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{{SK}} pulse-temperature deficit; relative bradycardia


==Overview==
==Overview==
In [[medicine]], the '''Faget [[sign (medicine)|sign]]''' is the unusual constellation of [[fever]] and [[bradycardia]] (a slow [[pulse]]). It is often seen in [[yellow fever]].
{| style="float: right; width: 500px; margin: 5px 10px;"
! style="font-size: 85%; background: #545454; color: #F8F8FF; padding: 5px 10px;" colspan=3 | Table 1. Physiologic pulse-temperature relationship
|-
| style="font-size: 85%; background: #DCDCDC; padding: 5px 10px;" |
'''Body Temperature'''
: 106􏰄°F (41.1􏰄°C)
: 105􏰄°F (40.6°C)
: 104􏰄°F (40.0􏰄°C)
: 103􏰄°F (39.4°C)
: 102􏰄°F (38.9°C)
| style="font-size: 85%; background: #DCDCDC; padding: 5px 10px;" |
'''Pulse Rate'''
: 150 bpm
: 140 bpm
: 130 bpm
: 120 bpm
: 110 bpm
| style="font-size: 85%; background: #DCDCDC; padding: 5px 10px;" |
'''Pulse-Temperature Deficit'''
: <140 bpm
: <130 bpm
: <120 bpm
: <110 bpm
: <100 bpm
|-
! style="font-size: 85%; background: #545454; color: #F8F8FF; padding: 5px 10px;" colspan=3 | Table 2. Classic infectious etiologies associated with relative bradycardia
|-
| style="font-size: 85%; background: #DCDCDC; padding: 5px 10px;" colspan=3 |
* [[Gram-negative]] [[intracellular]] [[microorganism]]s
* [[Legionnaire's disease]] (''[[Legionella pneumophila]]'')
* [[Leptospirosis]] (''[[Leptospira]]'')
* [[Psittacosis]] (''[[Chlamydophila psittaci]]'')
* [[Q fever]] (''[[Coxiella burnetii]]'')
* [[Rocky Mountain spotted fever]] (''[[Rickettsia rickettsii]]'')
* [[Typhoid fever|Typhoid fever (''Salmonella enterica subsp. enterica'')]]
* [[Typhus]] (''[[Rickettsia]]'')
* [[Babesiosis]] (''[[Babesia]]'')
* [[Malaria]]
* [[Dengue fever]]
* [[Yellow fever]]
* [[Viral hemorrhagic fever]]s
|}
Faget's sign refers to a significant pulse-temperature deficit relative to the degree of fever.


Fever is usually accompanied by [[tachycardia]] (a fast pulse), an association known by the [[eponym]] ''[[Liebermeister's rule]]''.
==Historical Perspective==
Feget's sign is named after Jean Charles Faget, who characterized the unusual constellation of fever and bradycardia in 1859.<ref>Jean-Charles Faget. Études médicale de quelques questions importantes pour la Louisiane, et exposé succinct d’une endémie paludéenne de forme catarrhale qui a sévi à la Nouvelle-Orléans, particulièrement sur les enfants, pendant l’epidémie de fièvre jaune de 1858. New Orleans, 1859.</ref>
 
==Pathophysiology==
Physiologically, [[fever]] is accompanied by [[tachycardia]] rather than [[bradycardia]].  For every degree of temperature elevation in degrees Fahrenheit, there is a commensurate increase in pulse rate of 10 beats per minute. This physiologic relationship between temperature and pulse rate is known as ''Liebermeister's rule'' (Table 1).  When [[fever]] is associated with [[bradycardia]], it is referred to as ''Faget's sign''.
 
==Clinical Significance==
Abnormalities in the pulse-temperature relationship may be indiscernible when the body temperature falls below 102􏰄°F.  Relative bradycardia should not be applied to patients with [[pacemaker|paced rhythms]] or [[heart block|advanced AV block]] or to those taking [[beta-blocker]]s. [[Digoxin]], [[angiotensin-converting enzyme inhibitor]]s, and [[dihydropyridine]] [[calcium channel blocker]]s do not affect pulse-temperature relationships as do ˜[[beta-blocker]]s.<ref name="Cunha-2000">{{Cite journal  | last1 = Cunha | first1 = BA. | title = The diagnostic significance of relative bradycardia in infectious disease. | journal = Clin Microbiol Infect | volume = 6 | issue = 12 | pages = 633-4 | month = Dec | year = 2000 | doi =  | PMID = 11284920 }}</ref>
 
Relative bradycardia may aid differential diagnosis in selected clinical contexts.  Faget's sign may be used to discriminate ''[[Legionella pneumophila]]'' from ''[[Mycoplasma pneumoniae]]'' in [[community-acquired pneumonia]]s.<ref name="Johnson-1993">{{Cite journal  | last1 = Johnson | first1 = DH. | last2 = Cunha | first2 = BA. | title = Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections. | journal = Postgrad Med | volume = 93 | issue = 7 | pages = 69-72, 75-6, 79-82 | month = May | year = 1993 | doi =  | PMID = 8493198 }}</ref><ref>{{Cite journal| issn = 0032-5481| volume = 66| issue = 3| pages = 95–102| last1 = Cunha| first1 = B. A.| last2 = Quintiliani| first2 = R.| title = The atypical pneumonias: a diagnostic and therapeutic approach| journal = Postgraduate Medicine| date = 1979-09| pmid = 471855}}</ref>  When relative bradycardia is associated with fever of unknown origin, certain non-infectious causes including [[central nervous system]] [[lesion]]s, [[lymphoma]]s, [[drug fever]], [[fever|factitious fever]], and [[beta-blocker]]s should be considered in addition to the infectious etiologies (Table 2).


==Causes==
==Causes==
===Common Causes===
===Common Causes===
*[[Brucellosis]]
*[[Brucellosis]]
*[[Colorado tick fever]]
*[[Chlamydia]]
*[[Drug fever]] (eg, [[Beta-blocker]]s)
*[[Colorado tick fever virus]]
*[[Legionella]]
*[[Coxiella burnetii]]
*[[Mycoplasma]]
*[[Dengue Fever]]<ref name="Senanayake-2006">{{Cite journal  | last1 = Senanayake | first1 = S. | title = Dengue fever and dengue haemorrhagic fever--a diagnostic challenge. | journal = Aust Fam Physician | volume = 35 | issue = 8 | pages = 609-12 | month = Aug | year = 2006 | doi =  | PMID = 16894436 }}</ref>
*[[Drug fever]]
*[[Legionella]]<ref name="Johnson-1993">{{Cite journal  | last1 = Johnson | first1 = DH. | last2 = Cunha | first2 = BA. | title = Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections. | journal = Postgrad Med | volume = 93 | issue = 7 | pages = 69-72, 75-6, 79-82 | month = May | year = 1993 | doi =  | PMID = 8493198 }}</ref><ref name="Erdogan-2010">{{Cite journal  | last1 = Erdogan | first1 = H. | last2 = Erdogan | first2 = A. | last3 = Lakamdayali | first3 = H. | last4 = Yilmaz | first4 = A. | last5 = Arslan | first5 = H. | title = Travel-associated Legionnaires disease: clinical features of 17 cases and a review of the literature. | journal = Diagn Microbiol Infect Dis | volume = 68 | issue = 3 | pages = 297-303 | month = Nov | year = 2010 | doi = 10.1016/j.diagmicrobio.2010.07.023 | PMID = 20955914 }}</ref>
*[[Leptospirosis]]
*[[Leishmaniasis]]
*[[Mycoplasma]]<ref name="Johnson-1993">{{Cite journal  | last1 = Johnson | first1 = DH. | last2 = Cunha | first2 = BA. | title = Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections. | journal = Postgrad Med | volume = 93 | issue = 7 | pages = 69-72, 75-6, 79-82 | month = May | year = 1993 | doi =  | PMID = 8493198 }}</ref>
*[[Psittacosis]]
*[[Tularemia]]
*[[Tularemia]]
*[[Typhoid fever]]
*[[Yellow Fever]]<ref name="Cunha-2000">{{Cite journal  | last1 = Cunha | first1 = BA. | title = The diagnostic significance of relative bradycardia in infectious disease. | journal = Clin Microbiol Infect | volume = 6 | issue = 12 | pages = 633-4 | month = Dec | year = 2000 | doi =  | PMID = 11284920 }}</ref><ref name="Wittesjö-1999">{{Cite journal  | last1 = Wittesjö | first1 = B. | last2 = Björnham | first2 = A. | last3 = Eitrem | first3 = R. | title = Relative bradycardia in infectious diseases. | journal = J Infect | volume = 39 | issue = 3 | pages = 246-7 | month = Nov | year = 1999 | doi =  | PMID = 10714809 }}</ref>


===Causes by Organ System===
===Causes by Organ System===
 
{|style="width:80%; height:100px" border="1"
{|style="width:82%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
Line 47: Line 94:
|-
|-
|bgcolor="LightSteelBlue" | '''Drug Side Effect'''
|bgcolor="LightSteelBlue" | '''Drug Side Effect'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Beta blocker]], [[drug fever]]
|-
|-
|bgcolor="LightSteelBlue" | '''Ear Nose Throat'''
|bgcolor="LightSteelBlue" | '''Ear Nose Throat'''
Line 62: Line 109:
|-
|-
|bgcolor="LightSteelBlue" | '''Genetic'''
|bgcolor="LightSteelBlue" | '''Genetic'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Cyclic neutropenia]]
|-
|-
|bgcolor="LightSteelBlue" | '''Hematologic'''
|bgcolor="LightSteelBlue" | '''Hematologic'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Babesiosis]], [[cyclic neutropenia]], [[lymphoma]], [[malaria]]
|-
|-
|bgcolor="LightSteelBlue" | '''Iatrogenic'''
|bgcolor="LightSteelBlue" | '''Iatrogenic'''
Line 71: Line 118:
|-
|-
|bgcolor="LightSteelBlue" | '''Infectious Disease'''
|bgcolor="LightSteelBlue" | '''Infectious Disease'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Atypical pneumonia]], [[babesiosis]], [[brucellosis]], [[campylobacter fetus]], [[chagas disease]], [[chlamydia]], [[chlamydophila psittaci]], [[colorado tick fever virus]], [[coxiella burnetii]], [[cytomegalovirus|cytomegalovirus mononucleosis]], [[dengue fever]], [[ehrlichia|ehrlichia canis]], [[enteric fever]], [[francisella tularensis]], [[group A streptococcus]], [[Guanarito virus]], [[Junin virus]], [[Legionnaires' disease]], [[leishmaniasis]], [[leptospirosis]], [[listeria monocytogenes]], [[Machupo virus]], [[malaria]], [[mycoplasma]], [[orientia tsutsugamushi]], [[plasmodium vivax ]], [[Q fever]], [[rickettsiosis]], [[rickettsia|rickettsia typhi]], [[rocky mountain spotted fever]], [[salmonella enterica]], [[typhoid fever]], [[viral hemorrhagic fever]], [[yellow fever]]
|-
|-
|bgcolor="LightSteelBlue" | '''Musculoskeletal/Orthopedic'''
|bgcolor="LightSteelBlue" | '''Musculoskeletal/Orthopedic'''
Line 77: Line 124:
|-
|-
|bgcolor="LightSteelBlue" | '''Neurologic'''
|bgcolor="LightSteelBlue" | '''Neurologic'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Central nervous system]] [[lesion]]
|-
|-
|bgcolor="LightSteelBlue" | '''Nutritional/Metabolic'''
|bgcolor="LightSteelBlue" | '''Nutritional/Metabolic'''
Line 86: Line 133:
|-
|-
|bgcolor="LightSteelBlue" | '''Oncologic'''
|bgcolor="LightSteelBlue" | '''Oncologic'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Lymphoma]]
|-
|-
|bgcolor="LightSteelBlue" | '''Ophthalmologic'''
|bgcolor="LightSteelBlue" | '''Ophthalmologic'''
Line 98: Line 145:
|-
|-
|bgcolor="LightSteelBlue" | '''Pulmonary'''
|bgcolor="LightSteelBlue" | '''Pulmonary'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Atypical pneumonia]]
|-
|-
|bgcolor="LightSteelBlue" | '''Renal/Electrolyte'''
|bgcolor="LightSteelBlue" | '''Renal/Electrolyte'''
Line 104: Line 151:
|-
|-
|bgcolor="LightSteelBlue" | '''Rheumatology/Immunology/Allergy'''
|bgcolor="LightSteelBlue" | '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[Anaphylaxis]]
|-
|-
|bgcolor="LightSteelBlue" | '''Sexual'''
|bgcolor="LightSteelBlue" | '''Sexual'''
Line 116: Line 163:
|-
|-
|bgcolor="LightSteelBlue" | '''Miscellaneous'''
|bgcolor="LightSteelBlue" | '''Miscellaneous'''
|bgcolor="Beige" | No underlying causes
|bgcolor="Beige" | [[fever|Factitious fever]]
|-
|-
|}
|}
===Causes in Alphabetical Order===
===Causes in Alphabetical Order===
{{col-begin|width=85%}}
{{columns-list|
{{col-break|width=33%}}
* [[Anaphylaxis]]
{{col-break|width=33%}}
* [[Atypical pneumonia]]
{{col-break|width=33%}}
* [[Babesiosis]]
{{col-end}}
* [[Beta blocker]]
 
* [[Brucellosis]]
==Etymology==
* [[Campylobacter fetus]]
It is named after [[Jean Charles Faget]], who characterized it in 1859.<ref>Jean-Charles Faget. Études médicale de quelques questions importantes pour la Louisiane, et exposé succinct d’une endémie paludéenne de forme catarrhale qui a sévi à la Nouvelle-Orléans, particulièrement sur les enfants, pendant l’epidémie de fièvre jaune de 1858. New Orleans, 1859.</ref><ref name="www.whonamedit.com">{{Cite web  | last =  | first =  | title = Whonamedit - Faget's sign | url = http://www.whonamedit.com/synd.cfm/3753.html | publisher =  | date =  | accessdate = 14 July 2013 }}</ref>
* [[Central nervous system]] [[lesion]]
* [[Chagas disease]]
* [[Chlamydia]]
* [[Chlamydophila psittaci]]
* [[Colorado tick fever virus]]
* [[Coxiella burnetii]]
* [[Cyclic neutropenia]]
* [[Cytomegalovirus|Cytomegalovirus mononucleosis]]
* [[Dengue fever]]
* [[Drug fever]]
* [[Ehrlichia|Ehrlichia canis]]
* [[Enteric fever]]
* [[fever|Factitious fever]]
* [[Francisella tularensis]]
* [[Group A streptococcus]]
* [[Guanarito virus]]
* [[Junin virus]]
* [[Legionnaires' disease]]
* [[Leishmaniasis]]
* [[Leptospirosis]]
* [[Listeria monocytogenes]]
* [[Lymphoma]]
* [[Machupo virus]]
* [[Malaria]]
* [[Murine typhus]]
* [[Mycoplasma]]
* [[Orientia tsutsugamushi]]
* [[Plasmodium vivax]]
* [[Q fever]]
* [[Rickettsia|Rickettsia typhi]]
* [[Rickettsiosis]]
* [[Rocky mountain spotted fever]]
* [[Salmonella enterica]]
* [[Typhoid fever]]
* [[Viral hemorrhagic fever]]
* [[Yellow fever]]
}}


==Reference==
==References==
{{Reflist|2}}
{{Reflist|2}}


{{Symptoms and signs}}
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[[Category:Medical signs]]
[[Category:Signs and symptoms]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: pulse-temperature deficit; relative bradycardia

Overview

Table 1. Physiologic pulse-temperature relationship

Body Temperature

106􏰄°F (41.1􏰄°C)
105􏰄°F (40.6°C)
104􏰄°F (40.0􏰄°C)
103􏰄°F (39.4°C)
102􏰄°F (38.9°C)

Pulse Rate

150 bpm
140 bpm
130 bpm
120 bpm
110 bpm

Pulse-Temperature Deficit

<140 bpm
<130 bpm
<120 bpm
<110 bpm
<100 bpm
Table 2. Classic infectious etiologies associated with relative bradycardia

Faget's sign refers to a significant pulse-temperature deficit relative to the degree of fever.

Historical Perspective

Feget's sign is named after Jean Charles Faget, who characterized the unusual constellation of fever and bradycardia in 1859.[1]

Pathophysiology

Physiologically, fever is accompanied by tachycardia rather than bradycardia. For every degree of temperature elevation in degrees Fahrenheit, there is a commensurate increase in pulse rate of 10 beats per minute. This physiologic relationship between temperature and pulse rate is known as Liebermeister's rule (Table 1). When fever is associated with bradycardia, it is referred to as Faget's sign.

Clinical Significance

Abnormalities in the pulse-temperature relationship may be indiscernible when the body temperature falls below 102􏰄°F. Relative bradycardia should not be applied to patients with paced rhythms or advanced AV block or to those taking beta-blockers. Digoxin, angiotensin-converting enzyme inhibitors, and dihydropyridine calcium channel blockers do not affect pulse-temperature relationships as do ˜beta-blockers.[2]

Relative bradycardia may aid differential diagnosis in selected clinical contexts. Faget's sign may be used to discriminate Legionella pneumophila from Mycoplasma pneumoniae in community-acquired pneumonias.[3][4] When relative bradycardia is associated with fever of unknown origin, certain non-infectious causes including central nervous system lesions, lymphomas, drug fever, factitious fever, and beta-blockers should be considered in addition to the infectious etiologies (Table 2).

Causes

Common Causes

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Beta blocker, drug fever
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic Cyclic neutropenia
Hematologic Babesiosis, cyclic neutropenia, lymphoma, malaria
Iatrogenic No underlying causes
Infectious Disease Atypical pneumonia, babesiosis, brucellosis, campylobacter fetus, chagas disease, chlamydia, chlamydophila psittaci, colorado tick fever virus, coxiella burnetii, cytomegalovirus mononucleosis, dengue fever, ehrlichia canis, enteric fever, francisella tularensis, group A streptococcus, Guanarito virus, Junin virus, Legionnaires' disease, leishmaniasis, leptospirosis, listeria monocytogenes, Machupo virus, malaria, mycoplasma, orientia tsutsugamushi, plasmodium vivax , Q fever, rickettsiosis, rickettsia typhi, rocky mountain spotted fever, salmonella enterica, typhoid fever, viral hemorrhagic fever, yellow fever
Musculoskeletal/Orthopedic No underlying causes
Neurologic Central nervous system lesion
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic Lymphoma
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary Atypical pneumonia
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy Anaphylaxis
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Factitious fever

Causes in Alphabetical Order

References

  1. ↑ Jean-Charles Faget. Études médicale de quelques questions importantes pour la Louisiane, et exposé succinct d’une endémie paludéenne de forme catarrhale qui a sévi à la Nouvelle-Orléans, particulièrement sur les enfants, pendant l’epidémie de fièvre jaune de 1858. New Orleans, 1859.
  2. ↑ 2.0 2.1 Cunha, BA. (2000). "The diagnostic significance of relative bradycardia in infectious disease". Clin Microbiol Infect. 6 (12): 633–4. PMID 11284920. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 Johnson, DH.; Cunha, BA. (1993). "Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections". Postgrad Med. 93 (7): 69–72, 75–6, 79–82. PMID 8493198. Unknown parameter |month= ignored (help)
  4. ↑ Cunha, B. A.; Quintiliani, R. (1979-09). "The atypical pneumonias: a diagnostic and therapeutic approach". Postgraduate Medicine. 66 (3): 95–102. ISSN 0032-5481. PMID 471855. Check date values in: |date= (help)
  5. ↑ Senanayake, S. (2006). "Dengue fever and dengue haemorrhagic fever--a diagnostic challenge". Aust Fam Physician. 35 (8): 609–12. PMID 16894436. Unknown parameter |month= ignored (help)
  6. ↑ Erdogan, H.; Erdogan, A.; Lakamdayali, H.; Yilmaz, A.; Arslan, H. (2010). "Travel-associated Legionnaires disease: clinical features of 17 cases and a review of the literature". Diagn Microbiol Infect Dis. 68 (3): 297–303. doi:10.1016/j.diagmicrobio.2010.07.023. PMID 20955914. Unknown parameter |month= ignored (help)
  7. ↑ Wittesjö, B.; Björnham, A.; Eitrem, R. (1999). "Relative bradycardia in infectious diseases". J Infect. 39 (3): 246–7. PMID 10714809. Unknown parameter |month= ignored (help)
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