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Fever in Adults

By

Larry M. Bush

, MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University

Last full review/revision Jul 2020| Content last modified Jul 2020
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Fever is an elevated body temperature. Temperature is considered elevated when it is higher than 100.4° F (38° C) as measured by an oral thermometer or higher than 100.8° F (38.2° C) as measured by a rectal thermometer. Many people use the term “fever” loosely, often meaning that they feel too warm, too cold, or sweaty, but they have not actually measured their temperature.

Although 98.6° F (37° C) is considered normal temperature, body temperature varies throughout the day. It is lowest in the early morning and highest in the late afternoon—sometimes reaching 99.9° F (37.7° C). Similarly, a fever does not stay at a constant temperature. Sometimes temperature peaks every day and then returns to normal. This process is called intermittent fever. Alternatively, temperature varies but does not return to normal. This process is called remittent fever. Doctors no longer think that the pattern of the rise and fall of fever is very important in the diagnosis of certain disorders.

Consequences of fever

The symptoms people have are due mainly to the condition causing the fever rather than the fever itself.

Although many people worry that fever can cause harm, the typical temporary elevations in body temperature to 100.4° to 104° F (38° to 40° C) caused by most short-lived (acute) infections are well-tolerated by healthy adults. However, a moderate fever may be slightly dangerous for adults with a heart or lung disorder because fever causes the heart rate and breathing rate to increase. Fever can also worsen mental status in people with dementia.

Causes of Fever in Adults

Substances that cause fever are called pyrogens. Pyrogens can come from inside or outside the body. Microorganisms and the substances they produce (such as toxins) are examples of pyrogens formed outside the body. Pyrogens formed inside the body are usually produced by monocytes and macrophages (two types of white blood cells). Pyrogens from outside the body can cause fever by stimulating the body to release its own pyrogens or by directly affecting the area of the brain that controls temperature Fever Natural barriers and the immune system defend the body against organisms that can cause infection. (See also Lines of Defense.) Natural barriers include the skin, mucous membranes, tears, earwax... read more .

Many disorders can cause fever. They are broadly categorized as

  • Infectious (most common)

  • Neoplastic (cancer)

  • Inflammatory

An infectious cause is highly likely in adults with a fever that lasts 4 days or less. A noninfectious cause is more likely to cause fever that lasts a long time or returns.

Many cancers cause fever.

Also, an isolated, short-lived (acute) fever in people with cancer or a known inflammatory disorder is most likely to have an infectious cause. In healthy people, an acute fever is unlikely to be the first sign of a chronic illness.

Drugs sometimes cause fever. For example, beta-lactam antibiotics (such as penicillin Penicillins Penicillins are a subclass of antibiotics called beta-lactam antibiotics (antibiotics that have a chemical structure called a beta-lactam ring). Carbapenems, cephalosporins, and monobactams... read more ) and sulfa drugs can trigger a fever. Drugs that can cause an extremely high temperature include certain illicit drugs (such as cocaine Cocaine Cocaine is an addictive stimulant drug made from leaves of the coca plant. Cocaine is a strong stimulant that increases alertness, causes euphoria, and makes people feel powerful. High doses... read more , amphetamines Amphetamines Amphetamines are stimulant drugs that are used to treat certain medical conditions, but are also subject to abuse. Amphetamines increase alertness, enhance physical performance, and produce... read more , or phencyclidine Ketamine and Phencyclidine (PCP) Ketamine and phencyclidine are chemically similar drugs used for anesthesia but are sometimes used recreationally. Ketamine is available in powder and liquid form. The powder can be snorted... read more ), anesthetics Anesthetics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more , and antipsychotic drugs Antipsychotic drugs Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually, hearing voices), firmly held false beliefs (delusions), abnormal thinking... read more .

Most common causes

Risk factors

Certain conditions (risk factors) make people more likely to have a fever. These factors include the following:

  • The person's health status

  • The person's age

  • Certain occupations

  • Use of certain medical procedures and drugs

  • Exposure to infections (for example, through travel or contact with infected people, animals, or insects)

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Evaluation of Fever in Adults

Usually, a doctor can determine that an infection is present based on a brief history, a physical examination, and occasionally a few simple tests, such as a chest x-ray and urine tests. However, sometimes the cause of fever is not readily identified.

When doctors initially evaluate people with an acute fever, they focus on two general issues:

  • Identifying other symptoms such as headache or cough: These symptoms help narrow the range of possible causes.

  • Determining whether the person is seriously or chronically ill: Many of the possible acute viral infections are difficult for doctors to diagnose specifically (that is, to determine exactly which virus is causing the infection). Limiting testing to people who are seriously or chronically ill can help avoid many expensive, unnecessary, and often fruitless searches.

Warning signs

In people with an acute fever, certain signs and characteristics are cause for concern. They include

  • A change in mental function, such as confusion

  • A headache, stiff neck, or both

  • Flat, small, purplish red spots on the skin (petechiae), which indicate bleeding under the skin

  • Low blood pressure

  • Rapid heart rate or rapid breathing

  • Shortness of breath (dyspnea)

  • A temperature that is higher than 104° F (40° C) or lower than 95° F (35° C)

  • Recent travel to an area where a serious infectious disease such as malaria is common (endemic)

  • Recent use of drugs that suppress the immune system (immunosuppressants)

When to see a doctor

People who have any warning signs should see a doctor right away. Such people typically need immediate testing and often admission to a hospital.

People without warning signs should call the doctor if the fever lasts more than 24 to 48 hours. Depending on the person's age, other symptoms, and known medical conditions, the doctor may ask the person to come for evaluation or recommend treatment at home. Typically, people should see a doctor if a fever lasts more than 3 or 4 days regardless of other symptoms.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the fever and the tests that may need to be done.

A doctor begins by asking a person about present and previous symptoms and disorders, drugs currently being taken, any blood transfusions, exposure to infections, recent travel, vaccinations, and recent hospitalizations, surgeries, or other medical procedures. The pattern of the fever rarely helps the doctor make a diagnosis. However, a fever that returns every other day or every third day is typical of malaria. Doctors consider malaria as a possible cause only if people have traveled to an area where malaria is common.

Recent travel may give the doctor clues to the cause of a fever because some infections occur only in certain areas. For example, coccidioidomycosis (a fungal infection) occurs almost exclusively in the southwestern United States.

Recent exposures are also important. For example, people who work in a meatpacking plant are more likely to develop brucellosis (a bacterial infection spread through contact with domestic animals). Other examples include unsafe water or food (such as unpasteurized milk and milk products, and raw or undercooked meat, fish, and shellfish), insect bites (such as ticks or mosquitoes), unprotected sex, and occupational or recreational exposures (such as hunting, hiking, and water sports).

Pain is an important clue to the possible source of fever, so the doctor asks about any pain in the ears, head, neck, teeth, throat, chest, abdomen, flank, rectum, muscles, and joints.

Other symptoms that help determine the cause of the fever include nasal congestion and/or discharge, cough, diarrhea, and urinary symptoms (frequency, urgency, and pain while urinating). Knowing whether the person has enlarged lymph nodes or a rash (including what it looks like, where it is, and when it appeared in relation to other symptoms) may help the doctor pinpoint a cause. People with recurring fevers, night sweats, and weight loss may have a chronic infection such as tuberculosis or endocarditis (infection of the heart's lining and usually the heart valves).

The doctor may also ask about the following:

  • Contact with anyone who has an infection

  • Any known conditions that predispose to infection, such as HIV infection, diabetes, cancer, organ transplantation, sickle cell disease, or heart valve disorders, particularly if an artificial valve is present

  • Any known disorders that predispose to fever without infection, such as lupus, gout, sarcoidosis, an overactive thyroid gland (hyperthyroidism), or cancer

  • Use of any drugs that predispose to infection, such as cancer chemotherapy drugs, corticosteroids, or other drugs that suppress the immune system

  • Use of illicit drugs that are injected

The physical examination begins with confirmation of fever. Fever is most accurately determined by measuring rectal temperature. Then the doctor does a thorough examination from head to toe to check for a source of infection or evidence of disease.

Testing

The need for testing depends on what the doctor finds during the medical history and physical examination.

Otherwise healthy people who have an acute fever and only vague, general symptoms (for example, they feel generally ill or achy) probably have a viral illness that will go away without treatment. Therefore, they do not require testing. Exceptions are people who have been exposed to an animal or insect that carries and transmits a specific disease (called a vector), such as people with a tick bite, and people who have recently been in an area where a particular disorder (such as malaria) is common.

If otherwise healthy people have findings that suggest a particular disorder, testing may be needed. Doctors select tests based on those findings. For example, if people have a headache and stiff neck, a spinal tap (lumbar puncture) is done to look for meningitis. If people have a cough and lung congestion, a chest x-ray is done to look for pneumonia.

People who are at increased risk of infection, people who appear seriously ill, and older people often need testing even when findings do not suggest a particular disorder. For such people, doctors often do the following:

  • A complete blood count (including the number and proportion of different types of white blood cells)

  • A chest x-ray

  • Urinalysis

An increase in the white blood cell count usually indicates infection. The proportion of different types of white blood cells (differential count) gives further clues. For example, an increase in neutrophils suggests a relatively new bacterial infection. An increase in eosinophils suggests the presence of parasites, such as tapeworms or roundworms. Also, blood and other body fluids may be sent to the laboratory to try to grow the microorganism in a culture. Other blood tests can be used to detect antibodies against specific microorganisms.

Fever of unknown origin (FUO)

A fever of unknown origin may be diagnosed when

  • People have a fever of at least 101° F (38.3° C) for several weeks

  • Extensive investigation does not detect a cause

In such cases, the cause may be an unusual chronic infection (such as tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs. Tuberculosis is spread mainly when people breathe air... read more Tuberculosis (TB) , bacterial infection of the heart Infective Endocarditis Infective endocarditis is an infection of the lining of the heart (endocardium) and usually also of the heart valves. Infective endocarditis occurs when bacteria enter the bloodstream and travel... read more Infective Endocarditis , HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and can cause acquired immunodeficiency syndrome (AIDS). HIV is transmitted... read more Human Immunodeficiency Virus (HIV) Infection , cytomegalovirus Cytomegalovirus (CMV) Infection Cytomegalovirus infection is a common herpesvirus infection with a wide range of symptoms: from no symptoms to fever and fatigue (resembling infectious mononucleosis) to severe symptoms involving... read more , or Epstein-Barr virus Infectious Mononucleosis Epstein-Barr virus causes a number of diseases, including infectious mononucleosis. The virus is spread through kissing. Symptoms vary, but the most common are extreme fatigue, fever, sore throat... read more Infectious Mononucleosis ) or something other than an infection, such as a connective tissue disorder (such as lupus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic autoimmune inflammatory connective tissue disorder that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls. Problems in the... read more Systemic Lupus Erythematosus (SLE) or rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more Rheumatoid Arthritis (RA) ) or cancer (such as lymphoma Overview of Lymphoma Lymphomas are cancers of lymphocytes, which reside in the lymphatic system and in blood-forming organs. Lymphomas are cancers of a specific type of white blood cells known as lymphocytes. These... read more Overview of Lymphoma or leukemia Overview of Leukemia Leukemias are cancers of white blood cells or of cells that develop into white blood cells. White blood cells develop from stem cells in the bone marrow. Sometimes the development goes awry... read more ). Other causes include drug reactions, blood clots (deep vein thrombosis Deep Vein Thrombosis (DVT) Deep vein thrombosis is the formation of blood clots (thrombi) in the deep veins, usually in the legs. Blood clots may form in veins if the vein is injured, a disorder causes the blood to clot... read more Deep Vein Thrombosis (DVT) ), inflammation of organ tissues (sarcoidosis Sarcoidosis Sarcoidosis is a disease in which abnormal collections of inflammatory cells (granulomas) form in many organs of the body. Sarcoidosis usually develops in people aged 20 to 40, most often people... read more Sarcoidosis ), and inflammatory bowel disease Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more . In older people, the most common causes of FUO are giant cell arteritis Giant Cell Arteritis Giant cell arteritis is chronic inflammation of large and medium arteries of the head, neck, and upper body. Typically affected are the temporal arteries, which run through the temples and provide... read more , lymphomas, abscesses, and tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs. Tuberculosis is spread mainly when people breathe air... read more Tuberculosis (TB) .

Doctors usually do blood tests, including a complete blood cell count, blood cultures, liver blood tests Liver Blood Tests Liver tests are blood tests that represent a noninvasive way to screen for the presence of liver disease (for example, hepatitis in donated blood) and to measure the severity and progress of... read more , and tests to check for connective tissue disorders. Other tests, such as chest x-ray, urinalysis, and urine culture, may be done.

If these test results are negative, doctors may need to take a sample of tissue from the liver, bone marrow, or another site of suspected infection for biopsy. The sample is then examined under a microscope, cultured, and analyzed.

Treatment of Fever in Adults

Because fever helps the body defend against infection and because fever itself is not dangerous (unless it is higher than about 106° F [41.1° C]), there is some debate as to whether fever should be routinely treated. However, people with a high fever generally feel much better when the fever is treated. Plus, people with a heart or lung disorder and those with dementia are considered to be at particular risk of dangerous complications, so when they have a fever, it should be treated.

Drugs used to lower body temperature are called antipyretics.

The most effective and widely used antipyretics are acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen.

Typically, people may take one of the following:

  • 650 milligrams of acetaminophen every 6 hours (not to exceed 4,000 milligrams in 1 day)

  • 200 to 400 milligrams of ibuprofen every 6 hours

Because many over-the-counter cold or flu preparations contain acetaminophen, people must be careful not to take acetaminophen and one or more of these preparations at the same time.

Other cooling measures (such as cooling with a tepid water mist and using cooling blankets) are needed only if the temperature is about 106° F (41.1° C) or higher. Sponging with alcohol is avoided because alcohol can be absorbed through the skin and may have harmful effects.

People who have a blood infection or who have abnormal vital signs (such as low blood pressure and a rapid pulse and breathing rate) are admitted to the hospital.

Essentials for Older People: Fever

Fever can be tricky in older people because the body may not respond the way it would in younger people. For example, in frail older people, infection is less likely to cause fever. Even when elevated by infection, the temperature may be lower than the standard definition of fever, and the degree of fever may not correspond to the severity of the illness. Similarly, other symptoms, such as pain, may be less noticeable. Frequently, a change in mental function or a decline in daily functioning is the only other initial sign of pneumonia Hospital-Acquired Pneumonia Hospital-acquired pneumonia is lung infection that develops in people who have been hospitalized, typically after about 2 days or more of hospitalization. Many bacteria, viruses, and even fungi... read more or a urinary tract infection Overview of Urinary Tract Infections (UTIs) In healthy people, urine in the bladder is sterile—no bacteria or other infectious organisms are present. The tube that carries urine from the bladder out of the body (urethra) contains no bacteria... read more .

However, older people with a fever are more likely to have a serious bacterial infection than are younger adults with a fever. As in younger adults, the cause is commonly a respiratory or urinary tract infection. Skin and soft-tissue infections are also common causes in older people. Older people are more likely to have serious manifestations of respiratory viral infections such as influenza Influenza (Flu) Influenza (flu) is a viral infection of the lungs and airways with one of the influenza viruses. It causes a fever, runny nose, sore throat, cough, headache, muscle aches (myalgias), and a general... read more and COVID-19 COVID-19 COVID-19 is an acute respiratory illness that can be severe and is caused by a newly identified coronavirus officially named SARS-CoV-2. COVID-19 was first reported in late 2019 in Wuhan, China... read more .

Diagnosis of fever in older people is similar to that for younger adults, except that for older people, doctors usually recommend urine tests (including culture) and a chest x-ray. Samples of blood are cultured to rule out a blood infection (bacteremia Bacteremia Bacteremia is the presence of bacteria in the bloodstream. Bacteremia may result from ordinary activities (such as vigorous toothbrushing), dental or medical procedures, or from infections ... read more ).

Key Points about Fever in Adults

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