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					Profile and clinical manifestations
of patients suffering from febrile
 illness admitted in a tertiary care
               setting




Guided by:                                 submitted by:
             Dr.Zinia.T.Nujum                          Anoop. R.Nair
             Asst .Professor                           Arun.B.S
             Dept. of Community Medicine               Jyotish Raj
             Medical College, Trivandrum
                            CERTIFICATE


         DEPARTMENT OF COMMUNITY MEDICINE
           GOVERNMENT MEDICAL COLLEGE
             THIRUVANANANTHAPURAM




Certified that this report is a bonafide record of research project
undertaken to fulfill the curriculum of graduate medical education as
stipulated by Medical Council of India and was done during the year
2009-2010.


Guided by:                                       Done by:
         Dr.Zinia.T.Nujum                                   Anoop.R.Nair
         Asst .Professor                                    Arun.B.S
         Dept. of Community Medicine                        Jyotish Raj
         Medical College, Trivandrum


Date
Office Seal                                 Dr.Vijayakumar
                                             Professor and Head
                                             Dept.of community medicine
                                             Govt.Medical College,
                                             Thiruvananthapuram
                   ACKNOWLEDGMENT




First of all we would like to express our heartfelt gratitude to
Dr.Vijayakumar, Professor and Head, Department of community
medicine for supporting us and granting us permission to proceed with
our study.
              Our sincere gratitude to Dr.B.Jayakumar, Professor and
Head, Department of Internal medicine for granting permission to
conduct our study in the medicine wards.
        We would also like to thank Dr Aruna, Associate professor
Department of Internal medicine for her valuable inputs and guidance
during the course of study.
         We are indebted to our guide Dr.zinia.T.Nujum, Assistant
Professor, Department of community medicine for her support and
guidance which helped us to overcome all obstacles and complete our
project work.
      We would also like to specially thank Dr.Reshmi,Junior resident,
Department of community medicine for her timely support.
                          Contents


                                     Page No.
1. Introduction

2. Review of literature

3. Objective

4. Methodology

5. Results & discussion

6. Conclusion

7. Recommendations

8. Limitations

9. Reference
10. Proforma
Introduction


    Recently the incidence of febrile illness has increased much, and
    most with severe complications like thrombocytopenia. The
    high morbidity pattern restricts the patient from work and cause
    loss of pay. The increased mortality and morbidity pattern
    disorients the rhythm of normal life.


    Fever is only a symptom of disease which should alert the
    physician to the underlying abnormality. Careful history and
    physical examination help to identify the cause in many cases.
    Even in those cases, where the cause is evident, investigations
    are required to identify the causal factor and institute
    appropriate treatment.
Review of literature
Febrile illness is perhaps the oldest and most universally known
hallmark of disease.It occurs in all homeothermic animals like
vertebrates,birds,amphibians,reptiles etc. The thermoregulatory
mechanism behave as if they are set at a higher than normal level. The
temperature receptors then signal that the actual temperature is below
the newly set point and the temperature raising mechanisms are
activated. Endotoxins release endogenous pyrogens, mainly cytokines.
They cause release of prostaglandins in the hypothalamus. Many
microorganism grow best within a narrow range of temperature, and a
rise in temperature inhibits their growth. In addition, antibody
production is increased whe body temperature is elevated.
Fever is the abnormal elevation of temperature above 37.2 degree in
the morning and 37.7 in the evening. The normal diurnal variation is 1
degree Fahrenheit. Heat production is increased by increase in the
metabolic rate and rapid muscular contraction as in rigor. Heat loss by
radiation is reduced by peripheral vasoconstriction. Rise of temperature
may occur rapidly in pneumococcal pneumonia and influenza, or it may
be gradual an stepladder as in enteric fever and brucellosis. It is
essential to record the temperature in every four hours or even more
frequently to identify the pattern of fever.
Short febrile illness, for practical purposes, is termed as the fever
lasting for 5-7 days. Pyrexia of unknown origin is defined as a persistant
temperature of more than 38.4 degree Celsius lasting for more than 3
weeks and whose cause remain obscure despite considerable
diagnostic workup. Hyperpyrexia denotes a temperature equal to or
more than 41 degree Celsius seen as in heat stroke, neuroleptic
malignant syndrome, malignant hyperthermia and thyrotoxicosis.
Patterns of fever
1) Continuous fever- Temperature remain elevated above normal
   without touching the base line and fluctuation does not exceed 1
   degree Fahrenheit.
2) Remittent fever- Temperature fluctuation exceeds 1 degree
   Fahrenheit without touching baseline.
3) Intermittent fever- Elevated temperature rise and fall touching
   normal in between peaks.
4) Relapsing fever- Febrile episodes are separated by normal
   temperature for more than 1 day.


General accompaniments of fever
  Increase in BMR, rapid loss of weight, anorexia, dehydration,
headache, myalgia and vomiting. The heart rate is increased at a rate
of 18 beats per minute for 1 degree rise of temperature. Respiratory
rate increases along with heart rate. Rashes may occur over the skin
and mucous membrane and are of diagnostic importance.
General causes of fever
 1) Infection – bacterial, viral, rickettsial, Chlamydia, protozoal,
    fungal and helminthic. In India, the most frequent underlying
    cause of fever is infection and this has to be ruled out in all cases.

 2) Inflammatory causes not attributable to infection- connective
    tissue disorders. Eg; SLE
 3) Hypersensitivity reactions- drugs, antisera, biological products.
 4) Trauma- accidents, surgeries etc.

 5) Neurological disorders- pontine hemorrhages.


 6) Endocrine causes- hyperthyroidism, ovulation.

 7) Physical causes- heat, hyperpyrexia, post irradiation fever,
    dehydration fever in infants and children.


 8) Neoplasm- lymphoma, a/c leukemia, primary carcinoma of liver.

 9) Psychogenic causes- anxiety, maniacal excitement.


10) Severe muscular effort- convulsions, status epilepticus tetany

11) Factitious fever- malingering
Objective




1) To assess the clinical presentation and profile of patients having
   febrile illness admitted in medicine wards 1&3 of MCH
   Trivandrum between October 20 - November 17,2009.
METHODOLOGY:



  STUDY DESIGN       Descriptive Study.



  STUDY SUBJECTS     Patients admitted with short
                      febrile illness in medicine
                      wards 1&3 of MCH, TVM


  STUDY PERIOD       Oct 20 – Nov 17, 2009


  SAMPLE SIZE        144 patients having short febrile
                       febrile illness admitted in
                       medicine wards 1 & 3


  DATA COLLECTION interview technique using a Semi
   structured questionnaire
    INCLUSION CRITERIA- All febrile patients admitted in wards 1 &3
                           of MCH,Trivandrum
    EXCLUSION CRITERIA – Critically ill patients and patients who are
                           not willing for the study


 STUDY TOOLS-

                     Piloted Semi structured Questionnaire
                     Validated NRS scoring system for joint pain
                     Case sheets of patients
                     Temperature charts
                     Ultra sonogram results



      DATA ANALYSIS
                     Studied using proportions and tested the
                     association using chi-square
                     Analysis done using SPSS Version 17
      VARIABLES

       Age group-      four groups were made, below 20, 20-40,
                        above 60 for convenience
 Sex-           male and female

 Socioeconomic status- APL/BPL


 Fever duration- 5-7 days duration, fever of more than
                  7 days duration




 Fever type- continuous or intermittent type of fever

 Chills and rigor- if present or not

 . Thrombocytopenia- A count below 1,00,000 is generally
    considered to have thrombocytopenia

 Platelet transfusion- the number of pints of platelet given to
   those having thrombocytopenia is taken

 Joint pain- nrs system of scoring of pain is used; it classify
   pain into 3, mild, moderate and severe.

 Head ache- the duration and episodes of headache
   assessed, and considered present or absent

 Conjunctival congestion- examined the patient’s
   conjunctiva. Also notes on case sheets are used to assess
   conjunctival congestion
 Vomiting- the number of episodes of vomiting and number
   of days for which it persists are considered, 2-4 episodes
   for more than 2 days are considered as vomiting present.
   Rest as no vomiting

 Myalgia-those having muscle pain for more than 2 days,
  without any relief even with rest are considered as myalgia
  present

 Organomegaly – this includes both hepatomegaly and
   spleenomegaly, it is assessed by the clinical examination of
   the patient, the clinical records, the ultrasonogram results
   etc

 Bradycardia –pulse rate below 60/min during period of
   illness

 ECG changes-as recorded in case sheet

 ARDS-acute respiratory distress syndrome

 Shock

 Myocarditis

 Hemorrhagic manifestations
 ETHICAL CONSIDERATION
 Consent for the project was obtained from Head of dept of
 community medicine
Consent obtained from headof dept of medicine
        144 patients were included in the study and the clinical
        condition is as follow:




Age



            Age group                            Percentage
              Below 20                            8.3

             20-40                                47.2

             40-60                                37.5

             >60                                  6.9




According to our study 47.2% of patients with thrombocytopenia
belongs to the economically productive group, ie 20-40 years of age
Socioeconomic status



      Socioeconomic status                    Percentage

            APL                                51.4

            BPL                                48.6




According to our study 48.6% of patients with thrombocytopenia
belong to the BPL category.
Sex




               sex                            Percentage

               male                             52.1

               female                           47.9




52.1% of our study subjects having fever with thrombocytopenia where
males.
Fever duration




Fever duration                     Percentage
5-7 days                           53.5

>7days                             46.5




53.5% of study subjects with thrombocytopenia had a fever of duration
of 5-7 days.
Type of fever




           Type fever                         Percentage

             intermittent                       75.7

             continuous                         24.3




75.7% of patients with thrombocytopenia had intermittent type of
fever. Rest 24.3% had continuous type of fever.




  RESULTS & DISCUSSION
Signs and symptoms          % of cases




  Myalgia                     97.2


  Joint pain                  80.6



  Headache                    79.2



  Vomiting                    75.7


  Conjunctival congestion     27.8


  0rganomegaly                45.8
Present/NO      Count-day      Count-day         Count-day   Count-day   Count-day   Count-day   Count-day   Plt trans   No of pint
                1              2                 3           4           5           6           7           req/no      req




JOINT PAIN [NRS SCORING]

YES/NO
INTENSITY--MILD
MODERATE
SEVERE


ASSOCIATED SYMPTOMS

                                   YES              NO
HEADACHE
SORE THROAT
Conjuntivalcongestion



VOMITING
MYALGIA
BLEEDING MANIFESTATIONS
ASSOCIATED SIGNS




                      YES            NO
BRADYCARDIA
MYOCARDITIS
ORGANOMEGALY
ECG CHANGES




TREATMENT SEEKING BEHAVIOUR

Onset of illness-

Self treatment- Y/N

Treatment at local hospital- Y/N

If yes,number of days stay in local hospital -

Initiative for treatment at medical college hospital - SELF/REFFERED
Cause of delay if any :




                          PROFILE           PERCENTAGE




         Consent was obtained from all patients interviewed
  Age group 20-40            47.2
              40-60          37.5

 Sex- male                   52.1



 Socioeconomic status- BPL   48.6



 Fever onset within 5 days   53.5



Intermittent type of fever   75.7



Chills and rigor             63.9



Thrombocytopenia             50
Reference


  Harrison's text of internal medicine 17th Edition
  Robbins and cotran ,Textbook of pathology
  K V Krishnadas-clinical medicine 3rd Edition
  Ganong,Review of medical physiology 23rd Edition
  Park’s textbook 19th edition
  Alagappan text of Internal medicine
Conclusions

Our study conducted in medicine wards of MCH, Trivandrum include 72
patients having febrile illness with thrombocytopenia and 72 patients having
febrile illness without thrombocytopenia

Description of patient having thrombocytopenia

More than 47.2% of patients with thrombocytopenia belong to age group
between 20 to 40 yrs. About 38% of patients have platelet count below
30,000. 48.6% of patients required platelet transfusion. 97.2% patients had
myalgia,89% patients had intermittent type of fever,84.7% patients had joint
pain & headache,79.2%patients had vomiting,71%patients had chills &
rigor,55.6% had organomegaly.

      When the clinical features of patient with thrombocytopenia was
compared with those without thrombocytopenia. It was found that fever
onset within seven days was significantly more among those with
thrombocytopenia (chi square- 27.574;p-value .050). Fever of less than
seven days was 2.083 times more in those with thrombocytopenia (95%
confidence interval 1.070-4.056). Intermittent type of fever was also more
among those with thrombocytopenia (chi square value-13.626;p-
value.000) . Intermittent fever was 4.8 times more in those
withthrombocytopenia(95% confidence interval 1.9-11.5). Conjunctival
congestion was also significantly more in those with thrombocytopenia
(chisquare value16.754; p-value .000). Conjunctival congestion was 5.293
times more in those with thrombocytopenia(95% confidence interval
2.285-12.258). Organomegaly was more in those with thrombocytopenia(chi
square value 5.483;p value .019). Organomegaly was 2.212 times with
thrombocytopenia(95% confidence in 1.133-4.317)
Questionnaire- Profile of patients suffering from febrile illness
admitted in medicine wards of medical college Trivandrum




Name :                                      Sex : M/F

Age     :                                   Marital status : Married

                                                                Unmarried

DOA :

DOD :

Occupation : unemployed                     house wife                         Unskilled

                Semiskilled                 Skilled                            Professional

Education Status : illetrate                       primary

                   High school                        graduate

                   Professional/pg

Socioeconomic status :      APL                       BPL

Presence of co-morbidities : diabetes                       hypertension

                                  Osteoarthritis            chronic cardiac disease

Resting habits : squatting                     In chair

                 In bed

                                                            Clinical profile

FEVER

Onset in    Type of       Chills and
days        fever         rigor
Clinical              Odds    95%           P value   Chi value
manifestation         ratio   confidence
                              interval



Fever duration        2.083   1.040-       0.050      27.574
of less than 7                4.056
days


Intermittent          4.8     1.9-11.5     0.000      13.626
type of fever


Conjunctival          5.293   2.285-       0.000      16.754
congestion                    12.258




0rganomegaly          2.212   1.133-       0.019      5.483
                              4.317

   THROMBOCYTOPENIA
 Patients with and without thrombocytopenia were
 classified and chi-square was done. Following were
 the findings:




Conjunctival congestion    (Odd’s-5.293; 95% CI-2.2852 to 12.258)
Intermittent type of fever (Odd’s-4.8; 95% CI-1.9 to 11.5) .
Fever duration of less than 7 days (Odd’s-2.083; 95% CI- 1.040-4.056)
Organomegaly               ( Odd’s-2.212, 95% CI- 1.133-4.317)
Recommendations




 Since, majority of patients belong to economically
  productive group, adequate measures should be taken to
  diagnose cases early, limit the morbidity and its impact on
  economy.


 Patient presenting with intermittent fever, conjunctival
  congestion, fever onset within 5 days should be suspected
  and investigated for thrombocytopenia


 Measures should be instituted to reduce the complications
  and morbidity.
Limitations



  Since it is a tertiary hospital we cannot generalize our
   results to the general population.

  The cases were taken from only two medicine ward.

  The exact diagnosis of the cases were not made.


  The study period and the sample size was small.

  A case control study is required to explain the exact
   clinical condition.
     The incidence of Hemorrhagic fevers are increasing in the
community.the prevalent ones in our society include dengue fever,
leptospirosis etc.fever wil be associated with haemorrhagic
manifestations like petechiae, purpura ,ecchymosis, gum
bleeing,haematemesis etc..later on as the severity progresses it can
produce shock like syndrome.
      By our study we could interestingly find that 50% of our study
subjects had thrombocytopenia associated with fever.so out of
curiosity we did a cross tab analysis so as to find out whether any of our
study variables had a positive association with thrombocytopenia.we
could find that four variables,
                    1-duration of fever
                    2-type pf fever
                    3-conjunctival congestion
                     4-organomegaly
. . .had a positive association with thrombocytopenia




DURATION OF FEVER


          T+           T-      total

  <7                           77
          45           32

                               67
  >7      27           40

          72           72      144
total


Odds       - 2.083
P value   - 0.050
Chi square -27.574
95% CI       - 1.040-4.056




Type of fever


                  T+          T-   total

Continous                          35
                   8         27

                                   109
                   64        45
Intermittent
                                   144
                   72        72
total




0dds – 4.8
P value – 0.000
Chi square – 13.626
95% CI - 1.9- 11.5




CONJUNCTIVAL CONGESTION


           T+         T-   total

cc+                        40
          31          9

                           104
cc-       41         63


total     72         72    144




odds ratio- 5.293
p value -    0.000
chi square- 16.754
95% CI      -2.285-12.258




Organomegaly


            T+          T-   total

O+                           66
            40         26

                             78
            32         46
O-
total
            72         72    144




odds ratio - 2.212
p value      - 0.019
chi square - 5.483
95% CI   - 1.133-4.317




Chills and rigor
According to our study 63.9% 0f patients having febrile illness had
associated chills and rigor.




Thrombocytopenia
50% of patients having febrile illness in our study had associated
thrombocytopenia.




Myalgia
97.2% of febrile patients had associated myalgia.




Joint pain
80.6% of febrile patients had associated joint pain.




Vomiting
75.7% of the febrile patients had associated vomiting.




Headache
79.2% of febrile patients had associated headache.

				
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