Causes of fever up to 38-39.5 in adults and children

Our body has an interesting system that maintains the constancy of the internal environment of a person by controlling the temperature. But if we are sick, it sometimes fails and the thermometer begins to scare us when the temperature on it is steadily rising 38-38.5-39-39.5 degrees, and sometimes even higher. The first thought that comes to mind is the question of what fever and heat can be associated with. And the second is whether it is necessary to bring down such a high temperature, which is within 38-39.5 degrees? We will try to understand these questions.

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Causes of fever in adults

An increase in temperature is not a serious reason to panic until it goes beyond the 39.5-40 degree mark. But this is already an alarming signal to think about your health, because such failures in thermoregulation usually do not occur out of nowhere. And even if there are no other symptoms of the disease besides the temperature, you should not relax too much, because fever, if it is not caused by overheating, in most cases turns out to be a manifestation of an inflammatory process in the body.

If the body temperature rises to 38-39.5 degrees in an adult, the following pathologies can be suspected:

• Respiratory infections of viral and bacterial origin.

• Viral infections most often debut with a sharp increase in thermometer readings, accompanied by a feverish state. The most popular diseases of this nature are considered to be acute respiratory viral infections and flu, which occur extremely rarely without an increase in temperature. But the fever does not last long and indicates that the body has actively joined the fight against pathogens.
• A little later, the temperature also appears with bacterial infections. And since here we have not only the activation of the protective forces and the body's desire to create conditions for bacteria that are unsuitable for their life and reproduction, but also intoxication with the waste products of pathogens, the thermometer readings in some cases can even reach 40-41 degrees. And the more severe the infection, the higher the temperature will be.

Diseases such as pharyngitis (inflammation of the tissues of the pharynx), laryngitis (inflammatory process in the larynx), tonsillitis (inflammation of the tonsils or sore throat) in acute form almost always occur with an increase in temperature, regardless of what caused the disease: bacteria or viruses.

Temperature above 38 degrees can also rise in acute bacterial infections of the nose, typical for sinusitis: maxillary sinusitis, frontal sinusitis, ethmoiditis, sphenoiditis. Fever is more typical for purulent pathologies occurring in an acute form, while catarrhal forms and chronic course of the disease are rarely characterized by an increase in thermometer readings above 37.5-38 degrees.

Acute lower respiratory tract diseases can also occur with a high temperature: bronchitis, tracheitis, pneumonia, as well as a purulent process in the middle ear (otitis). The causative agents of the above diseases are rarely viruses, most often we are talking about a bacterial infection. And if Staphylococcus aureus (a representative of the opportunistic microflora found on the human body) contributed to the inflammation, then a purulent process and temperature are guaranteed for the person.

With a fungal infection, on the contrary, the temperature remains subfebrile.

• Inflammation of the internal tissues of the brain or its membranes.

Diseases such as meningitis and encephalitis may begin with a rise in temperature to 38-39 degrees. This is the most common febrile form of inflammatory pathologies of the brain caused by viruses, bacteria, and protozoa.

In secondary forms of diseases, an increase in temperature can be observed at different stages of the disease development.

• Acute infectious and inflammatory processes in the genitourinary system.

We are talking mainly about such common diseases of the urinary tract as cystitis (inflammation of the bladder), pyelo- and glomerulonephritis (inflammation of the renal pelvis, calyces, parenchyma or glomeruli), which can be diagnosed in both men and women.

But an increase in temperature can also be observed in severe forms of urethral inflammation (most often, an increase in thermometer readings to 38-39 degrees is associated with the generalization of the infection and its spread to the tissues of the back wall of the urethra in gonorrheal urethritis). Uncomplicated urethritis rarely causes an increase in temperature, as do inflammatory diseases of the female genital tract.

As for sexually transmitted infections, with a temperature rise above 38 degrees the following may occur:

• secondary syphilis caused by Treponema pallidum,
• endometritis (inflammation of the inner lining of the uterus) and adnexitis (inflammation of the appendages and fallopian tubes) in women, as well as prostatitis (inflammation of the prostate tissue) in men, caused by gonococci,
• epididymitis and orchitis (inflammation of the appendages and testicles) in men caused by Trichomonas infection.

True, fever usually occurs against the background of complicated course of the above-mentioned pathologies and is accompanied by other severe symptoms from various organs (severe weakness, significant deterioration in appetite, muscle pain, migraines, etc.).

• Gastrointestinal diseases and intestinal infections.

It should be said that inflammatory diseases such as gastritis, gastric ulcer and duodenal ulcer, duodenitis, colitis and enterocolitis rarely cause a temperature increase to 37.5-38 degrees. Even if they occur in an acute form. Although with a severe form of acute pancreatitis (inflammation of the pancreas), a temperature increase to 38-39 degrees is not excluded, which is considered a very alarming symptom, and acute cholecystitis and cholangitis (inflammation of the gallbladder and its ducts) can be accompanied by an even higher fever (up to 40 degrees).

An increase in temperature to 38-39 degrees is possible with a perforated stomach ulcer and gastrointestinal bleeding, while hyperthermia is usually observed some time after the onset of the process, and this is already a reason to sound the alarm.

A temperature above 38 degrees accompanied by symptoms of acute appendicitis most often indicates that the inflamed organ has ruptured and its contents have entered the abdominal cavity, causing a life-threatening inflammatory process (peritonitis). In this case, the temperature may rise to 40-41 degrees.

In intestinal infections, which occur with severe intoxication of the body and malfunctions of various organs, including the hypothalamus, responsible for thermoregulation, the temperature rises almost always, while its range can fluctuate within 37-40 degrees. The causative agents of such infections as dysentery, salmonellosis, cholera, typhoid fever, infectious hepatitis and others can be bacteria, viruses or parasites. In this case, diseases very rarely occur in a latent form and are characterized by pronounced symptoms from the gastrointestinal tract.

• Myocardial infarction.

In this case, the temperature rises already in the post-infarction period on the 2-3 day after damage to the heart tissue. Usually it does not exceed 38 degrees, but its increase above this indicator may indicate serious complications, one of which is pneumonia.

• Blood diseases.

Febrile temperature is more typical for leukemia. In the acute form of the pathology, the thermometer readings reach 40 degrees, while no drugs help to normalize the temperature.

• Diseases of bones and joints.

Often, such diseases do not cause a strong increase in temperature, since they tend to proceed in a chronic form. But sometimes in the acute stage of arthritis (inflammation of the joints, especially if we are talking about the rheumatoid form of the disease), bursitis (inflammation of the periarticular bag), osteomyelitis (inflammation of bone tissue) a temperature of 38-38.5-39-39.5 and even 40 degrees can be observed. And we are not talking about a local increase in temperature, but about a feverish state.

• Oncological diseases.

It should be said that temperature, like pain, in malignant diseases increases already in the late stages of pathology development as a result of poisoning of the body with tumor decay products. Thermometer readings in this case rarely go beyond 38.5 degrees.

• Vascular diseases.

Temperature usually rises in inflammatory diseases. For example, in thrombophlebitis, it often stays within 37.5-38 degrees. But acute deep vein thrombophlebitis is characterized by hyperthermia with a temperature range of 39-40 degrees already in the first days of the disease.

• Diseases of the hypothalamus.

The destruction of cells in this part of the brain, responsible for body thermoregulation and many other processes in the body, is called hypothalamic syndrome. The body temperature can fluctuate within 38-39 degrees.

• Thyroid diseases: hyperthyroidism.

It should be said that elevated body temperature in patients is observed only against the background of increased production of thyroid hormones by the thyroid gland, and it rarely rises above 37.2-37.5. But excess hormones cause intoxication of the body (it is not for nothing that the disease is also called thyrotoxicosis) and at some point a thyrotoxic crisis may occur. And it is already characterized by an increase in temperature to 39-40 degrees.

• Psychoneurological disorders.

Temperature fluctuations in the range of 37.5-39.5 degrees (sometimes the thermometer can reach 40-41 degrees) are observed in malignant neuroleptic syndrome, which develops against the background of mental illnesses that require behavioral correction using potent drugs from the category of neuroleptics.

A rise in temperature to 38-40 degrees is one of the main somatic symptoms of a particularly severe form of schizophrenia – febrile, which is sometimes called fatal or lethal catatonia.

• Mastitis and lactostasis.

Women have problems during breastfeeding that can cause a temperature rise above 38-39 degrees. This is inflammation of the mammary gland caused by hypothermia or milk stagnation in the breast. Sometimes mastitis can develop outside of breastfeeding, which does not exclude a rise in temperature.

As we can see, a strong increase in temperature in an adult is an alarming symptom, because it can signal serious health problems. Most often, hyperthermia is caused by viral and bacterial infections, or rather the inflammation and intoxication caused by them. The infection can hide in different organs and systems of a person, and depending on this, other symptoms of diseases arise, in addition to high temperature, which in itself does not allow a diagnosis to be made.

One of the risk factors for difficult to diagnose infections is considered to be a trip to exotic countries, from which one can bring back rare, but very dangerous diseases that occur with fever and heat.

But colds and infectious diseases are most easily caught by a person who is not hardened, as well as by those whose body is weakened by chronic diseases. As for the ways of pathogens entering the body, the most common is the oral route (through unwashed hands and poor-quality food, as well as during breathing through the mouth).

Non-pathological risk factors for a strong increase in temperature include prolonged exposure to the open sun on days of its increased activity. In this case, a child, an adult, and an elderly person can get overheated. Less often, the temperature above 38 degrees can rise against the background of severe stress.

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High temperature in children

The child's immune system is formed for another 3 years after birth, so it is not surprising that babies usually get sick more often and more severely. In addition, newborn babies have an insufficiently developed thermoregulation mechanism, so their body temperature can change often, although a slightly higher than 38 degrees, not associated with illness, can only be in the first days after birth.

Heat transfer in a child's body stabilizes only by the age of 7-8. It is from this age that sweating, which helps cool the body, also stabilizes.

Children in the first years of life overheat very quickly, so the reason for their temperature rising to 38-38.5 degrees can be even increased physical activity in dry hot weather or improper selection of clothes. By the way, both points can be considered risk factors for colds that occur with an increase in temperature. After all, from overheating to hypothermia is only one step: as soon as the baby sits down to rest in a cool room or undresses after he has become hot and sweaty, the body begins to cool down sharply. The difference in temperatures, and now the baby is sniffling, refuses food because of a sore throat, and begins to cough.

A temperature of 38-39.5 in a child, as in an adult, is not considered a normal variant and in most cases indicates a cold. After all, hypothermia is a strong blow to the immune system, which is weak from birth, and becomes unable to resist infection.

Most often, we are talking about bacterial and viral ENT infections that cause inflammation in the throat, nasal passages and sinuses, and hearing organs. Tonsillitis, pharyngitis, otitis, acute respiratory infections, and acute respiratory viral infections are considered the most common diagnoses in young children. At the same time, the lack of treatment or its ineffectiveness very quickly leads to the transition of the same pharyngitis to laryngitis, bronchitis, tracheitis, pneumonia, which are very difficult for children with a temperature increase of up to 40 degrees.

In principle, an increase in temperature in response to the invasion of pathogens is a normal protective reaction of the body, but due to the imperfection of the thermoregulation mechanism, the increase in temperature indicators can be excessive, which becomes dangerous not only for pathogenic microorganisms, but also for the child himself.

Many viral infections common to young children can occur with high temperatures: measles, rubella, chickenpox, rotavirus infection, epidemic parotitis (mumps), sudden exanthema. However, the disease does not necessarily have to be accompanied by symptoms from the respiratory system. Thus, rotavirus infection and sudden exanthema caused by herpes viruses types 6 and 7 can debut with diarrhea against the background of a sharp increase in temperature.

The herpes virus in children can provoke the development of stomatitis, which is quite severe. Fever in this case is considered a fairly common symptom against the background of deterioration in general health and a significant decrease in appetite, and sometimes a complete refusal to eat.

As for bacterial infections, the reason for the thermometer readings going off the scale in a child may be the corresponding pathologies of the urinary system: cystitis, pyelonephritis, glomerulonephritis. Moreover, the latter disease is characterized by a very severe course in childhood with a rise in temperature to 40 degrees. Inflammatory pathologies of the urinary tract can be recognized by an increase in the frequency of urination, pain and colic during them, which is why the child begins to cry and be capricious.

Non-pathological causes, in addition to overheating, which can increase the child's body temperature to 38-38.5-39-39.5 degrees, include teething. Teething occurs with a noticeable increase in temperature and extreme anxiety in children up to 2-2.5 years old. At the same time, the child himself often cannot explain the reason for his anxiety and whims. Particularly high temperature readings are observed in children under one year old.

Later, at the age of 6-8 years, the shedding of milk teeth to permanent ones begins, which is not often, but can occur with a temperature. However, it rises to the mark of 38-38.5 degrees extremely rarely.

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Basics of self-diagnosis by symptoms

When the temperature rises, we do not always have the desire or opportunity to see a doctor. The easiest way is to bring down the temperature with a pill and watch if other symptoms of the disease appear, and they will definitely appear, because we create all the conditions for the reproduction of the infection and the progression of the pathology. But before running for medication, you need to at least roughly understand what the fever is associated with and how dangerous this condition is. After all, a wait-and-see attitude often only worsens the prognosis for recovery, and sometimes becomes the cause of a fatal outcome.

Most people tolerate temperatures up to 38 degrees well and may not even pay attention to it, not suspecting the disease. This often happens if subfebrile fever is only the only, first sign of pathology. But a temperature of 38-38.5-39-39.5 degrees can no longer remain unnoticed. In this case, a person's condition worsens even in the absence of other manifestations of infection.

Temperature of 38-39.5 without symptoms may be the first sign of some inflammatory disease, or a consequence of overheating of the body. In the second case, in addition to the increase in temperature, weakness, drowsiness, and apathy may be observed. The higher the degree of overheating, the more severe its symptoms become. When the body temperature rises to 38-38.5 degrees, a person becomes thirsty, it becomes unbearably hot, and the pulse rate increases noticeably even at rest.

With a further increase in body temperature, the victim's skin turns red, sweating increases (as they say, sweat pours out), apathy gives way to excitement, but at the same time the person is tormented by a severe headache and a feeling of pressure on the head in the temple area.

The extreme degree of overheating is considered to be heat stroke, which disrupts the activity of the cardiovascular and nervous systems. Symptoms of heat stroke are considered to be an increase in body temperature to 39.5-40 degrees, nausea and vomiting, severe headaches, increased pulse and heartbeat, arrhythmia, fainting, delirium, coma.

A high temperature without symptoms should not be ignored, because it is direct evidence that the body has begun an active fight against an invisible enemy. Other symptoms of the disease may appear a little later, on the second or third day, if the increase in temperature did not lead to the destruction of pathogens.

For example, a person may not even notice the first signs of osteomyelitis in the form of malaise, minor muscle and joint pain, and suspect a certain disease only when his temperature rises (with a local form of pathology up to 38 degrees, and with a generalized one - up to 39-39.5). Severe pain, swelling of the affected area, aching bones, deterioration of health due to intoxication, neurological symptoms and kidney failure are observed after the temperature rises.

But with joint inflammation, the opposite may happen: first, joint pain appears, joint mobility is limited, and then the temperature rises.

Many infectious diseases can occur in a latent form: meningitis, endocarditis, prostatitis, pyelonephritis and even pneumonia. Often, patients are brought to the hospital by ambulance with fever and heat, and an X-ray examination shows pneumonia, which the person did not even suspect. A temperature of over 39 degrees can, for a time, be the only manifestation of such a dangerous pathology as sepsis.

Tuberculosis and tonsillitis, many viral infections can debut with a high temperature without any other symptoms. But in blood diseases and oncology, fever is a late symptom, however, before its appearance, a person may not suspect the disease for several months or even years.

It is easier to diagnose a disease if it has other symptoms in addition to a high temperature. Thus, a temperature of 38-39.5 and a sore throat are typical clinical pictures of acute tonsillitis (angina), a runny nose in addition to the described symptoms is more typical of acute respiratory infections, acute respiratory viral infections and flu, and a cough is typical of inflammatory diseases of the lower respiratory tract (bronchitis, tracheitis, pneumonia). That is, these are all symptoms of respiratory infections.

With otitis, in addition to high temperature, there will be severe pain in the affected ear, as well as headaches. The latter, by the way, often accompany viral infections along with increased sensitivity of the eyes to light.

Diarrhea with colds rarely occurs when the infection penetrates the digestive tract. An exception is rotavirus infection, which mainly affects children. This disease, popularly called intestinal flu, is characterized by a tandem of intestinal and respiratory symptoms (especially at the beginning of the disease).

Rotavirus is characterized by: a sharp increase in temperature to 38-39.5 degrees, vomiting, grayish-yellow liquid feces, which are combined with a runny nose, hyperemia of the throat tissue, pain when swallowing, i.e. a combination of enteritis and tonsillitis. And light feces and dark urine are generally more reminiscent of the symptoms of liver damage (hepatitis).

Diarrhea itself most often indicates an upset stomach caused by eating poor-quality or unsuitable food, especially if it is not accompanied by respiratory symptoms. But if a person has diarrhea and a stomach ache, and the temperature is within 38-39.5 degrees, most likely, it is not a simple poisoning, but an intestinal infection, for the treatment of which gastric lavage and sorbent intake alone are not enough.

By the way, similar symptoms can also characterize acute hepatitis and appendicitis. In these cases, fever, pain in the right hypochondrium (with appendicitis, they can go lower), as well as diarrhea, nausea and vomiting, which do not bring relief to the patient, are also possible.

In any case, the combination of diarrhea, abdominal pain, nausea, vomiting and fever is considered very dangerous. In this case, you need to go to the hospital as soon as possible, calling an ambulance.

Intestinal poisoning, hepatitis, appendicitis are dangerous in themselves. But similar symptoms are also characteristic of a disease with a high risk of mortality – peritonitis (inflammation of the peritoneum), which is often diagnosed as a result of a ruptured appendix and the release of its contents into the abdominal cavity. This is accompanied by sharp abdominal pain, nausea and weakness, and a significant increase in temperature.

Later symptoms of peritonitis include: severe pallor of the skin, acute pain when pressing on the abdominal wall and tension of its muscles, vomiting, increased blood pressure, increased heart rate, hyperhidrosis, the appearance of symptoms of dehydration (thirst, decreased amount of urine excreted).

The combination of symptoms may look a little strange: temperature of 38-39.5 and cold feet. Although this looks like an oddity, in fact we are talking about a very serious and quite logical situation. Let us remember that at the first stage of fever, in order to reduce heat loss, the peripheral vessels narrow and the skin temperature decreases. The extremities are especially cold in this situation. And until the temperature stabilizes at a certain level, the skin and extremities will remain cold regardless of the cause of hyperthermia.

If the body becomes warmer, this indicates that the temperature will not increase further. But cold hands and feet indicate the opposite. If the temperature goes off the scale over 39.5 degrees, we can talk about a potentially life-threatening condition - hyperthermic syndrome, accompanied by depression or, conversely, excitation of the nervous system, cyanosis of the skin, heart problems (high blood pressure and heart rate due to increased load on the organ).

Often, at a temperature of 38-39.5, we notice that our head hurts and our body aches. Most often, this situation is observed with acute respiratory and intestinal infections, as well as with inflammation of the membranes of the brain occurring with a sharp increase in temperature. The appearance of headaches in the temples, forehead and eyes, caused by inflammation and intoxication of the body, does not raise questions. But why do muscle pains and body aches appear?

An increase in body temperature causes muscle fibers to break down, which results in the release of a special enzyme called creatine phosphokinase. When this substance enters the bloodstream, pain occurs.

Body aches have the same causes – changes in the characteristics of muscle fibers under the influence of high temperatures. Muscles become denser and more tense, unable to relax. This leads to a slowdown in blood circulation in muscle and joint tissues, the development of oxygen deficiency in them, as a result of which organs cannot normally perform their functions, and therefore signal about disorders with aches and pains.

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Why does body temperature rise?

When a person is healthy, moderately active, not exposed to strong solar radiation and heat, their body temperature is maintained within 36.6-36.8 degrees. This temperature is considered normal, although for some people the norm may be slightly higher or lower.

A temperature increase above 38 degrees can no longer be called normal. Moreover, a further increase in thermometer readings is fraught with the development of reactions that are dangerous to human health and life, since blood viscosity increases and it becomes harder for the heart to pump it through the vessels. That is why doctors recommend bringing down the temperature if its readings are above 38.2 -38.5 degrees, and earlier if you feel very unwell.

Despite the fact that many children tolerate heat well, remaining active and cheerful, it is believed that a temperature above 38 degrees is very dangerous for children due to the increased risk of febrile seizures. In this case, the opinions of pediatricians differ slightly. Some insist that a child's temperature above 38 degrees should be brought down in any case. Others believe that a child's cheerful state at a temperature of 38-39 degrees does not require drug correction, which negatively affects the liver. But given that 39.5 degrees is already a critical indicator for everyone, it is not worth bringing it to it.

We have already figured out that we need to bring down the temperature only when we see high readings on the thermometer and our health noticeably worsens. But the pathogenesis of the increase in temperature in various diseases remains unclear, i.e. why does overheating occur at all if the human thermoregulation system is so perfect?

Let's start with the fact that viruses and bacteria that enter the body and actively reproduce are not called pathogens for nothing. The cell membrane of these microorganisms and the products of their vital activity contain special substances called pyrogens (fire-producing). These pyrogens belong to the category of exogenous substances, i.e., coming from outside.

Exogenous pyrogens themselves are not capable of increasing the human body temperature, but they stimulate the production of endogenous pyrogens (interleukins, interferons, cytokines, etc.) in the lymphatic system. The active production of such substances is perceived by the hypothalamus in its own way. The normal body temperature now seems lowered and the regulating center strives to increase it.

In order for the temperature to be constant, heat production in the body must correspond to heat emission. If this does not happen, the thermometer column moves up or down. When heat production prevails over heat emission, the temperature rises. In adults, this occurs due to a decrease in heat emission, and in small children, due to increased heat production.

Heat loss is reduced by the constriction of peripheral vessels and decreased sweat secretion, triggered by the sympathetic nervous system. Spasm of small vessels reduces blood flow to the body's tissues, the skin becomes pale, dry and cold, retaining heat inside the body. Reduced sweating helps retain the heat that we lose through evaporation of liquid.

A decrease in skin temperature and activation of sensitive thermoreceptors on it leads to the occurrence of chills. After all, the receptors send a signal about freezing to the brain, where a signal is formed for a certain behavior that helps to preserve heat (a person tries to dress warmer, wrap himself in a warm blanket and move less).

At the same time, the body's metabolism intensifies, which in turn increases the body's heat production. On the thermometer, this entire process is reflected as a consistent increase in temperature to 38-38.5-39-39.5 degrees.

At some point, the body's heat production and heat loss become balanced, identical to normal, but the thermometer readings will be significantly higher than normal. Now the temperature stops rising, but can remain at high, constant values for several hours, days, and even weeks.

The hypothalamus believes that it has completed its task and stabilized the temperature, which means that it can send a signal to reverse the expansion of the vessels. This leads to the skin acquiring its previous shade and even becoming bright pink, when touched, a noticeable warmth is felt, and there is no trace of chills. If the temperature remains within 38.5-39 degrees, the fever is called febrile, and an increase in temperature to 41 degrees is called pyretic fever.

If no action is taken, the temperature will increase or remain high until the amount of exogenous pyrogens in the body decreases or the synthesis of endogenous heat provocateurs decreases. The reduction of pyrogen content in the body can be achieved by the action of medicinal antipyretic agents, or naturally, when the immune system suppresses the reproduction of pathogenic microorganisms and makes microbes inactive.

A decrease in the amount of pyrogens in the body is a signal to the hypothalamus to reduce the temperature, because it begins to perceive the existing one as elevated. The expansion of blood vessels leads to the removal of excess heat. This is also facilitated by the activation of the sweating process, the evaporation of liquid from the skin and the increase in diuresis (urine production). When heat transfer and heat production are balanced, we see normal readings on the thermometer.

As we can see, thermoregulation in the human body is a rather complex process. Pyrogens in our body are special substances of protein nature, the production of which is controlled by the immune system. These substances provide protection of the body from foreign invasion, because both the inflammatory process and the increase in temperature are a kind of protective reaction, the purpose of which is to create conditions unsuitable for the life and reproduction of pathogens. After all, for most of them, the normal human body temperature is optimal.

Warming up the body leads to:

• to the activation of metabolic processes, as a result of which toxic substances are more actively removed from the body,
• increased production of antibodies and antiviral substances that provide local immunity (interferons),
• destruction of pathogenic microorganisms that die from overheating, and reduction of their numbers in the patient’s body.

This once again speaks in favor of the fact that it is not worth bringing down the temperature without extreme necessity and, thus, preventing the body from fighting the infection. After all, if the temperature stabilizes, it will not be so easy to fight pathogens. It is another matter if the thermometer readings begin to approach critical ones, which will be more dangerous than the influence of viruses and bacteria.