A chill with chattering of the teeth and shaking followed by a fever is almost invariably due to an infectious process. Furthermore, the infection is usually bacterial, and the chill indicates that the bacteria have invaded the bloodstream. The exceptions to the above are discussed later in this chapter.
Anatomy is the key to a differential diagnosis. To start with, each organ in the body can be infected by an “itis” of the parenchyma, an “itis” of the capsule, or an abscess.
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TABLE 15. Mass in the Chest Wall |
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1. “Itis” of the parenchyma. Here one should recall encephalitis, otitis media, mastoiditis, pharyngitis, pneumonitis, endocarditis, pyelonephritis, hepatitis, cholecystitis, cholangitis, gastroenteritis, appendicitis, diverticulitis, prostatitis, orchitis, endometritis, salpingitis, cellulitis, osteomyelitis, and arthritis. Because some of these infections are frequently viral (e.g., hepatitis, gastroenteritis, and encephalitis), a chill would be unusual. Myositis is usually viral but in trichinosis, a chill is not rare.
2. “Itis” of the capsule. In this group are meningitis, pleuritis or pleurisy, pericarditis, and peritonitis.
3. Abscess. This should prompt the recall of cerebral abscess, epidural or subdural abscess, dental abscess, retropharyngeal abscess, lung abscess or empyema, liver abscess, subdiaphragmatic abscess, perinephric abscess, abscessed diverticulum, appendiceal abscess, tubo-ovarian abscess, pelvic abscess, prostatic abscess, and furuncles or carbuncles. Abscesses are especially prone to cause chills.
4. Systemic infection. Some systemic infections are particularly likely to be associated with a chill. Malaria, relapsing fever, Weil disease, rat-bite fever, yellow fever, smallpox, Rocky Mountain spotted fever, acute poliomyelitis, and pulmonary tuberculosis belong in this group.
5. Venous thrombosis. Phlebitis in various portions of the body is often associated with chills. Cavernous sinus thrombosis, lateral sinus thrombosis, pyelophlebitis, and, less frequently, thrombophlebitis of the extremities may be associated with a chill.
6. Miscellaneous. Chills are often associated with intravenous injection of drugs or antibiotics, transfusion, hemolytic anemia, and introduction of contaminated equipment into the body. Chills are rare in rheumatic fever.
Approach to the Diagnosis
The approach to the diagnosis of a patient with chills is similar to that of a patient with fever. Association with other signs (e.g., jaundice or dysuria) will often point to the organ involved. However, when fever and chills are the only symptoms, a workup similar to that found below may be necessary. Careful charting of the temperature while the patient remains off aspirin or other antipyretics will be rewarding, especially in the diagnosis of malaria.
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Chills |
Other Useful Tests
1. CBC (infection)
2. Sedimentation rate (inflammation, neoplasm)
3. Urinalysis (pyelonephritis)
4. Urine culture and sensitivity (urinary tract infection [UTI])
5. Culture discharge from any body orifice
6. Blood cultures (bacterial endocarditis, septicemia)
7. Bone marrow smear and culture (bacterial endocarditis, metastasis)
8. Blood smear for parasites (malaria)
9. Febrile agglutinins
10. Monospot test (infectious mononucleosis)
11. ASO titer (rheumatic fever)
12. Sickle cell prep (sickle cell anemia)
13. Cerebrospinal fluid (CSF) smear and culture (meningitis, encephalitis)
14. Tuberculin test
15. Other skin test as indicated
16. Chest x-ray
17. Flat plate of abdomen
18. Gallbladder sonogram (cholecystitis)
19. ANA (collagen disease)
20. CT scan of abdomen and pelvis (abscess)
21. Indium scan (occult abscess)
