College of medicine and health science school of medicine

Department of pediatrics & child health

Seminar presentation on: Approach to febrile child

Moderator: DR. Abiye Zeleke(MD,Pediatrician, Assistant

Professor Of Pediatrics And Child Health)

Presented By: Belsti Bazie & Berhanu Addisu (CI-

student)
 Presentation outline
Objective
Definition
Pathogenesis
Etiology
Patterns of fever
Clinical features
Approach to febrile child
Fever with out focus
 Objectives
After the end of the session the participants are
expected to:-
Define fever
Describe pathogenesis of fever
Identify etiologies of fever
List patterns of fever
Describe approaches of febrile child
Describe fever with out focus
 Introduction
Definition of terms
Fever is defined as a rectal temperature ≥38°C
Hyperpyrexia is a fever of rectal temprature>40.0
°C
Hyperthermia is uncontrolled increase in body
temperature that exceeds the body's ability to lose
heat
Introduction cont…

Body temperature fluctuates in a defined normal range

(36.6-37.9°C rectally
 Lowest point morning
 Highest point early evening
Rectal temperatures are generally 0.4°C higher than oral
readings
Oral temprature are 0.5°C higher than axillary readings
 PATHOGENESIS
 Body temperature is regulated by:-
Thermosensitive neurons
cold and warm receptors in the skin
Thermoregulatory responses include ;
Redirecting blood to or from cutaneous vascular
beds
increased or decreased sweating
regulation of ECF volume via arginine
vasopressin
 behavioral responses
 Pathogenesis cont…
• Three different mechanisms can produce fever:
Pyrogens
 heat production exceeding loss
Defective heat loss
 Pathogenesis cont…
1.Pyrogens
• It involves endogenous and exogenous pyrogens
• Endogenous pyrogens include:
Cytokines
 interleukins 1 and 6,
 tumor necrosis factor α, and
 interferons β and γ
 Stimulated leukocytes and other cells produce
lipids (prostaglandin E2)
 malignancy and inflammatory diseases
 Pathogenesis cont…
Exogenous pyrogens
• come from outside the body include mainly infectious
pathogens;
Microbes,
microbial toxins,
superantigens or other products of microbes and
drugs
• Endotoxin can directly affect thermoregulation in the
hypothalamus as well as stimulate endogenous pyrogen
release
 Pathogenesis cont…
• Many drugs cause fever
• The mechanism for increasing body temperature varies
with the class of drug
vancomycin,
amphotericin B, and
Allopurinol are Drugs that are known to cause fever
 Pathogenesis cont…
2.Heat production exceeding heat loss
as in salicylate poisoning and malignant
hyperthermia
3. Defective heat loss
in children with ectodermal dysplasia or victims of
severe heat exposure.
Fever production pathway
 Etiology
Grouped into 4 main categories:
1.Infectious
2.Inflammatory
3.Neoplastic
4.Miscellaneous
 Etiology cont …
Self-limited viral infections and uncomplicated
bacterial infections are the most common causes of
acute fever
Rarely rises above potentially lethal levels (42°C) in
the neurologically intact child unless extreme
hyperthermic environmental conditions are present or
 Other extenuating circumstances exist, such as
underlying malignant hyperthermia or thyrotoxicosis
 Etiology cont …
 Pattern of the fever can provide clues to the
underlying etiology.
Viral infections are associated with a slow decline
of fever over a week
bacterial infections are often associated with a
prompt resolution of fever after effective
antimicrobial treatment is employed
But if tissue injury has been extensive, the
inflammatory response and fever can continue for
days after all microbes have been eradicated
 Etiology cont …
• In general, a single isolated fever spike is not
associated with an infectious disease
• Such a spike can be attributed to the infusion of
blood products and some drugs, as well as to
some procedures, or to manipulation of a catheter
on a colonized or infected body surface
 Etiology cont…
• Similarly temperatures in excess of 41°C are most
often associated with a noninfectious cause:
central fever
malignant hyperthermia
Malignant neuroleptic syndrome,
drug fever, or
 heatstroke
 Patterns of fever
•Intermittent fever
•Sustained fever
•Remittent fever
• Relapsing fever
•Biphasic fever
•Factious fever
 Approach to febrile child
History
• Thorough history: onset, other symptoms, exposures ,
travel, medications, other underlying disorders,
immunizations
• Most AFI episodes in a normal host can be diagnosed by a
careful history and physical examination and require few,
& laboratory tests
• Because infection is the most likely etiology of the acute
fever, the evaluation should initially be geared to
discovering an underlying infectious cause
• The details of the history should include the onset and
pattern of fever and any accompanying signs and
symptoms
 Approach …
Physical examination
• Physical examination: complete, with focus on
localizing symptoms
• should begin with a complete evaluation of vital
signs.
• In the acutely febrile child, the physical examination
should focus on any localized complaints,
• a complete head-to-toe screen is recommended
e.g. palm and sole lesions provide a clue for
infection with coxsackievirus.
 Approach…
Laboratory studies :
• Rapid antigen testing
• Nasopharyngeal: respiratory viruses by polymerase
chain reaction
• Throat culture: group A Streptococcus
• Stool: rotavirus
• Blood: complete blood count, blood culture, C-reactive
protein, sedimentation rate, procalcitonin
 Approach…
• Urine: urinalysis, culture
• Stool: Hemoccult, culture
• Cerebrospinal fluid: cell count, glucose,
protein, Gram stain, culture
• Chest radiograph or other imaging studies
on a case-by-case basis
 Management
• Fever with temperatures <39°C (102.2°F) in healthy
children generally does not require treatment
• Antipyretic therapy is beneficial in high-risk patients
 chronic cardiopulmonary diseases,
 metabolic disorders, or neurologic diseases and
 in those who are at risk for febrile seizures
 Management cont …
• Hyperpyrexia (>41°C [105.8°F]) indicates high
probability of hypothalamic disorders or central
nervous system hemorrhage and should be treated with
antipyretics
Antipyretics
• Acetaminophen at a dose of 10-15 mg/kg/dose every 4
hr and
• Ibuprofen in children >6 mo at a dose of 5-10
mg/kg/dose every 8 hr are the most commonly
employed
Pathogenesis and fever production and mechanism of drugs
 Fever Without a Focus
Definition
• Fever without a focus refers to a rectal temperature of
38°C (100.4°F) or higher as the sole presenting feature
• The terms “fever without localizing signs” and “fever of
unknown origin” (FUO) are subcategories of fever
without a focus
 1. Fever Without Localizing Signs
• Fever of acute onset, with duration of <1 wk and without
localizing signs, is a common diagnostic dilemma in
children <36 mo of age.
• The etiology and evaluation of fever without localizing
signs depends on the age of the child.
• Traditionally, 3 age groups are considered:
 Neonates ,
infants >1 mo to 3 mo of age, and
children >3 mo to 3 yr of age
 A. Neonates
• Neonates who experience fever without focus are a
challenge to evaluate
• because they display limited signs of infection,
• making it difficult to clinically distinguish between a
serious bacterial or viral infection and
• self-limited viral illness
• Immature immune responses in the 1st few months of life
also increase the significance of fever in the young infant
• In general, neonates who have a fever and do not appear
ill have a 7% risk of having a serious bacterial infection
Cont……..
Acquired serious bacterial infections includes-
• bacteremia
• meningitis
• pneumonia
• osteomyelitis
• septic arthritis
• enteritis
• urinary tract infections
Cont……..
• Although neonates with serious infection can acquire
community pathogens, they are mainly at risk for late-
onset neonatal bacterial diseases
• This includes ,Group B streptococci, E. coli, and Listeria
monocytogenes
• And perinatally acquired herpes simplex virus (HSV)
infection
Cont…
• Owing to the unreliability of physical findings and the
presence of an immature immune system,
• All febrile neonates should be hospitalized;
• Blood, urine, and (CSF) should be cultured,
• CSF studies should include cell counts, glucose and
protein levels, gram stain, and culture;
• HSV and enterovirus polymerase chain reaction should
be considered.
• Stool culture and chest radiograph may also be part of
the evaluation
• The child should receive empirical intravenous
antibiotics
Cont…
• Combination antibiotics, such as ampicillin and
cefotaxime or ampicillin and gentamicin, are
recommended
• Acyclovir should be included if ;
 HSV infection is suspected because of seizures
,hypotension, transaminase elevation, CSF
pleocytosis or
known maternal history of genital HSV, especially
at the time of delivery.
 B. 1 to 3 months of age
• The large majority of children with fever without
localizing signs in the 1-3 mo age group likely have a
viral syndrome
• In contrast to bacterial Infections,
• most viral diseases have a distinct seasonal pattern:-
• respiratory syncytial virus and influenza A virus
infections ( during the winter),
• enterovirus and par-echovirus infections (usually in
summer and fall).
Cont…
• Although a viral infection is the most likely etiology,
fever in this age group should always suggest the
possibility of serious bacterial disease.
• Organisms to consider includes
• E. coli,
• group B Streptococcus,
• L. monocytogenes,
• Salmonella enteritidis,
• N. meningitidis,
• S. pneumoniae,
• H. influenzae type b, and S. aureus
Cont…
• Pyelonephritis is the most common serious bacterial
infection in this age group and
• more common in uncircumcised infant boys and infants
with urinary tract anomalies.
• E. coli is the most common pathogen identified in
bacteremic infants,
• the majority having pyelonephritis
Cont…
• Most significant blood cultures turn positive within :
24 hr (91%),
 99% positive by 48 hr
• Other potential bacterial diseases in this age group
include otitis media, pneumonia, omphalitis, mastitis, and
other skin and soft tissue infections
Cont…
• Ill-appearing (toxic) febrile infants 3 mo of age or
younger require
• prompt hospitalization and immediate parenteral
antimicrobial therapy after cultures of blood, urine, and
CSF are obtained.
• Ampicillin(to cover L.monocytogenes and
Enterococcus) plus either
• ceftriaxone or cefotaxime is an effective initial
antimicrobial regimen for ill appearing infants without
focal findings.
Cont...
• This regimen is effective against the usual bacterial
pathogens causing:
 sepsis,
urinary tract infection, and
enteritis in young infants
• If meningitis is suspected because of CSF abnormalities,
vancomycin should be included to treat possible
penicillin-resistant S. pneumoniae until the results of
culture and susceptibility tests are known.
 C. 3 to 36 Months of Age
• Approximately 30% of febrile children in the 3-36 mo
age group have no localizing signs of infection.
• Viral infections are the cause of the vast majority of
fevers in this population,
• But serious bacterial infections do occur and are
caused by the same pathogens listed for patients 1-3
months of age,
• Except for the prenatally acquired infections.
Cont..
• S. pneumoniae,
• N. meningitides and
• Salmonella account for most cases of occult
bacteremia.
• H. influenzae type b remains common in under
developed countries that have not implemented these
vaccines in their immunization schedule.
Cont…
• Risk factors indicating increased probability of occult
bacteremia include
 temperature ≥39°C (102.2°F),
 WBC count ≥15,000/µL, and
 elevated absolute neutrophil count, band count,
 ESR, or C-reactive protein.
• The probability of bacteremia and/or pneumonia or
pyelonephritis among infants 3-36 mo of age increases as
the temperature (especially >40°C [104°F]) and WBC
count (especially >25,000/µL) increase.
• no combination of laboratory tests or clinical assessment is
sensitive enough to predict the presence of occult
bacteremia.
Diagnostic algorism for febrile child 3 to 24
monts
 Fever Of Unknown Origin(FUO )
•The classification FUO is best reserved for
children with:
 fever documented by a healthcare provider and
for which the cause could not be identified after
 3 weeks of evaluation as an out patient or
after 1 week of evaluation in the hospital
 Etiology
• Many causes of FUO in children are infections,
• Rheumatologic(connective tissue or autoimmune)
diseases, or auto inflammatory diseases
• Neoplastic disorders should also be seriously considered,
although most children with malignancies do not have
fever alone.
Cont…
Diagnostic considerations of fever of unknown origin
in children
Abscesses
Bacterial diseases
Localized infections
Spirochetes
Fungal diseases
Rickettsia
Viruses
Cont…
Parasitic diseases
Rheumatologic diseases
Hypersensitivity diseases
Neoplasms
Granulomatous diseases
Familial and hereditary diseases
Cont…
Diagnosis
• History
• Physical 
Examination
• Laboratory Evaluation
• Diagnostic imaging
Cont…
Management
• The ultimate treatment of FUO is tailored to the
underlying diagnosis.
• Empirical trials of medication should generally be
avoided.
• Children with FUO have a better prognosis than do
adults.
Types of fever of unknown origin
 References
• Nelson text book of pediatrics 21st edition
• Nelson essentials of pediatrics 8th edition
• Uptodate 21.6