Budi Setiawan, Leonard Nainggolan,Widayat Djoko Santoso, Khie Chen

Division of Tropical and Infectious DiseasesDepartment of Internal Medicine

FMUI / Cipto Mangunkusumo Hospital

Introduction

(N) Range of body temperature 36.20 C – 37.70 C

Diurnal variation

Fever:>37.20C in the morning / 37.70C in the afternoon

Fever:Physiologic response against diseases characterized with

the increase of body temperature above normal rangecaused by the stimulation of pyrogens to the

hypothalamic thermoregulatory center

Introduction…(2)Diurnal variation of human body temperature

06.00 16.00-18.00 06.00 16.00-18.00 06.00

36.5

37

37.5

0C

Introduction…(2)

• Hyperpyrexia > 41.50C• Hypothermia < 350C • Body temperature measuring

Rectal temperature

Oral temperature

Tympanic membrane temperature

0.40 C

0.40 C

• Easy to be performed• Response quickly to

changes in core temperature

Thermoregulation

Food Metabolic pool in the body

Energy reservation

Internal work

External work

Heat energy (Heat)

Energy source Energy utilization

• A relatively stable body temperature important for the optimal body functions

Thermoregulation…(2)

Internal heat

production

External environment

Heat input

Core temperature

Heat outputTotal body heat

content

Heat lossHeat gain

.

Thermoregulation…(3)Core temperature

Sweat glands

Control of heat loss

Control of heat

production or heat loss

Sympathetic Nervous System

Parasympathetic Nervous System

Hypothalamic Thermoregulatory Integrating Centre

Skin temperature

Pheripheral thermoreceptor (in skin)

Central thermoreceptors (In hypothalamus,other area of CNS, abdominal organs)

Behavioral adaptation

Motor neurons

Skeletal muscles Skin blood vessels

Muscle tone, shivering

Skin vasocontriction & vasodilation

Sweating

Control of heat

productionControl of heat loss

Thermoregulation…(4)

Thermoregulation…(5)

CONCLUSION : Thermoregulation = a body temperature controlling system which conducted by increasing the releasing of body heat when the body heat is more than the tolerable maximum value, and by increasing the producing and reducing the releasing of body heat when it is below the tolerable minimum level

Thermoregulation…(5)

Termostat

HIP

OTA

LAM

US

Set Point

-

-

-

-

-

-

-

-

-

Body temperature

Thermoregulation is conducted by hypothalamus bydetermining the set-point based on the environment

temperature

Hot Set down

Cold Set up

Pathogenesis & Pathophysiology of Fever

Any substances that causes fever = PYROGEN

Exogenous Pyrogen Endogenous Pyrogen

• Endogenous antipyretics (intrinsic antipyretics):– Arginine vasopressin (AVP)– Alphamelanocyte-stimulating hormone– Corticotrophin releasing factor

Pathogenesis & Pathophysiology of Fever

Pathogenesis & Pathophysiology of Fever

Triggers of endogenous pyrogensMicrobial agents Viruses, bacteria, fungi, parasitesMicrobial toxins Endotoxin

Exotoxin

Enterotoxins, toxic shock syndrome, toxin-1, streptococcal pyrogenic exotoxins, erythrogenic toxins

Microbial breakdown products

Peptidoglycans, muramyl peptides, lipoteichoic acid, rhamnose glucose polymers, lipoarabinomannan

Immune components & cytokines

Antigen-antibody complexes, complement components (C5a, C3a), lymphocyte products (IL-2, IFN), pyrogenic cytokines (IL-1, TNF-α)

Drugs Etiocholanolone, bleomycin, penicillin (through lymphocyte products in sensitized individuals)

Tumors Through production of pyrogenic cytokines

Pathogenesis & Pathophysiology of Fever

• Fever fighting the infection process: body temp serum levels of Fe, Zn & Cu needed for bacterial replication

body temp lysosomal breakdown & cells autodestruction preventing viral replication in infected cells

Types of feverTypes Description Diseases

Intermittent

Body temperature increase and then fall to normal level for a few hours or days

Abscess, falciparum malaria, still’s disease

Remittent Body temperature could decrease everyday but never reach the normal level

TBC, endocarditis, typhoid fever

Relapse Fever re-occur after a few days or weeks

Relapsing fever, brucellosis, tertiana or quartana malaria, limphoma

Biphasic Fever re-occur only once Leptospirosis, dengue, colorado tick fever, coriomeningitis limphocityc

Continue The variation of body temperature in a day is not > 10 C

Encephalitis, drug fever, salmonella, fastitious fever

Body Temperature Pattern (Typhoid fever)

Wk IVWk IIIWk IIWk IInc

Suhu TubuhFrekuensi Nadi

Types of fever

Body Temperature Pattern (Malaria)

Types of fever

PMAMPMAMPMAMPMAM

Day IV Day III Day II Day I

P. vivax

Body Temperature Pattern (Malaria)

Types of fever

PMAMPMAMPMAMPMAM

Day IV Day III Day II Day I

P. falciparum

Body Temperature Pattern (Acute hepaititis)

Types of fever

Preicteric phase Icteric phase(3 – 10 days) (7 – 21 days or more)

Conclusion

• Fever as a complex physiologic response against a disease which is characterized by the increase of human body temperatures above normal range

• Happens when pyrogens, either endogenous or exogenous pyrogens, affect the thermoregulator in hypothalamus

Conclusion…(2)

• Exogenous pyrogens (infection or non-infection ones) induce the macrophages, monocytes, lymphocytes and endotels to release endogenous pyrogens (IL-1, IL-6, TNF-α, IFN- α).

• Endogenous pyrogens stimulate the release of arachidonic acid changed into PGE2 elevate the ‘set point’ in hypothalamic thermoregulatory center and cause fever