difference between prolonged fever and saddleback fever

Never give a child aspirin, as this increases the risk of . [Open Forum Infect Dis 2020;7:ofaa375]. FOIA Patients were categorized as having prolonged fever (lasting >7 days), saddleback fever (defined as recurrent fever which lasts for <24 hours, after defervescence beyond day 7 of illness), or controls if their fever was 7 days. Hospitalized COVID-19 patients with prolonged fever showed more pronounced inflammatory response and were more likely to require ICU admission than cases with saddleback fever or with fever lasting Members of the National Centre for Infectious Diseases COVID-19 Outbreak Research Team. None had symptoms of urinary tract infection, thrombophlebitis, or Clostridioidesdifficile diarrhea. Statistical analyses were performed with the Mann-Whitney U test (*P<.05; **P<.01; ***P<.001). Angela Chow Li Ping, Brenda Sze Peng Ang, Chen Seong Wong, Cheng Chuan Lee, Ding Ying, Jun-Yang Tay, Kalisvar Marimuthu, Lawrence Soon U. Lee, Yee-Sin Leo, Li Min Ling, Li Wei Ang, Lin Cui, Mark I-Cheng Chen, Monica Chan, Mucheli Sharavan Sadasiv, Oon-Tek Ng, Pei Hua Lee, Poh Lian Lim, Sapna Pradip Sadarangani, Shawn Vasoo, Stephanie Sutjipto, Tsin Wen Yeo, Tze Minn Mak. Statistical data analysis on the types of fevers A fever is a rise in your body temperature. 2013 Oct 20;20(1):75. doi: 10.1186/1423-0127-20-75. Interestingly, there are also higher plasma levels of IL-1RA in patients with prolonged fever compared with control patients. Available at: Wang D, Hu B, Hu C, et al. Fever duration was longer in patients 6 to 12 months old and 12 to 18 . PLoS One. Conclusions: ELIZABETH C. HERSCH, COL, MC, USA, AND C. ROBERT, OH, LTC, MC, USA. Nevertheless, as patients in the ICU are at higher risk of nosocomial infections, due diligence should be done to exclude other causes of fever [17]. If there are no potentially diagnostic clues, the patient should undergo a minimum diagnostic workup, including a complete blood count, chest radiography, urinalysis and culture, electrolyte panel, liver enzymes, erythrocyte sedimentation rate, and C-reactive protein level testing. Results: Repeat laboratory investigations and CXR were done for those with prolonged or saddleback fever and collected. On repeat testing, prolonged fever was associated with a drop in hemoglobin and a rise in CRP and LDH (Table 2). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Background: Both prolonged (27.8% vs 0.9%, p <0.01) and saddleback fever (14.3% vs 0.9%, p= 0.03) were associated with hypoxia compared to controls. Symptoms of RSV include runny nose, cough, fever, and . Saddleback fever refers to biphasic fever with an initial peak that remits and appears again. Rash. Elevated lactate dehydrogenase levels can be indicative of infectious and malignant causes of FUO, including malaria, lymphoma, and leukemia.15,21 Measurement of ferritin levels may also be helpful.33 An elevated ferritin level in prolonged febrile illness may indicate malignancy (especially myeloproliferative disorders) and other noninfectious inflammatory diseases, such as systemic lupus erythematosus or temporal arteritis.21,33 One study established a ferritin level of 561 ng per mL (1,261 pmol per L) as the optimal cutoff value to predict that FUO was due to a noninfectious cause.22 Extreme elevation of ferritin levels (greater than 1,000 ng per mL [2,247 pmol per L]) can point to adult Still disease.34 Infection is the most common reason ESR is extremely elevated, but if there is no evidence of infectious causes, clinicians should consider malignancy, renal disease, and inflammatory disorders if the ESR is 100 mm per hour or greater.29. Fever of unknown origin has been described as a febrile illness (temperature of 101F [38.3C] or higher) for three weeks or longer without an etiology despite a one-week inpatient evaluation. In particular, fever was reported in about 72%98.6% of patients, usually lasting <7 days [4, 710]. Despite being an anti-inflammatory cytokine that acts as a modulator for the IL-1 pathway [22, 23], IL-1RA has been found to be also associated with increased viral load, lung injury, and severe clinical outcomes [20]. However, this view of fever is merely an oversimplification as a growing body of evidence now suggests that fever represents a complex adaptive response of the host to various immune challenges whether infectious or non-infectious. Additional searches included the Cochrane database, Essential Evidence Plus, the Agency for Healthcare Research and Quality evidence reports, and the National Guideline Clearinghouse. Demographics were similar across the 3 groups (Table 1); 7.0% (10/142) of patients had comorbidities, such as diabetes (n=4), ischemic heart disease (n=3), and asthma (n=3). Adverse outcomes were hypoxia, intensive care unit (ICU) admission, mechanical ventilation, and mortality. Search for other works by this author on: Singapore Immunology Network, Agency for Science, Technology and Research, Department of Biological Sciences, National University of Singapore, National University of Singapore Graduate School for Integrative Sciences and Engineering, National University of Singapore, Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, National Centre for Infectious Diseases COVID-19 Outbreak Research Team. Our cohort only had 1 mortality, and this may be reflective of the overall low mortality rate in Singapore. 2016 May 20;10(5):e0004575. Would you like email updates of new search results? official website and that any information you provide is encrypted . Although DHF and SD were more likely to occur in patients in those with saddleback fever, DSS was not. The 4 cases who were excluded from the primary analysis demonstrated a saddleback pattern of fever that lasted >24 hours. Methods We conducted a hospital-based case-control study of patients admitted for COVID-19 with prolonged fever (fever >7 days) and saddleback fever (recurrence of fever, lasting <24 hours, after defervescence beyond day 7 of illness). National Centre for Infectious Diseases COVID-19 Outbreak Research Team, See this image and copyright information in PMC. sharing sensitive information, make sure youre on a federal Trials. This study demonstrates that prolonged fever may be associated with various warning signs and more severe forms of dengue (SD, DSS, DHF), while saddleback fever showed associations with DHF and SD but not DSS. Saddleback fever was present in 165 (5.8%). Dengue fever is gaining importance in Singapore with an increase in the number of cases and mortality in recent years. sharing sensitive information, make sure youre on a federal Confirmed imported case of novel coronavirus infection in Singapore; multi-ministry taskforce ramps up precautionary measures. A comprehensive history and physical examination should be performed if there are no localizing signs and symptoms in patients with prolonged febrile illness. Lancet 2020; 395:497506. This corresponded with a rise in CRP and LDH seen in cases with prolonged fever, which are known to be associated with adverse prognostic factors in COVID-19 [15, 16]. In contrast, cases with saddleback fever showed no significant change upon repeating their laboratory tests. JAMA 2020; 323(11):10619. In one study of patients with FUO, chest and abdominal CT had high sensitivity (82% and 92%, respectively) and were recommended if the initial evaluation was unrevealing.15 CT specificity ranged from 60% to 70%, consistent with other case series.15,16 Echocardiography is recommended if there are clinical indications of endocarditis.5,20 Venous Doppler ultrasonography is indicated for suspected thromboembolism.20 Magnetic resonance imaging of the aortic arch and great vessels of the neck was shown to be helpful when vasculitis was suspected.36, Nuclear imaging studies are noninvasive, image the whole body, and can localize a potential infectious or inflammatory cause for FUO.5,14,19,3740 Recently, 18F fluorodeoxyglucose positron emission tomography technology has been evaluated for guiding further invasive testing, especially in patients who have an elevated ESR or CRP level.14,37 The 18F fluorodeoxyglucose is taken up by inflammatory and cancer cells because of their high rate of glucolysis.14,18,37 Several studies examining this method in patients with FUO found diagnostic yields ranging from 16% to 69%,15,37,38 with a high positive predictive value (93%) and negative predictive value (100%).39,40 A hybrid of CT and 18F fluorodeoxyglucose positron emission tomography has a higher diagnostic yield (sensitivity of 56% to 100%; specificity of 75% to 81%18). An official website of the United States government. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy. A prolonged fever of unknown origin (FUO) is simply one that lasts longer than usual, for example, more than the seven to 10 days that you would expect with a simple viral infection. Ying-Hao P, Yuan-Yuan G, Hai-Dong Z, Qiu-Hua C, Xue-Ran G, Hai-Qi Z, Hua J. Although there are more than 200 diseases in the differential diagnosis, most cases in adults are limited to several dozen possible causes. Patients with saddleback fever appeared to have good outcomes regardless of the fever. A dysregulated immune response in COVID-19 has been postulated to lead a deleterious cytokine storm [12]. Cases without prolonged or saddleback fever were included as controls. In health, body temperature is regulated around a set point of 37 1C, and a circadian temperature rhythm exists in which the highest temperature of each day occurs around 6 p.m. Cases with prolonged fever were also more likely to require ICU admission compared with controls (11.1% vs 0.9%; P = .05). Epub 2020 Oct 21. Cytokines were determined with multiplex microbead-based immunoassay for a subgroup of patients. Prolonged fever is associated with adverse outcomes in dengue viral infection. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). JAMA Intern Med. Seven more confirmed cases of novel coronavirus infection in Singapore. Keywords: Patient information: See related handout on fever of unknown origin in adults, written by the authors of this article. Similar fever patterns are observed in COVID-19 with unclear significance. Cases with saddleback fever were defined as patients with recurrence of fever lasting <24 hours, after defervescence, beyond day 7 of illness. This circadian rhythm may differ among individuals but should be consistent in each person . B, Comparison of immune mediator levels in patients with prolonged fever (n=11), patients with saddleback fever (n=8), and patients with fever that lasted 7 days (control; n=56). PLoS Negl Trop Dis. Fever of unknown origin (FUO) in adults is one of the most vexing clinical conditions for clinicians and patients. Prolonged fever in children: review of 100 cases. Notably, in a study of 3 COVID-19 patients, peak IL-1 appeared to precede the nadir of lung function [33], which may herald worsening inflammation. 2 A diagnosis of classic KD is made in patients with prolonged fever (five or more days) and four or more of the following principal . PMC Infections predominate early in FUO diagnoses, and the longer FUO remains undiagnosed, the less likely it is caused by an infection.27 After infections, the etiology of FUO transitions to noninfectious inflammatory diseases and malignancies, which can guide subsequent testing. Cases with prolonged fever were also more likely to require ICU admission compared with controls (11.1% vs 0.9%; P=.05). Plasma immune mediator levels in COVID-19 patients experiencing different fever patterns. Careers. A lower IP-10 level is consistent with the finding that saddleback fever cases tend to have better clinical outcomes than prolonged fever cases. The site is secure. Empiric antibiotics or steroids are generally discouraged in patients with fever of unknown origin. Fever of unknown origin has been described as a febrile illness (temperature of 101F [38.3C] or higher) for three weeks or longer without an etiology despite a one-week inpatient evaluation. -. In this study, saddleback fever was defined as temperature >37.5C with defervescence of at least one day, followed by a second peak lasting at least one day. A lower IP-10 level is consistent with the finding that saddleback fever cases tend to have better clinical outcomes than prolonged fever cases. Another 4 patients were excluded from the primary analysis as they had a saddleback pattern of fever that lasted >24 hours; 12.7% (18/142) of cases had prolonged fever and another 9.9% (14/142) had saddleback fever. Both prolonged fever and saddleback fever were not significantly associated with mechanical ventilation as compared with the control group (Table 1). A total of 2843 polymerase-chain reaction (PCR) confirmed dengue patients admitted to Tan Tock Seng Hospital from 2004 to 2008 were included in the study. Clinico-laboratory spectrum of dengue viral infection and risk factors associated with dengue hemorrhagic fever: a retrospective study. 2016 Dec 9;11(12):e0167025. QJM. The results of these microbiological investigations were also collected and analyzed. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. 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Note that serologic tests are helpful only if there are potentially diagnostic clues and if the patient lives in or has visited an area where the suspected disease is prevalent.15, Chest, abdominal, or pelvic computed tomography (CT) may be useful in the secondary evaluation. In patients with a prolonged febrile illness, a minimum diagnostic workup should be performed before classifying the disease process as a fever of unknown origin. Similar fever patterns are observed in COVID-19 with unclear significance. A larger cohort might help to improve our understanding of these patients. Search dates: November 28, 2011; February 8, 2012; and April 18, 2014. J Microbiol Immunol Infect. For cytokine profiling, the Mann-Whitney U test was applied to ascertain significant differences in immune mediator levels between patients experiencing different fever patterns. Higher respiratory rate, lower SpO2, and lower systolic BP were also associated with saddleback fever compared with the control group. For most people, a temperature of 98.6 F or 37 C is baseline. https://www.moh.gov.sg/content/moh_web/home/Publications/Reports/2006/co http://www.who.int/tdr/publications/documents/dengue-swg.pdf, Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Joen AG, et al. Singapore reported its first imported case of COVID-19 in a traveler from Wuhan on January 23, 2020, followed by its first locally transmitted case on February 7, 2020 [2, 3]. Grasselli G, Greco M, Zanella A, Albano G, Antonelli M, Bellani G, Bonanomi E, Cabrini L, Carlesso E, Castelli G, Cattaneo S, Cereda D, Colombo S, Coluccello A, Crescini G, Forastieri Molinari A, Foti G, Fumagalli R, Iotti GA, Langer T, Latronico N, Lorini FL, Mojoli F, Natalini G, Pessina CM, Ranieri VM, Rech R, Scudeller L, Rosano A, Storti E, Thompson BT, Tirani M, Villani PG, Pesenti A, Cecconi M; COVID-19 Lombardy ICU Network. Home or community isolation facilities are commonly used globally for less sick patients such that hospital beds are free up to cater for sicker patients. Author disclosure: No relevant financial affiliations. A total of 142 patients were included in the study; 12.7% (18/142) of cases had prolonged fever, and 9.9% (14/142) had saddleback fever. Plasma fractions, MeSH The classic presentation is one of fever, malaise, diffuse abdominal pain, and constipation. Recommendations of the Scientific Working Group on Dengue. Although there were no significant differences in white blood cell counts or absolute values of lymphocytes and CRP, we found significant differences in plasma IL-6 and IP-10 levels between the prolonged fever and control patients. Copyright 2023 American Academy of Family Physicians. Those with prolonged fever had a median duration of fever (interquartile range [IQR]) of 10 (9-11) days for prolonged fever cases, while fever recurred at a median (IQR) of 10 (8-12) days for those with saddleback fever. Another limitation of our study is that onset of fever was dependant on self-reporting by patients. Extreme poverty first: An argument on the equitable distribution of the COVID-19 vaccine in Peru. Cases with prolonged fever were found to have higher levels of anti-inflammatory IL-1RA, pro-inflammatory IL-6, and chemokine interferon- IP-10 compared with controls (Figure 1B). Previous testing (ESR, complete blood count, electrolyte panel, chest radiography, urinalysis, blood culture) may be repeated periodically to evaluate for trends as the illness evolves. Upon admission, all patients underwent a chest x-ray (CXR), admission full blood count (FBC), renal and liver panel, C-reactive protein (CRP), lactate dehydrogenase (LDH), and nasopharyngeal swab for SARS-CoV-2 PCR. If the diagnosis remains elusive, 18F fluorodeoxyglucose positron emission tomography plus computed tomography may help guide the clinician toward tissue biopsy. Clipboard, Search History, and several other advanced features are temporarily unavailable. Unauthorized use of these marks is strictly prohibited. Over- or under-reporting of the onset of fever before admission could affect the number of patients found to have prolonged or saddleback fever. HHS Vulnerability Disclosure, Help However, as the number of patients with prolonged fever requiring ICU admission is small in this cohort, further studies should be done to prove this correlation. Mucosal bleeding, anorexia, diarrhea, abdominal pain, nausea or vomiting, lethargy, rash, clinical fluid accumulation, hepatomegaly, nosocomial infection, leukopenia, higher neutrophil count, higher hematocrit, higher alanine transaminase (ALT) and aspartate transaminase (AST), higher creatinine, lower protein and prolonged activated partial thromboplastin time (APTT) were significantly associated with prolonged fever but not platelet count or prothrombin time (PT). Epub 2022 Aug 11. Published by Oxford University Press on behalf of Infectious Diseases Society of America. Approval for data collection by retrospective chart review with a waiver of written informed consent from study participants was granted by the Singapore Ministry of Health under the Infectious Diseases Act as part of the outbreak investigation [14]. Laboratory Results for Prolonged and Saddleback Fever. Statistical analyses were performed with the Mann-Whitney. Potentially diagnostic clues should be sought during the history and physical examination to guide further evaluation of prolonged febrile illness. Response in COVID-19 has been postulated to lead a deleterious cytokine storm [ 12 ] in the of... Is one of fever was present in 165 ( 5.8 % ) content of the fever 200 Diseases the., Hai-Qi Z, Qiu-Hua C, Xue-Ran G, Hai-Dong Z, Qiu-Hua,. The 4 cases who were excluded from the primary analysis demonstrated a saddleback pattern fever... Microbiological investigations were also associated with adverse outcomes in dengue viral infection a child aspirin, as increases. 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