FEVER IN A CHILD

Prof. Dr. Imran Ansari

207/05/13
INTRODUCTION

 Most common cause for OPD/ER visits

 Common to fail to find specific focus

 Most often, self-limited viral illnesses

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TYPE & GRADE

•Intermittent: fever only for few hours; then normal

• Quotodian (24-hr periodicity) (sJIA)
• Tertian (48-hr periodicity) (P. vivax & P. ovale)
• Quartan (72-hr periodicity) (P. malariae)
•Remittent: fluctuation >2o C/24 h; not touching normal
•Continuous: fluctuation <1o C/24 h; not touching normal

•Low: 100.5–102.1°F (38.1–39°C)

•Moderate: 102.2–104.0°F (39.1–40°C)

•High: 104.1–106.0°F (40.1-41°C)

•Hyperpyrexia: >106.0°F (>41°C)

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DURATION
 Acute (<2 wks)
 Up to 1 wk: Viral

1 – 2 wk: Bacterial

 Prolonged (>2 wks)

 Chronic infections

 Collagen vascular disease

 Malignancy

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ACUTE FEBRILE ILLNESS
<2 weeks
ASK FOR
1. Age:
1. Newly born
 Perinatal events
 Maternal Flora
2. Up to two months
 Can’t localize
 Management same as newborn
3. Two months to two years
 UTI as hidden cause
4. Up to five years
 Hib

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ASK FOR….

2. Organ specific symptoms

1. Rhinorrhea, cough, sore throat, earache

2. Headache, vomiting, seizures, LOC

3. Increased frequency, dysuria

4. Pain abdomen, loose motion, urine color

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ASK FOR….
3. Fever characteristics
 Degree: viral/bacterial
 Type: viral, typhoid
 Response to anti-pyretics
5. Systemic upset: viral/bacterial
6. Address/travel : malaria
7. Immunization: cause, effect
8. Contact: viral
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LOOK FOR
1. General condition: sick, toxic, temperature
2. Head to toe
 Ant fontanel
 Icterus
 Ear: TM, discharge
 Throat: tonsillitis
 Chest: RR, WOB, auscultate
 Abdomen: organomegaly, renal angle
 Skin rash: viral/meningococcal/rickettsial
3. Signs of meningeal irritation
4. Switch order in young children
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INVESTIGATIONS

1. None if >2 mo, otherwise well, for 72 hr

2. Ill, toxic, high fever: CBC, CRP, Blood c/s

3. Urine in <2 yr without clear source

4. LP – 18 mo: signs (-), older: signs (+)

5. CXR – if severe respiratory signs

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COMPLETE SEPTIC WORK UP (≤ 60 D)
 Complete Blood Count (CBC)
 CRP
 Blood Culture
 Lumbar Puncture
 Urine culture if > 48 hr (cath/suprapubic)
 CXR if respiratory signs

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PROLONGED FEVER
> Two weeks
ASK FOR
1. Degree and type of fever
2. Cough, loss of wt, appetite
3. Organ specific symptoms
4. Bleeding, bruising tendency
5. Bone pain
6. Contact history
7. Immunization
8. Address, living condition
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LOOK FOR
1. Lymhadenopathy
2. Pallor
3. Skin: rash, petechiae/pupura/bruises
4. Chest auscultation
5. Liver, spleen enlargement
6. Bony tenderness
7. Joints: arthritis
8. Anthropometry: wasting, underweight

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INVESTIGATIONS
1. TCDC, Hb, platelet
2. ESR
3. Peripheral film
4. X-ray: chest, long bone
5. Mantoux test
6. Sputum: AFB, culture, Genexpert
7. USG abdomen: lymph nodes, mass
8. RF, Anti-ds DNA
9. Lymph node aspiration/biopsy
10. Bone marrow
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NON INFECTIOUS CAUSES
 Infections most common cause
 Non-infectious cause to be considered if:
 Etiologynot obvious
 Fever despite antibiotic
 Causes?
1. Malignancy
2. Collagen vascular diseases
3. Central fever
4. Environmental temperature

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 Questions/Comments

THANK YOU

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SMALL GROUP DISCUSSION

1. Rheumatic fever: diagnosis and prophylaxis –

primary and secondary

2. JRA – management

3. Enteric fever – management and

complications

4. Viral exanthema
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CASE 1
 Page 1

A 10-year old boy presented to the pediatric

OPD with complaints of fever for 3 months.
One day before coming to hospital he had an
episode of focal seizure.
 What more information will you require to
make a historical diagnosis?

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CASE 1
Page 2
The mother said fever is low grade mainly in the
evening. He is also coughing and bringing out
sputum which has reddish tinge to it. He has
lost appetite as well as weight. The mother is
not sure about BCG vaccination. The boy lost his
grandfather recently with similar illness. The
seizure was very brief and was limited to left
side of face and left upper limb and was tonic in
nature. The consciousness was not affected.
 What is the differential diagnosis?
 What will you look for in the examination?
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CASE 1
Page 3
On examination he was mildly pale. Lymph nodes
were not enlarged. There was no bony tenderness.
BCG scar was absent. There was decreased air
entry in the left lower chest which was dull on
percussion. No organomegaly was detected. The
boy was confused. Neck stiffness was present and
Kernig sign was positive. There was no neurological
deficit. Nor was there any sign of raised ICP.
 What is the provisional diagnosis?
 What is the likely cause of chest signs?
 What investigations will you advise?

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CASE 1
Page 4
TC = 15,000 (N 30%, L 70%); Platelet=
300,000/cmm, ESR = 62; Mantoux 02 mm;
chest x-ray: Pleural effusion (L); CSF: WBC
570 (P 10%, L90%), Protein 200 mg%, Sugar 50
mg% (dextrostix 100 mg%). Sputum AFB and
Genexpert reports awaited.
 Interpret the CSF report.
 What is the diagnosis?
 Any other investigation? What to expect?

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CASE 2
Page 1

A 6-year old child presented with fever,

headache and pain abdomen for 10 days.

There is mild cough but no chest pain.

 What more will you ask in the history?

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CASE 2
Page 2
The maximum temperature recorded at
home was 1040 F. It is continuous and not
responding to paracetamol. She is
constipated. There is no dysuria. The color
and frequency of urine is normal. There is
no history of ear discharge. She
hasheadache with severe anorexia and
vomits when food is offered.
 What are the differential diagnoses?
 What will you look for in examination?
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CASE 2
Page 3
The child looks toxic. Temperature is 1030F
and pulse rate 100/min. She is mildly
icteric. Throat is mildly congested. Ear
drums look normal. The chest is clear.
Spleen is 3 cm below left costal margin.
Liver span is 11 cm. The renal angles are
not tender. Neck is supple, Kernig and
Brudzinski negative.
 What is the differential diagnosis? Why?
 What investigations will you advise?
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CASE 2
Page 4

TC 18,400 (P 60%, L 40%); Hb 9.5 gm%; CRP

128; ESR 10; CXR Normal; SGPT 240; Urine

R/E: pus cells 2-4, RBC nil.

 Interpret the report.

 What is your diagnosis?

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CASE 3
Page 1

A 7-year old girl presented to the ER with

fever and rash. The fever is high grade
intermittent. The rash does not itch.
 What are the differential diagnoses?
 What more will you ask to the mother?

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CASE 3
Page 2
Temperature curve is
shown here. Fever is there
for one month and the
rash appeared on day 4 She has not lost weight and
of fever and comes and appetite significantly during
goes with fever. The child this period. Vaccination is
does not have much complete as per EPI. Nobody in
cough. She started the family is suffering from any
complaining of pain and chronic illness.
swelling in both knees
•only
Whicha couple
type ofoffever
days is
ago.
this?
•Which differential diagnoses are now less likely?
•What should be the focus of examination?

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CASE 3
Page 3
The child is irritable. BCG scar is present. The
affected joints are swollen and tender. She has
blanching maculopapular rash all over the body.
There is no bony tenderness. Several axillary
and cervical lymph nodes are >2 cm. Both liver
and spleen are significantly enlarged.
 What are the differential diagnoses now?
Some investigations are sent and the child is put
on antibiotics.
 What could be those investigations? Why will
you ask for these tests?
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CASE 3
Page 4
TC 20,500/cmm (N 80%, L19%, E01%); Hb 9
gm%; Platelet 700,000/cmm; Blood culture:
no growth; ESR 125; RA factor negative; ANA
negative; CXR – no mediastinal enlargement;
no lung infiltrates. Mantoux negative. The
fever persists even after 7 days of antibiotic
treatment.
 Interpret the results.
 What is the diagnosis?

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CASE 4
Page 1
A 12-year old male child is suffering from
high grade fever for three weeks along with
swelling in the neck and armpits. He has lost
appetite and weight significantly. The
mother also says that the boy has become
very weak.
 What are the differential diagnoses? Put
them in order of most likelihood.
 What will you enquire in the history to rule
in or rule out those conditions?
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CASE 4
Page 2
The child has been coughing a lot and is also
having difficulty in breathing. There is
profuse sweating in the night. There is no
history of bleeding from anywhere. Nobody
in the family has tuberculosis. He is fully
immunized as per EPI schedule of Nepal.
 What will be the order of your d/d now?
 What will you look for in the examination
and why?

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CASE 4
Page 3
The child is sick looking. There is generalized
lyphadenopathy involving cervical and axillary
lymph nodes which are discrete, painless, firm
and rubbery. BCG scar is present. The patient
is significantly pale. There is no bony
tenderness. Skin survey is normal. The chest
is clear. Liver is palpable 4 cm below right
costal margin and spleen is palpable 3 cm
below left costal margin.
 How has your d/d changed now?
 What investigations will you ask for and why?
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CASE 4

Page 4

TC 13,200 (P 17%, L 87%). Hct 15%, ESR 75;

Blood culture sterile; Mantoux 2 mm. Sputum

for AFB negative. CXR mediastinal mass.

 What is the provisional diagnosis?

 How will you confirm?

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 HODGKIN/REED-STERNBERG (HRS) CELL

R-S cells: L (bone marrow); R (l. node); Clear area surrounding nucleoli in R
(red arrows), "owl's eyes" appearance to the nuclei; Shrinkage artifact
causes these cells to separate from the adjacent tissue, leaving a clear area
surrounding these cells (blue arrows). 35
FEVER OF UNKNOWN ORIGIN
(FUO)
 A consensus definition lacking
 Adult
 Petersdorf and Beeson (1961):
T >101°F on several occasions
 for at least three weeks
 Unclear diagnosis after 1 week of hospital study
 Refinements: eliminating in-hospital evaluation;
increased sophistication of outpatient evaluation
 Children: T >101°F at least once per day for
≥8 days with no apparent diagnosis after
initial outpatient or hospital evaluation  

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BEFORE LABELING AS FUO
 Following evaluation should have been
performed and should have been unrevealing:
●History
●Physical examination
●CBC, including differential and platelet count
●Blood cultures (3 sets, different sites, interval of hrs)
●Blood chemistry, including liver enzymes and bilirubin
●Liver tests abnormal: hepatitis A, B, and C serologies
●Urine microscopic examination, and urine culture
●Chest radiograph
 Signs/symptoms pointing to a particular organ
system: further testing, imaging, and/or biopsy
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CAUSES
1. Infections

2. Rheumatologic

3. Malignancy
 In many cases, fever resolves before
definitive diagnosis is established
 Common disorders, unusual presentation

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INFECTIONS
1. Typhoid fever

2. Tuberculosis

3. Brucellosis

4. Leptospirosis

5. Salmonellosis

6. Toxoplasmosis

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EVALUATION
 Detailed history, physical examination
 Repeated on several occasions
 History: details about the fever, associated
complaints, and exposures
 Examined while febrile
 Important aspects: vital signs, growth
parameters, skin, scalp, eyes, sinuses,
oropharynx, chest, abdomen,
musculoskeletal, genitourinary

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INVESTIGATIONS
 Initial
 CBC, peripheral smear
 ESR, CRP
 Blood cultures
 Urinalysis and urine culture
 Chest radiograph
 Tuberculin skin testing
 S. electrolytes, BUN, creatinine, hepatic
aminotransferases
 HIV
 Selected
 USG, CT, MRI, PET scan
 Bone marrow, FNAC, lymph node biopsy

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PLEURAL FLUID (PED
PROTOCOL)
Transudate Purulent Empyema Complicated

WBC 1,000 5,300 25,900 55,000

PMN% 50 >90 >95 >95

Protein <0.5 >0.5 >0.5 >0.5

(F:S)

LDH <200 >200

Glucose >60 <60 <60 <40

PH 7.4 – 7.5 7.35 – 7.45 7.2 – 7.35 <7.2

Indications for chest tube insertion:

PH ≤7.2, Glucose <40, gram stain shows organisms, purulent
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fluid
ANSWER TO CBD

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CASE 1
Page 1: History

1. Fever: Type, Grade

2. Organ specific symptom (cough, sputum)

3. Weight, Appetite

4. Vaccination (BCG)

5. Contact history

6. Seizure: details

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CASE 1 PAGE 2: D/D; EXAM
1. D/D:
1. TB
2. Malignancy
2. Exam
1. General exam: pallor, lymph nodes
2. Bony tenderness
3. BCG scar
4. Chest exam
5. Abdomen: organomegaly
6. CNS: men irritation, neurol deficit, ICP
7. Raised ICP
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CASE 1 PAGE 3
 CBC = 15,000 (N 30%, L 70%)
 ESR = 62; Mantoux 02 mm after 48 hours;
Left sided pleural effusion on chest x-ray;
CSF: WBC 570 (P 10%, L90%), Protein 200 mg
%, Sugar 50 mg% (dextrostix 100 mg%).
Sputum AFB and Genexpert reports awaited

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