Correspondence

Diagnosis Still in Question

N Engl J Med 2002; 347:1805-1806November 28, 2002

Article

To the Editor:

Jha et al. (June 6 issue)1 define hectic fever as a fever characterized by a daily spike in temperature. They state that this finding suggests the possibility of tuberculosis or another systemic inflammatory condition.

To respond to what we regard as an unfounded emphasis on fever patterns in the medical literature in the 1960s, we studied these patterns in more than 300 patients.2 We found “hectic fever,” defined as a difference between the peak and trough temperatures of more than 2.5°F (1.4°C), in 12 percent of 302 febrile patients. Eleven percent of the patients with infectious disease had hectic fever, as compared with 17 percent of those who had a fever of noninfectious cause. Hectic fever was twice as frequent in patients with bacteremia as in those without bacteremia.

Our overall results are consistent with the findings of Wunderlich and Seguin3 — namely, that in the majority of persons with fever, whatever the cause, the fever has a daily “spike.” We hypothesized that this pattern simply reflects an exaggeration of the normal diurnal variation. The characterization of fever as “hectic,” or “spiking,” is unlikely to be helpful diagnostically, and we believe that these terms should be avoided.

Daniel M. Musher, M.D.
Edward J. Young, M.D.
Veterans Affairs Medical Center, Houston, TX 77030
daniel.musher@med.va.gov

3 References

1. 1

   Jha AK, Collard HR, Tierney LM. Diagnosis still in question. N Engl J Med 2002;346:1813-1816
   Full Text | Web of Science | Medline

2. 2

   Musher DM, Fainstein V, Young EJ, Pruett TL. Fever patterns: their lack of clinical significance. Arch Intern Med 1979;139:1225-1228
   CrossRef | Web of Science | Medline

3. 3

   Wunderlich CA, Seguin E. Medical thermometry and human temperature. New York: William Wood, 1871.
   

Author/Editor Response

The authors reply:

To the Editor: Musher and Young remind us that although much has been made of fever patterns, their diagnostic value remains unclear, since most febrile diseases have no specific pattern associated with them. Although the fever pattern itself is rarely diagnostic, certain patterns are more common in some diseases than in others. Although the classic pattern of fever in adult Still's disease is a twice-daily spike in temperature, once-daily spikes can still be seen.1 Taken in context, we believe that fever patterns should not be disregarded altogether.

Ashish K. Jha, M.D.
Brigham and Women's Hospital, Boston, MA 02115
ajha@partners.org

Harold R. Collard, M.D.
University of Colorado Health Sciences Center, Denver, CO 80262

Lawrence M. Tierney, Jr., M.D.
University of California, San Francisco, San Francisco, CA 94143

1 References

1. 1

   Cunha BA. The clinical significance of fever patterns. Infect Dis Clin North Am 1996;10:33-44
   CrossRef | Web of Science | Medline