By PBL 2 Supervised by Dr. Raghda Farag Fever with Jaundice By PBL 2 Supervised by Dr. Raghda Farag

ILOs Definition of fever Definition of jaundice Causes of fever with jaundice Clinical approach to diagnose fever with jaundice ILOs

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. θ in the anus ≥ 37.5-38.3ᵒC in the mouth ≥ 37.7 ᵒC axillary/otic ≥ 37.2 ᵒC Temperature in the anus (rectum/rectal) is at or over 37.5–38.3 °C (99.5–100.9 °F)[1][2] Temperature in the mouth (oral) is at or over 37.7 °C (99.9 °F)[9] Temperature under the arm (axillary) or in the ear (otic) is at or over 37.2 °C (99.0 °F)

PATTERN OF FEVER Sustained (Continuous) Fever Intermittent Fever (Hectic Fever) Remittent Fever Relapsing Fever: Tertian Fever Quartan Fever Days of Fever Followed by a Several Days Afebrile Pel Ebstein Fever Fever Every 21 Day

JAUNDICE

Jaundice – is it a disease or a sign of a disease? Yellowish staining of the skin and sclerae High levels of bilirubin in blood Jaundice is a condition in which an excess of bilirubin builds up in the blood and causes the skin and eyes to turn a yellowish color. Bilirubin is a byproduct of the process by which the liver removes dead red blood cells. Excess bilirubin can be caused by a number of health problems, many of which are serious. Jaundice with fever can be a sign of malaria, acute pancreatitis or certain liver problems. If someone shows signs of jaundice, doctors will look to treat the condition that's causing it rather than jaundice itself.

Clinical Aspects of Jaundice Clinically detectable if SB is >2.0 mg% With edema and dark skin – Jaundice may be masked What is special about the sclera ? – Rich Elastin Skin discoloration – Yellowish, - Carotinemia – Eyes N Mucosa – hard palate (in dark skinned) Greenish hue of skin and sclera - due Biliverdin – indicates long standing jaundice Generalized Pruritus – Obstructive Jaundice – Why ?

Jaundice – Classification Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg% Jaundice may be due to: Over production of Bilirubin (Hemolytic) From hemolysis of RBC Lysis of RBC precursors – Ineffective erythropoesis Impaired hepatic function (Hepatitic) Hepatocellular dysfunction in handling bilirubin Uptake, Metabolism and Excretion of bilirubin Obstruction to bile flow (Obstructive) Intrahepatic cholestasis Extrahepatic Obstruction (Surgical Jaundice)

Causes of fever with Jaundice Infectious : viral causes Viral Hepatitis A,B,C,D,E Immune deficiency , acquired (AIDS/HIV) Infectious mononucleosis Viral haemorrhagic fevers: Ebola virus Yellow fever African hemorrhagic (Marburg) virus disease Dengue fever

Bacterial Bacterial overwhelming sepsis Leptospirosis Ictohemorrhagica (Leptospirosis):Leptospiral disease/severe (Weils) type Listeria hepatitis, newborn Streptococcus/toxic shock/type A strn Toxic shock syndrome Bacterial Relapsing fever (Borrelia) Typhiod fever

Parasitic Newborn TORCH syndrome Malaria (Blackwater fever) Amebic abscess, liver Babesiosis Cryptosporidiosis Biliary Ascariasis with ascending cholangitis 

Allergic, Collagen, Auto-Immune Disorders: Autoimmune hemolytic anemia Transfusion reaction, hemolytic Evan's syndrome (AHA/Immune TP) Autoimmune hepatitis

Neoplastic Disorders Carcinoma, hepatocellular Metastatic liver disease Adenocarcinoma, pancreatic Carcinoma, gallbladder Carcinoma, biliary tree

Hereditary, Familial, Genetic Disorders: Sickle cell anemia Cirrhosis/childhood Indian type

An Approach to Jaundice & fever Is it isolated elevation of serum bilirubin ? If so, is the↑unconjugated or conjugated fraction? Is it accompanied by other liver test abnormalities ? Is the disorder hepatocellular or cholestatic? If cholestatic, is it intra- or extrahepatic? These can be answered with : History and physical examination Interpretation of laboratory tests and Radiological tests and procedures.

Diagnosis History Physical examination Blood tests - laboratory Ultrasonography CT MRI Liver biopsy ERCP Endoscopic ultrasound

Clinical History – Imp clues Duration of jaundice – Acute / Chronic Abdominal pain v/s painless jaundice Pruritus - obstructive Affect appetite – Hepatocellular infection / Malignancy Weight loss – Malignancy – CAH Colour of stools –chalky white –obstructive Family history – Hemolytic – Inherited dis. H/o transfusion, IDU Alcohol abuse, Medications.

Laboratory Tests Complete blood count Prothrombin time Bilirubin level in serum (total and direct) Aminotransferase Alkaline phosphatase U/A for bilirubin and urobilogen Complete blood count Prothrombin time Other laboratory tests pertinent to history Coombs test Electrophoresis of hemoglobin Viral hepatitis panel

First Step Estimate Serum Bilirubin Is it less than 1 mg % - Normal Is it more than 1 mg % - Elevated

Second Step : If SB > 1.0 mg Is it unconjugated bilirubin ? Haemolytic Jaundice Is it Conjugated Bilirubin ? (> 20%) Hepatocellular jaundice Obstructive jaundice

↑ in Unconjugated Bilirubin Hemolytic Jaundice - 1. Hemolytic Disorders + Anemia 2. Ineffective Erythropoesis –B12, Fe, F 3. Drugs – Rifampicin, Probenecid 4. Inherited –Crigler Najjar, Gilberts

Third Step : If CSB is increased Do - AST and ALT (SGOT and SGPT) Elevated AST and ALT Hepatocellular jaundice AKP, 5N, GGT will be normal Do - Alkaline Phosphatase and GGT AKP, GGT ↑↑ in Obstructive Jaundice AST and ALT will be normal

Fourth Step : Hepatocellular Hepatocellular – Features and D.D Conjugated SB is increased AST and ALT are increased AKP, 5NS, GGT are normal Hepititis – A,B,C,D,E, CMV,EBV Toxic Hepatitis – Drugs, Alcohol Malignancy – Primary Ca Cirrhosis – ALD, NAFLD

Treatment Treatment requires a precise diagnosis of the specific cause and should be directed to the specific problem

PBL Members Alif Alia Syafiq Yasmin Malisa Deanna Fatimah Fadhillah Mohamed Shawameera Thank You!