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

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

3. Fever

4. 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 ≥ ᵒC
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)

5. 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

6. JAUNDICE

7. 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.

8. 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 ?

9. 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)

10. 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

11. 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

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

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

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

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

16. 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.

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

18. 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.

19. 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

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

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

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

23. 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

24. 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

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

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