Why fever with confusion matters
Fever with new confusion is sepsis or a brain infection until proven otherwise. Start treatment quickly while you look for the source, because the outcome depends on how soon the right antibiotics and fluids arrive.
What to ask in the history
- How long the fever has lasted, shivering
- Where the pain is
- Urinary symptoms
- Vomiting, diarrhoea
- Headache, neck stiffness, rash, seizures
- Diabetes, other illness, medicines that lower immunity
- Recent travel, mosquitoes, water or animal exposure
- Medicines, alcohol
- Could she be pregnant
Red flags
- Low blood pressure, fast breathing, confusion
- Little urine
- Low glucose
- Neck stiffness or a rash
- Jaundice
What to examine
- Airway, breathing, circulation; conscious level; glucose
- Full observations
- Skin: rash, perfusion
- Neck stiffness
- Chest
- Abdomen, including the flanks and liver
- Focal neurological signs
First investigations
- Blood cultures before antibiotics, without delaying them
- Lactate and blood gas
- Full blood count, CRP, kidney and liver function, glucose, clotting
- Urine test and culture
- Malaria test
- Chest X-ray
- Ultrasound of the abdomen
- CT head and lumbar puncture if meningitis or encephalitis is suspected
Differential diagnosis of fever with confusion
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Brain
- Meningitis
- Encephalitis
- Cerebral malaria
Tropical infections
- Malaria
- Leptospirosis
- Scrub typhus
- Dengue
- Typhoid
Sources of sepsis
- Kidney infection
- Infection of the bile ducts or a liver abscess
- Pneumonia
Metabolic
- Low glucose
- Low sodium
- Diabetic ketoacidosis
Common mistakes
- Holding antibiotics until every test is back.
- Blaming the confusion on the fever alone.
- Forgetting the malaria test.