Midnight musings on importance of fever and imminence of death

Well, let’s state things as they are — Thailand spoiled me rotten. In many ways from being unconcerned or only mildly bothered with leaving the phone on the table in cafes, leaving the scooter parked gods know where and leaving it there for ages, carrying smartphone in the not sufficiently big back pocket so that it is clearly visible to anyone behind me and having not being seriously ill in more than five years. Sure enough, there were a few colds, food allergy for one particular soup I swore to avoid in future only to not see it in any other place ever again, and that ridiculous time when I cut my foot while cutting a pineapple (yeah, one’s mom is almost always right— do not cut anything you could avoid cutting toward yourself, especially when you sit with an unfamiliar fruit on the floor in a hotel room with your feet on both sides of the plate with the said fruit, and you’ve just bought a new, sharp knife; I must say that the cut was not deep, but I probably severed a superficial vessel, and feet, similarly to palms for that matter, are very well supplied with blood via multiple small to smalish blood vessels. I’ve applied a rather over the top occlusive bandage and got driven to the local hospital where female surgeon was very much concerned with my story and the size of bandage, but could not help but laugh when she finally managed to cut of the dressing and saw the barely centimeter long line that had already closed by itself. Seeing my concern however she put on three stitches and I have insisted on tetanus shot, as well. That came to bite me later, as it turned out that hospital did not have a separate tetanus shot, so they gave me full dosed DTaP that is normally given to children under age of seven as a first shot. My arm was swollen for a few days and it gave me considerable post vaccination fever. But it was actually time for a booster shot in my case anyway, so not dying from tetanus in short term and boosting my antibody counts for pertussis and diphtheria with a some pain and fever on the side. All in all, not that bad, but I digress).

I think you can guess where that’s going. I know enough to understand that apart from living in warmth with fresh fruit and vegetables available year round, and being a lady of leisure, as it were, to boot, I just straight up had lower chances of contracting or developing upper respiratory infections that are common back in the North. I did not necessarily had it coming, or it was too good to last, as there is no balance in the world, no one is taking note. However, the nature of immune system being what it is, my lucky streak meant that I had not received a significant immunity update for while and after usual, normal (no one sneezed at me, spit into my mouth and I haven’t been liking doorknobs) half a day in a public place I got sick. It began as a mild sore throat around 4 p.m, but as the night fell (a familiar pattern I’ve forgotten) it became worse. Rising fever took me from tired to miserable, angry, enlarged tonsils made swallowing near impossible and all I had in my home apothecary were ibuprofen and “natural” camomile spray (latter only made things worse as after using it one feels the need to swallow increase, thus increasing the pain). I rediscovered the pleasing though temporary effects of very warm liquids (but not milk, I still shudder to think what I was made to drink while being young and sick — hot milk with a teaspoon of baking soda and dollop of butter, yuck!), the uselessness but distracting effects of gargling and how the softest pillow becomes a brick when one’s neck is stuffed with incensed lymph nodes.

I’ve took my temperature, it was miserly 37,2 C. I was cold, shivering as body struggled to produce heat required by the new norms established by hypothalamus. Time was approaching midnight, I was in pain, tired and angry. Tears of self pity tried to push through. I’ve managed to stop them as a stuffed nose would have been the last thing I needed. I’ve checked thermometer again — 37,5, damn! And then they came, the ever present, but normally stuck to the back of one’s mind, the thoughts of death. The hypochondriac has awakened and screamed, as it were. What if I am dying? What is there was always something wrong with me and now it finally came to a head? What will happen to people I care about? My mom will be terribly upset. I haven’t talked to her for more than two weeks. What about this one, sleeping soundly next to me? And my sister, with whom we share so many features, that I sometimes feel that she’s my alter-ego, or I am her’s, or my dad, whom I resemble a lot — curious mind, a bit of a child forever and a bit of mustache, as well. And it went on like that for a few hours. (Even though generally, I am on the accepting side mortality issues. We are all going to die, it is normal and it is, as of now, inevitable.)

And then I thought, wait a minute. This is just a sore throat, I am feverish but on the low side. I haven’t been sick for a while and I’ve completely forgotten that such a dramatic turn to my feelings was actually typical me being ill. Drama queen all over, feeling guilty for being indisposed, needing people telling me that it is not my fault. I checked myself, I finally was feeling too warm so that I had to take of the socks and throw away the blanket. It was interesting how my feelings changed as my fever likely took a downturn.

You might say, but why you didn’t take an ibuprofen right away? Well, I thought I was being smart (and maybe I was). So here is the thing, fever is a normal reaction on the foreign agents’ invasion (though there are non-infectious causes of fever too, but I’ll omit them here). The microbes act as exogenous pyrogens and they initiate the fever cycle. Their presence triggers the synthesis and secretion of endogenous pyrogens, such as interleukin-1 (IL-1) and many others, but IL-1 is the major one. While in bloodstream it reaches the central nervous system, where it in turn start the production of prostaglandin E2 (PGE 2). PGE 2 then reprograms hypothalamic thermoregulatory center to a new temperature set point. Now the body metaphorically goes huh, scratches it’s head as it turns out we are rather cold, and we have to work toward our new standard of temperature. It does so by constricting the blood vessels in limbs and by induction of muscle contraction (shivering) which in total should help us conserve heat, as well as generate some too. All of these (and in fact much more, if truth be told) is needed to mount and enhance the immune response against the forces without as most processes and substances involved perform better at higher temperatures and pathogens are averse to changes in environmental temperature. Basically, immune system goes “We’ll see who burns first” and sets the whole house on fire, residents and intruders alike. Though it must be mentioned that it is not all that reckless, and hypothalamus stays in control even with temperature as high 41 degrees and over. That’s the basic pathology of fever (not to be confused with hyperthermia, as in a heat stroke for instance, where controlling mechanisms are out of whack and body either cannot get rid of the excess heat or over-produces it).

There seems to be some doubt on whether one should suffer through or not, but all in all fever is seen as generally adaptive and useful tool not to scoff at. Although, as a lot of other the physician’s decision making, this particular question is circumstance dependent and not set in stone. There are certainly evidence based guidelines and recommendations to help and some particular personal history that might push you toward either option. It must be mentioned here that apart from outright febrile seizures (more common in young kids), possibility of which haunts almost all new parents, there are other negative points, such as increased heart rate, oxygen consumption and metabolism. Fever might be exhausting.

Intervening with an antipyretic then could certainly reduce the suffering, allow a person to finally drift to sleep, away from all of it for at least a while. But one must never forget that there is no such thing as side-effect free medication. If something is 100% safe, then in almost all cases it is because this thing does not do anything. So one must always keep proper care, dosage and regimen in mind. The other aspect comes from intervention into the above-mentioned thermoregulation and it’s effects on immune response. As some studies suggest using aspirin and acetaminophen (also known as tylenol, or paracetamol) might prolong virus shedding time, plus increased nasal symptoms when infected by rhinovirus (one of the main suspects in common cold).

Back to me though, as I lay there from the very beginning of my symptoms, in perceived agony, I kept waiting for my body to do something. I thought come on, I gave you carte blanche, do you interleukin-interferon thingy and deliver me from my misery (or at least, bring me above 38–38,5 as then it would be simpler, I’d just lay there, almost unconscious). When I’ve started getting warmer at 37,8, I’ve got up for another cup of tea with a piece of cake (it was soft, layered cake of custard cream and layers of honey-rich dough, purely for medicinal use), it turned out to be 3 a.m. Finishing my soothing nibble, I’ve decided I had enough of feverish vacillating on to take or not to take antipyretic (interspersed with thoughts of death, of course). My body had several hours to produce whatever it needed to, and if it hadn’t then I guess I’ll just be ill one or two days longer but at least I am going to have sleep and I finally took that ibuprofen with half a glass of water.