Pathophysiology and treatment of fever in adults

INTRODUCTION
— Fever, an elevation in core body temperature above the daily range for an individual, is a characteristic feature of most infectious diseases but is also found in a number of non-infectious processes. Definitions of normal body temperature, the pathophysiology of fever, the role of cytokines, and the treatment of fever in adults will be reviewed here. Fever of unknown origin in adults, drug fever, and the treatment of fever in infants and children are discussed separately. (See "Approach to the adult with fever of unknown origin" and see "Etiologies of fever of unknown origin in adults" and see "Drug fever" and see "Pathophysiology and treatment of fever in infants and children").

NORMAL BODY TEMPERATURE
— Normal body temperature varies over the course of the day, controlled in the thermoregulatory center located in the anterior hypothalamus. The body is normally able to maintain a fairly steady temperature because the hypothalamic thermoregulatory center balances the excess heat production, derived from metabolic activity in muscle and the liver, with heat dissipation from the skin and lungs. However, faced with environmental extremes, humans cannot maintain the narrow daily variation of body temperature without the aid of clothing and protective environments [1].

In 1992, a detailed study of the range of oral temperature readings in 148 healthy men and women aged 18 to 40, was reported using over 700 measurements [2]. Oral temperatures in the cohort ranged from 35.6 ºC (96.0 ºF) to 38.5 ºC (100.8 ºF) with a mean of 36.8 ± 0.4 ºC (98.2 ± 0.7 ºF). Low levels occurred at 6 AM and higher levels at 4 to 6 PM. The maximum normal oral temperature at 6 AM is 37.2 ºC (98.9 ºF), and the maximum level at 4 PM is 37.7 ºC (99.9 ºF), both values defining the 99th percentile for healthy subjects. From these studies, a morning reading >37.2 ºC (98.9 ºF) or an afternoon temperature of >37.7 ºC (99.9 ºF) would be considered a fever. Rectal temperatures are generally 0.6 ºC (1.0 ºF) higher than oral readings. Oral readings are lower probably because of mouth breathing, which is particularly important in patients with respiratory infections and rapid breathing. Temperature measurements from the lower esophagus reflect core temperature, and tympanic membrane temperature readings are also close to core temperature.

The normal daily temperature variation is typically 0.5 ºC (0.9 ºF). However, in some individuals recovering from a febrile illness, this daily variation can be as high as 1.0 ºC. During a febrile illness, daily lows and highs temperature readings are maintained but clearly at higher levels.

In menstruating women, the morning temperature is generally lower during the two weeks prior to ovulation, rising by about 0.6 ºC (1.0 ºF) with ovulation and remaining at that level until menses occur. Seasonal variation in body temperature has been described, but this may reflect a metabolic change and is not a common observation. Elevation in body temperature occurs during the postprandial state, but this is not fever. Pregnancy and endocrinologic dysfunction also affect body temperature. The daily temperature variation appears to be fixed in early childhood. On the other hand, it is well-established that the ability to develop fever in the elderly is impaired, and that baseline temperature in the elderly is lower than in younger adults [3]. Thus, elderly patients with severe infections may only display a modest fever.