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.[4, 5]
- 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. There is a wide range of conditions that can be associated with rigors, such as:
- Over half of parturients experience shaking rigors.
- Epidurals and fever seem to be associated with the rigors
- Meningococcal septicaemia.
- Rat-bite fever.
- Brucellosis.[17, 18, 19]
- Tuberculosis (miliary).
- Lyme disease.
- Louse-borne relapsing fever (endemic in Ethiopia).
Drug reactions (usually intravenous)
- Jarisch-Herxheimer reaction.
- Interleukin II.
- Anti-TNF-alpha drugs.
- 30% of transfusion reactions are associated with rigors.
- Many types of blood product transfusions.
- After radiotherapy.
- After bone marrow transplant.
- Postoperative infections.
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:
- FBC, U&Es, ESR, CRP, and LFTs.
- Blood cultures.
- Urine for microscopy and culture.
- Lumbar puncture and cerebrospinal fluid analysis.
- CT scan.
- MRI scan.
- Temperature-lowering general measures, particularly in children, are important but antipyretic agents should not routinely be used with the sole aim of reducing the body temperature of a child with fever. However, if they are distressed due to a fever then antipyretics are recommended.
- 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 and references
McCabe WR, Treadwell TL, De Maria A Jr; Pathophysiology of bacteremia. Am J Med. 1983 Jul 2875(1B):7-18.
Tal Y, Even L, Kugelman A, et al; The clinical significance of rigors in febrile children. Eur J Pediatr. 1997 Jun156(6):457-9.
Pfitzenmeyer P, Decrey H, Auckenthaler R, et al; Predicting bacteremia in older patients. J Am Geriatr Soc. 1995 Mar43(3):230-5.
Suryati BA, Watson M; Staphylococcus aureus bacteraemia in children: a 5-year retrospective review. J Paediatr Child Health. 2002 Jun38(3):290-4.
Greenberg BM, Atmar RL, Stager CE, et al; Bacteraemia in the elderly: predictors of outcome in an urban teaching hospital. J Infect. 2005 May50(4):288-95.
Yung AP, McDonald MI; Early clinical clues to meningococcaemia. Med J Aust. 2003 Feb 3178(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 Dec50(12):2207-10.
Falagas ME, Siempos II, Tsakoumis I; Cure of persistent, post-appendectomy Klebsiella pneumoniae septicaemia with continuous intravenous administration of meropenem. Scand J Infect Dis. 200638(9):807-10.
Bhaskar G, Lodha R, Kabra SK; Severe acute respiratory syndrome (SARS). Indian J Pediatr. 2003 May70(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 15348(20):1986-94. Epub 2003 Apr 7.
Le BH, Rosenthal MA; Prostate cancer presenting with fever and rigors. Intern Med J. 2005 Oct35(10):638.
Benson MD, Haney E, Dinsmoor M, et al; Shaking rigors in parturients. J Reprod Med. 2008 Sep53(9):685-90.
Margaretten ME, Kohlwes J, Moore D, et al; Does this adult patient have septic arthritis? JAMA. 2007 Apr 4297(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 Jan24(1):49-51.
Elliott SP; Rat bite fever and Streptobacillus moniliformis. Clin Microbiol Rev. 2007 Jan20(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 Mar47(1):16-8.
Memish ZA, Alazzawi M, Bannatyne R; Unusual complication of breast implants: Brucella infection. Infection. 2001 Oct29(5):291-2.
Memish ZA, Bannatyne RM, Alshaalan M; Endophlebitis of the leg caused by brucella infection. J Infect. 2001 May42(4):281-3.
Memish ZA, Mah MW; Brucellosis in laboratory workers at a Saudi Arabian hospital. Am J Infect Control. 2001 Feb29(1):48-52.
Hawkes ND, Mutimer D, Thomas GA; Intermittent jaundice and rigors in a patient with longstanding ulcerative colitis. Postgrad Med J. 2001 Jun77(908):406-7, 412-3.
Greenberger PA; 8. Drug allergy. J Allergy Clin Immunol. 2006 Feb117(2 Suppl Mini-Primer):S464-70.
See S, Scott EK, Levin MW; Penicillin-induced Jarisch-Herxheimer reaction. Ann Pharmacother. 2005 Dec39(12):2128-30. Epub 2005 Nov 15.
Henderson RA, Pinder L; Acute transfusion reactions. N Z Med J. 1990 Oct 24103(900):509-11.
Iizuka H, Takahashi H, Ishida-Yamamoto A; Pathophysiology of generalized pustular psoriasis. Arch Dermatol Res. 2003 Apr295 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 Apr27(4):424-6. Epub 2006 Mar 29.
Fever in under 5s - assessment and initial management; NICE Guideline (updated August 2017)
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