and virulance of some organisms
Host defense-related response
Fever is an indicator of disease
Adverse effect of antipyretic drugs
Iatrogenic stress
Social benefits
DISCOMFORT DUE TO FEVER
For each 1 C elevation of body temperature:
Metabolic rate increase 10-15%
Insensible water loss increase
300-500ml/m2/day
O2 consumption increase 13%
Heart rate increase 10-15/min
TREATMENT OF FEVER
Reasons to treat fever:
The elderly individual with pulmonary or cardiovascular
disease
The patient at additional risk from the hypercatabolic state
(Poor nutrition, Dehydration)
The young child with a history of febrile convulsions
Toxic encephalopathy or delirium
Pregnant women (contraversy)
For the patient comfort
Hyperpyrexia
Treatment Fever
Oral Aspirin ( Anak # ReyeS Syndr)
Acetaminophen
NSAID ( ibuprofen, diclofenac )
Non-drugs :
Cooling : blangket, Fan, AC, Teppid sponge, ice bath.
IV Fluid
Internal cooling : gastric/ peritoneal lavage with
ice, hemodyalisis
IV dantrolene sodium 1 2,5 mg/kg BB/ 6 jam
Procainamide
 Treatment Strategies
Acetaminophen is generally a first-line
antipyretic due to being well tolerated
with minimal side effects.
Pediatric dose: 10-15mg/kg q4-6h (2400mg/day);
adult: 650mg q 4 h(4000mg)
Can be hepatotoxic in high doses; can upset stomach
FEVER & RASH
Centrally distributed Maculopapular Eruptions :
Measles, German measles, Primary HIV, Infec.
Mononuc.,leptospirosis, Typhoid, Rheumatic fever, SLE, Lyme
Peripherial Eruptions :
Secondary Syphylis, Hand Foot Dis, Endocarditis
Confluent Desquamtive Erythemas
Scarlet fever, TSS, Toxic epidermal necrolysis, Kawasaki dis.
Vesiculobullous Eruptions :
Hand foot Dis, Varicella, Diss. Herpes infec.,
Urticarial Eruptions
Urticarial vasculitis
Nodular Eruptions
Diss. Eruption
Purpuric Eruptions :
Viral Haemorhagic fever ( DHF), acute meningococaemia,
Eruptions with Ulcers & Eschars
Tularemia, Anthrax
 ACUTELY ILL FEBRILE PATIENT

History:nonspecific, onset, progression,

host factor ( immune status), source of
infection
Physical Examination :
Specific Presentations ;
SEPSIS
NEUROLOGIC INFECTIONS ( Bacterial
meningitis, Brain abcess, Cerebral Malaria, )
FOCAL SYNDROME WITH FULMINANT COURSES
 DETEKSI DINI KASUS MALARIA

Trias Malaria
Anamnesa Riwayat Perjalanan

Demam/Riwayat Demam, Berkemah/Berburu/

Sakit kepala Riwayat Pakai Obat Malaria
Pendatang/Pelancong
Keadaan non-imun

Pemeriksaan Fisik
Limpa, Hati, Kel. Limfe,
Ikterik, Petekien, Urin, Gangguan kesadaran

LEPTOSPIROSIS DEMAM TIFOID MALARIA DEMAM DENGUE

Mikrosk/ QBC / Rapid test Nyeri Otot
Trias Malaria Rash petekien
Nyeri Otot Keluhan Abdomen
Pucat/ anemis Tes Rumpel Leede
Nyeri Betis Bradikardi relatif
Splenomegali
Perdarahan
Rose spot

Pengobatan Malaria
PAKATUAN WO PAKALAWIREN
Sampai Baku Dapa !
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT Manado
RSU Bethesda -Tomohon

Telp.:
0431-356829 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com