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FEVER WITH JAUNDICE By PBL 2 Supervised by Dr. Raghda Farag

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

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FEVER

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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. in the anus 37.5-38.3C in the mouth 37.7 C axillary/otic 37.2 C

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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

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JAUNDICE

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JAUNDICE IS IT A DISEASE OR A SIGN OF A DISEASE? Yellowish staining of the skin and sclerae High levels of bilirubin in blood

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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 ?

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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)

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CAUSES OF FEVER WITH JAUNDICE o Infectious : viral causes o Viral Hepatitis A,B,C,D,E o Immune deficiency, acquired (AIDS/HIV) o Infectious mononucleosis o Viral haemorrhagic fevers: Ebola virus Yellow fever African hemorrhagic (Marburg) virus disease Dengue fever

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

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

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ALLERGIC, COLLAGEN, AUTO-IMMUNE DISORDERS: o Autoimmune hemolytic anemia o Transfusion reaction, hemolytic o Evan's syndrome (AHA/Immune TP) o Autoimmune hepatitis

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NEOPLASTIC DISORDERS o Carcinoma, hepatocellular o Metastatic liver disease o Adenocarcinoma, pancreatic o Carcinoma, gallbladder o Carcinoma, biliary tree

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HEREDITARY, FAMILIAL, GENETIC DISORDERS: o Sickle cell anemia o Cirrhosis/childhood Indian type

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AN APPROACH TO JAUNDICE & FEVER o Is it isolated elevation of serum bilirubin ? o If so, is the unconjugated or conjugated fraction? o Is it accompanied by other liver test abnormalities ? o Is the disorder hepatocellular or cholestatic? o If cholestatic, is it intra- or extrahepatic? o These can be answered with : History and physical examination Interpretation of laboratory tests and Radiological tests and procedures.

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

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

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

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FIRST STEP Estimate Serum Bilirubin Is it less than 1 mg % - Normal Is it more than 1 mg % - Elevated

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SECOND STEP : IF SB > 1.0 MG Is it unconjugated bilirubin ?Haemolytic JaundiceIs it Conjugated Bilirubin ? (> 20%)Hepatocellular jaundiceObstructive jaundice

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IN U NCONJUGATED BILIRUBIN Hemolytic Jaundice -1. Hemolytic Disorders + Anemia2. Ineffective Erythropoesis B12, Fe, F3. Drugs Rifampicin, Probenecid4. Inherited Crigler Najjar, Gilberts

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THIRD STEP : IF CSB IS INCREASED Do - AST and ALT (SGOT and SGPT)Elevated AST and ALTHepatocellular jaundiceAKP, 5N, GGT will be normalDo - Alkaline Phosphatase and GGT AKP, GGT in Obstructive Jaundice AST and ALT will be normal

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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

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

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PBL MEMBERS Alif Alia Syafiq Yasmin Malisa Deanna Fatimah Fadhillah Mohamed Shawameera