A CHILD WITH PERSISTENT FEVER

By : A/P Dr Shubhangi B Ogale (MBBS, D.C.H, MD – Paediatrics)

Fever
 T > 38.0 oC
 Mechanism = exo/endogenous pyrogens which trigger release of PG (E2), signal HT
to elevate body’s thermoregulation
 Fever unknown origin (FUO) defined as :
1. Temperature > 38.0 oC on several occasion
2. More than 3 weeks duration of illness
3. Fail to reach diagnosis despite 1 week inpatient investigation
 FUO – common causes
 Infection – bacteria (Salmonella, pneumonia, Tb), spirochetel (leptospirosis,
syphilis, Lyme’s disease). Viral (CMV, Hep, HIV, EBV), chlamydial,
rickettsial, fungal (blastomycosis). Parasite
 Malignancy (leukemia, lymphoma, neuroblastoma)
 Autoimmunie disease (SLE, RF)
 Granulomatosis disease – chron disease, sarcoidosis
 Familial hereditary disease – cyclic neutropenia, familial dusautomia, Familial
Mediterranean fever
 Miscellaneous – DI, Kawasaki disease, thyrotoxicosis, IBD

Check list history taking

 Age
 Onset and duration of fever
 Type of fever – low/high grade, continuous/intermittent (low grade, prolong – viral,
inflammatory/vasculitis d/o or malignancies), (recurrent/relapse – brucellosis,
borreliosis, Hodgkin disease)
 H/o night sweat – lymphoma, Tb, HIV
 Associated with chills and rigor – UTI, septicaemia, any abscess, malaria, IE)
 H/o RN, cough, SOB, cyanosis
 H/o otalgia/ ear discharge/ sore throat
 H/o chest pain, palpitation, SOB, cyanosis – cardiovascular causes
 H/o dysuria, increase micturition, abd pain, hematuria – renal inviolvement
 H/o alter behaviour, headache, visual disturbance, motor deficit – CNS
involvement
 H/o skin rash
 H/o swelling/lump- for Tb/malignancy
 H/o bone pain, joint pain, joint swelling – malignancies/autoimmune disease
 H/o contact with zoonotic
 Recent contact with cats – Cat Scratch Disease
 Any h/o pica – ingested of dirt for Toxocara canis and Toxoplasmosis gondii
  Past history of similar symptoms
 H/o ill contact
 H/o PTB contact
 H/o recent travel
 H/o insect/mosquito bite
 Diet history
 Detailed immunisation history – last immunisation, is the symptoms appear after
immunisation
 Developmental history
 Birth history, psychosocial history,
 Any history of LOA, LOW, FTT during afebrile period

Check list for physical examination

 Temperature
 Overall appearance –toxic?
 HR.RR,BP
 Pallor, cyanosis, clubbing icterus, lymphadenopathy, oral cavity, skin changes, eyes
 MSK – joint swelling, tenderness, erythema, bone tenderness
 Respi exam (breath sound, crackles), CVS exam (murmur) , Abdominal exam
(mass, ascites, perianal fissure, abscess, testicular pain) Nervous system exam
(Kerning’s & Brudzinski’s – meningeal sign ; focal neurological deficit)

Investigation
 FBC (WBC – high (bacteria), low (viral, sepsis); anemia – certain condition (IE,
amalria, malignancy, CKD) ; platelet – high (non-spesific), low ( severe bacteria/viral,
dengue)
 Peripheral blood smear – haematological d/o or malaria
 ESR and CRP
 Blood culture
 Urine, stool, CSF culture, morning gastric aspirates
 BUSE/creat
 LFT
 Serology test – EBV, CMV, HIV, leptospira, VDRL, HIV
 CXR
 Tuberculin skin test
 Additional test
 Stool test
 Bone marrow exam
 LP
 Serum ANA , Rf , TFT
 Skin biopsy, lymph node biopsy
 CT, MRI, USG
 Echo
Must know facts

 Mechanism of fever
 Definition of FUO
 Clinical feature of UTI in children – non-specific
(fever, irritable, poor feeding, vomiting)
 More specific feature – loin pain, frequency,
dysuria.
 Examination findings
 Risk factor of UTI (female, uncircumcised men,
VUR, toilet training, voiding dysfunction,
constipation)
 Clinical type of UTI (3) – 1. Pyelonephritis 2.
Cyctitis 3. Asymptomatic bacteriuria
 Ways to collect urine sample for Ix – mid-stream
urine sample, catheterisation, SPA
 Significant bacteriuria > 103 colonies
 Asymptomatic bacteriuria – (+ve urine culture,
w/o clinical manifestation)
 Pyuria – presence 4 or more neutrophil/hpf (can
be present without UTI)
 Sterile pyuria – (+ve leucocyte, -ve culture),
 Urine FEME – Leucocyte esterase, nitrites,
leucocytes
 Microscopic hematuria – in acute cystitis
 Ix recommended in UTI – Urine FEME, MCU
(micturating cytourethrogram). Radioisotope scan
(DMSA/DTPA)
 Drug use in UTI
 Reflux neuropathy