oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
A rigor is an episode of shaking or exaggerated shivering which can occur with a high fever. It is an extreme reflex response which occurs for a variety of reasons. It should not be ignored, as it is often a marker for significant and sometimes serious infections (most often bacterial). It is important to recognise the patient's description of a rigor, as the episode is unlikely to be witnessed outside hospital, and to be aware of the possible significance of this important symptom.
Shivering is a reflex which occurs when someone feels cold and, physiologically, it serves to raise body temperature. The trigger point at which this reflex occurs is set in the anterior hypothalamus. This has been likened to an internal thermostat. With infection or inflammation, pyrogens (probably cytokines and prostaglandins) 'reset' the trigger temperature so that the body feels cold and shaking occurs to raise temperature to the new hypothalamic 'temperature point'. The body's attempts to raise temperature are accompanied by other familiar reflex responses including contraction of erector pilae muscles ('goose bumps') and peripheral vasoconstriction. Peripheral vasoconstriction causes cold extremities and pallor. Most of the work done on various pyrogens responsible for mediating this response has been done on animals.
Rigors are a common accompaniment of high fever.
- They occur more commonly in children.
- They are less likely to occur in the elderly.
- However, they are a predictor of bacteraemia and bacterial infection in young and old.
- The sudden attack of severe shivering accompanied by a feeling of coldness ('the chills') is called a rigor and is associated often with a marked rise in body temperature. It may be described by patients as an attack of uncontrollable shaking.
- A history of rigors should raise suspicion of infection, particularly bacterial infection. Enquiry should be made about:
- Symptoms suggestive of local infection, particularly respiratory infections, urinary infections, biliary disease, and gastrointestinal (GI) infections.
- Recent surgical procedures.
- Any relevant past medical history such as rheumatic heart disease.
- Recent foreign travel.
- Medication and allergies.
- This should be performed according to the history.
- Care should be taken in children where even an otitis media or upper respiratory infection may have triggered a rigor.
- It should be remembered that rigors can be an early symptom in septicaemia, particularly meningococcal septicaemia. Appropriate care should be taken to examine for rashes as well as signs of meningism, especially in children.
- A history of rigors in the night may be followed by signs of a pneumonia the next day.
The classic differential diagnosis for rigors includes:
- Biliary sepsis (part of Charcot's triad)
- Visceral abscess (including lung, liver and paracolic)
It is important in children to differentiate a rigor from a febrile convulsion. In adults care should be taken to differentiate from a fit or convulsion.
A review of the recent literature demonstrates the range of conditions associated with rigors. These may be:
- Over half of parturients experience shaking rigors
- Epidurals and fever seem to be associated with the rigors
- Infectious diseases:
- Drug reactions (usually intravenous):
- Transfusion reactions:
- 30% of transfusion reactions are associated with rigors
- Many types of blood product transfusions
This will depend on the clinical assessment and likely cause. Very often history and examination will reveal a source of infection, and treatment can be commenced without extensive investigation. However, in children, extreme care should be taken and hospital admission will usually be indicated particularly when the child remains febrile and no source of infection is found (the pyrexia of unknown origin (PUO)).
The following list is not exhaustive. In particular, an ill child investigation is likely to include:
- Screening for infection, and basic blood tests:
- Chest X-ray
- CT scan
- MRI scan
- Temperature-lowering measures, particularly in children, are important.
- It is important to find and treat the source of infection.
- It is likely that hospitalisation will be required for diagnosis and treatment if the patient remains unwell and febrile. Admission to hospital is more likely to be required in children and in the elderly.
Further reading & references
- McCabe WR, Treadwell TL, De Maria A Jr; Pathophysiology of bacteremia. Am J Med. 1983 Jul 28;75(1B):7-18.
- Tal Y, Even L, Kugelman A, et al; The clinical significance of rigors in febrile children. Eur J Pediatr. 1997 Jun;156(6):457-9.
- Pfitzenmeyer P, Decrey H, Auckenthaler R, et al; Predicting bacteremia in older patients. J Am Geriatr Soc. 1995 Mar;43(3):230-5.
- Yung AP, McDonald MI; Early clinical clues to meningococcaemia. Med J Aust. 2003 Feb 3;178(3):134-7.
- Rahman SH, Larvin M, McMahon MJ, et al; Clinical presentation and delayed treatment of cholangitis in older people. Dig Dis Sci. 2005 Dec;50(12):2207-10.
- Leugers CM, Clover R; Lemierre syndrome: postanginal sepsis. J Am Board Fam Pract. 1995 Sep-Oct;8(5):384-91.
- Koay CB, Heyworth T, Burden P; Lemierre syndrome--a forgotten complication of acute tonsillitis. J Laryngol Otol. 1995 Jul;109(7):657-61.
- Payne CM, Winwood RS; Rigors in Dressler's syndrome. J R Soc Med. 1982 Aug;75(8):672-3.
- Falagas ME, Siempos II, Tsakoumis I; Cure of persistent, post-appendectomy Klebsiella pneumoniae septicaemia with continuous intravenous administration of meropenem. Scand J Infect Dis. 2006;38(9):807-10.
- Musgrave T, Verghese A; Clinical features of pneumonia in the elderly. Semin Respir Infect. 1990 Dec;5(4):269-75.
- Cockcroft DW, Stilwell GA; Lobar pneumonia caused by Mycoplasma pneumoniae. Can Med Assoc J. 1981 Jun 1;124(11):1463-8.
- Bhaskar G, Lodha R, Kabra SK; Severe acute respiratory syndrome (SARS). Indian J Pediatr. 2003 May;70(5):401-5.
- Lee N, Hui D, Wu A, et al; A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003 May 15;348(20):1986-94. Epub 2003 Apr 7.
- Le BH, Rosenthal MA; Prostate cancer presenting with fever and rigors. Intern Med J. 2005 Oct;35(10):638.
- Benson MD, Haney E, Dinsmoor M, et al; Shaking rigors in parturients. J Reprod Med. 2008 Sep;53(9):685-90.
- Margaretten ME, Kohlwes J, Moore D, et al; Does this adult patient have septic arthritis? JAMA. 2007 Apr 4;297(13):1478-88.
- Mendiratta DK, Bhutada K, Narang R, et al; Evaluation of different methods for diagnosis of P. falciparum malaria. Indian J Med Microbiol. 2006 Jan;24(1):49-51.
- Elliott SP; Rat bite fever and Streptobacillus moniliformis. Clin Microbiol Rev. 2007 Jan;20(1):13-22.
- Wijeyaratne SM, Sheriffdeen AH; The swollen leg: is it deep vein thrombosis? The experience of a tertiary referral center in Sri Lanka. Ceylon Med J. 2002 Mar;47(1):16-8.
- Memish ZA, Alazzawi M, Bannatyne R; Unusual complication of breast implants: Brucella infection. Infection. 2001 Oct;29(5):291-2.
- Memish ZA, Bannatyne RM, Alshaalan M; Endophlebitis of the leg caused by brucella infection. J Infect. 2001 May;42(4):281-3.
- Memish ZA, Mah MW; Brucellosis in laboratory workers at a Saudi Arabian hospital. Am J Infect Control. 2001 Feb;29(1):48-52.
- Lowry KJ, Stephan KT, Davis CE; Miliary tuberculosis presenting with rigors and developing unusual cutaneous manifestations. Cutis. 1999 Jul;64(1):23-8.
- al Attia HM, Shanaa ZA, al Ahmad YM; Prolonged fever and rigors in disseminated tuberculosis. Postgrad Med J. 1994 May;70(823):383.
- Harvey C, Eykyn S, Davidson C; Rigors in tuberculosis. Postgrad Med J. 1993 Sep;69(815):724-5.
- Maloy AL, Black RD, Segurola RJ Jr; Lyme disease complicated by the Jarisch-Herxheimer reaction. J Emerg Med. 1998 May-Jun;16(3):437-8.
- Daniel E, Beyene H, Tessema T; Relapsing fever in children--demographic, social and clinical features. Ethiop Med J. 1992 Oct;30(4):207-14.
- Hawkes ND, Mutimer D, Thomas GA; Intermittent jaundice and rigors in a patient with longstanding ulcerative colitis. Postgrad Med J. 2001 Jun;77(908):406-7, 412-3.
- Greenberger PA; 8. Drug allergy. J Allergy Clin Immunol. 2006 Feb;117(2 Suppl Mini-Primer):S464-70.
- Smak Gregoor PJ, van Saase JL, Weimar W, et al; Fever and rigors as sole symptoms of azathioprine hypersensitivity. Neth J Med. 1995 Dec;47(6):288-90.
- See S, Scott EK, Levin MW; Penicillin-induced Jarisch-Herxheimer reaction. Ann Pharmacother. 2005 Dec;39(12):2128-30. Epub 2005 Nov 15.
- Henderson RA, Pinder L; Acute transfusion reactions. N Z Med J. 1990 Oct 24;103(900):509-11.
- Iizuka H, Takahashi H, Ishida-Yamamoto A; Pathophysiology of generalized pustular psoriasis. Arch Dermatol Res. 2003 Apr;295 Suppl 1:S55-9. Epub 2003 Jan 25.
- Archibald LK, Khoi NN, Jarvis WR, et al; Pyrogenic reactions in hemodialysis patients, Hanoi, Vietnam. Infect Control Hosp Epidemiol. 2006 Apr;27(4):424-6. Epub 2006 Mar 29.
- Devereux S, Hatton MQ, Macbeth FR; Immediate side effects of large fraction radiotherapy. Clin Oncol (R Coll Radiol). 1997;9(2):96-9.
- Singh B, Depner TA; Catheter related bacterial infections mimic reactions to exogenous pyrogens during hemodialysis. ASAIO J. 1994 Jul-Sep;40(3):M674-7.
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Dr Richard Draper
Dr Richard Draper