MANAGEMENT IS AGE DEPENDANT• Management of the infant/child/adolescent with a fever, varies based on the age of the pt.• Common/arbitrary age divisions:• 0-28 days• 1-2 months• 2-3 months• 3-6 months• 6-36 months• 3 years to adulthood (Rosen’s, p2094)
FEVER DEFINED/ ROSEN’S• “Fever is defined as any elevation in body temperature equal to or above 38.0 C (100.4 F).” p 2094 THIS IS A RECTAL TEMP!!!• Rectal temps are the most reliable, as axillary, oral, and tympanic temps are not reliable.• No rectal temps in pts who are immunocompromised, such as cancer pts on cytotoxic medications.• HYPERTHERMIA: Is an elevation of the body’s set point, as in ASA od, Heatstroke, malignant hyperthermia, etc.
SERIOUS BACTERIAL ILLNESS (SBI)• Typically defined as “The presence of pathogenic bacteria in a previously sterile site.• This includes: Urinary tract infections (UTI), bacteremia, meningitis, osteomyelitis, bacterial gastroenteritis, bacterial pneumonia, cellulitis or septic arthritis.• RISK of SBI in for infants < 3 mo old, with a fever, is between 6% to 10%!!!
Common pathogens vary by age• 0-28 days: group B strep/ L monocytogenes/ Herpes Simplex Virus (HSV).• 1 to 2 Months: S. Pneumoniae/ H Influenzae/ N Meningitidis/ E coli. Varicella (CHICKENPOX)• ALL CHILDREN < 3MO, URINARY TRACT IS THE MOST COMMON SITE OF INFECTION(2094).• Infants < 3mo may present with a viral syndrome and still have a serious bacterial illness.
N Meningitidis• Bimodal distribution.• Highest incidence in children < 12 mo Old.• 2nd peak: adolescents, with highest group in the college students living in dorms.
Case: Sick looking 28 day old infant with temp > 39 C• What are the most likely organisms???• What antibiotic therapy should be started??
Case: Sick looking 28 day old infant with temp > 39 C• MOST COMMON ORGANISMS: L. monocytogenes, GP B strep, N meningitidis, S Pneumoniae, and E Coli.• TREATMENT:• Ampicillin (100mg/kg/24 divided Q 6 hours).• Plus either Gentamycin 5mg/kg/24 hours divided Q 8 to 12 hours) OR Cefotaxamine (150mg/kg/24 hours divided Q 8 hours). (R 2098)
HISTORY OF PEDIATRIC FEVER• Infants, 28 days: Ask about exposure to HSV, OR group B Strep.• Decrease in fever in response to Tylenol and/or Motrin use “HAS NOT BEEN SHOWN TO RELIABLY EXCLUDE BACTEREMIA (2096).”• Any HX of lethargy/ irritability/ or altered mental status: MUST include Meningitis/Encephalitis in the diff Dx.
PHYSICAL EXAM• Physical exam should be age adjusted. Look for the most serious problems based on the age of the pt and the serious infections in that age group.• RASH: Beware the rash!! Rashes are found in life threatening conditions: Meningococcemia/ Rocky Mountain spotted fever/ Toxic Shock Syndrome (TSS)• Watch the child: does the child stop breathing??
APPARENT LIFE THREATENING EVENT (ALTE)• Definition: ALTE is an episode that is frightening to the observer!! Findings: Combination of Apnea, color change ( red, blue, choking episode, and a marked decrease in muscle tone.• Pathologic apnea is a respiratory pause > 20 sec, or associated with cyanosis, pallor, hypotonic, or bradycardia.• “Near miss SIDS” IS NO LONGER USED!!!
PE: PURPURA• HENOCH-SCHONLEIN PURPURA.• What defines the syndrome??• PHYSICAL EXAM AND HX> How to identify the syndrome??• See the Handouts from Knoop,K.J. et al. “The Atlas of Emergency Medicine” 3rd ed. Pub• DISCUSSION!!!• Contrast with MENINGOCOCCEMIA!!!!
A child with a fever and a evolving petechial rash• “A CHILD WITH A FEVER AND AN EVOLVING PETECHIAL RASH MUST BE PRESUMED TO HAVE MENINGOCOCCEMIA (Knoop,K.J.; Atlas of Emergency Medicine, 3rd ED., Pub 2010, pg 423.)”• Henoch-Schonlein Purpura (HSP): The child usually has Abdominal Pain, Arthralgias, and lower body purpura, BUT DOES NOT LOOK SICK AND DOES NOT HAVE A HIGH TEMP (2180-2182)
PEER VII TQ #94• Compared to other purpuric eruptions, Henoch- Schonlein Purpura is more commonly found to:• A. Begin over the distal joints and spread centrally?• B. Frequently be associated with Bullae or infarcted areas?• C. Have lesions with necrotizing ecchymosis?• D. Occur in areas of pressure or minor trauma?• E. Occur symmetrically in the lower extremities?
PEER VII TQ #94 ANS• ANS: E. HSP THE PURPURIC LESIONS OCCUR SYMMETRICALLY IN THE LOWER EXTREMITIES.• Purpura is “bleeding in the skin that causes NON BLANCHING LESIONS.” tq 94 PEER VII.• Purpura are >3mm. Petechia are <3mm.• PURPURA FULMINANS: =Bullae or infarcted areas, associated with DIC from septic shock and bacteremia. Review/discuss case #90, Clin Emerg Med Casebook. By Levis & Garmel
PEER VII TQ # 131• Which of the following is included in the diagnostic criteria for KAWASAKI DISEASE?• A At least one coronary artery aneurysm?• B Fever unresponsive to acetaminophen?• C Many ulcerating lesions on both hands?• D Marked features of geographic tongue?• E Unilateral cervical lymphadenopathy?• Rosen’s pg 2161-2164, see pg2163, fig 169-14
PEER VII TQ 131: KAWASAKI DX• Unilateral cervical lymphadenopathy (E).• Kawasaki Dx: aka Mucocutaneous lymph node syndrome. Dx of young children. Apprx 80% of cases are in children< 5 y/o (peerVII).• Dx criteria: Fever for 5 or more Days (per Peer and no other dx found). Plus 4 of the 5 other:• Bilateral nonpurulent conjunctival injection +• Inflammation of lips and oral mucosa +• Erythema or swelling of the Hands or Feet +• Cervical lymphadenopathy (peer VII usually unilateral) +/or• Rash Nonvesicular, and Nonbullous. (R 2162/ box 169-17)
KAWASAKI DISEASE: Rosen’s p 2161- 2164.• Originally described by Dr T. Kawasaki in 1967• It is “ a significant cause of acquired cardiac Dx in children in the U.S. (2161).”• Annual US cases is: 3000 to 5000.• Up to 20% of untreated children develop some degree of coronary artery abnormality.• Etiology: UNKNOWN. Postulated to be a possible infectious agent. Nontransmissible person to person.
KAWASAKI DISEASE• Pathology: Vasculitis of the small and medium vessels. 25% of pts develop a mild diffuse myocardial inflammation (R 2162).• “All children with suspected Kawasaki Dx, either classic or incomplete, should undergo ECHOCARDIOGRAM to detect the presence and degree of coronary aneurysm (p 2162).”• Death: Due to MI due to coronary artery occlusion. (R 2164).
KAWASAKI DX: TREATMENT• 2 MAJOR parts of RX are: IV immunoglobulin infusion of 2 g/Kg over 10 to 12 hours. Pts must have EKG monitoring during the Rx.• Aspirin is started at 80 to 100 mg/kg/PO divided QID.• Aspirin is continued at this dose till the child has been afebrile for > 48 to 72 hrs.• Aspirin is then reduced to 3 to 5mg/kg each day for up to 6 to 8 weeks (R 2164).• IBUPROFEN MUST NOT BE GIVEN AS IT CAN ANTAGONIZE THE ANTIPLATELET EFFECT OF ASA.
KAWASAKI DX: COMPLICATIONS (TINTINALLI-PG 827)• Cardiac complications are the most severe sequelae of Kawasaki Dx. Included are:• Coronary artery aneurysms,• Myocarditis,• Pericarditis,• Pericardial Effusions,• Valvular dysfunctions,• Left ventricular dysfunction• Arrhythmias.• MI- Myocardial infarction is a complication of coronary artery aneurysm, and is the leading cause of death in Kawasaki Dx. (T-826)
ROSEN’S GENERAL APPROACH to the Febrile Infant & Child (p2098)• The “SICK” INFANT AND CHILD may need active resuscitation by following the A-B-C’s.• Evaluate the Airway and Breathing for need for intervention via O, BVM>>RSI.• Aggressively evaluate the “sick” Childs circulation, and start 0.9NS, check glucose, and give a 20mL/Kg bolus.• IV fluid bolus can be repeated up to 60 to 100mL/Kg.• Immediately start antibiotics. The pt with meningitis may be too ill to have a spinal tap (2098).• The CSF may become sterile in 15min to 2 hours in Meningococcal meningitis and within 4 to 10 hours in pts with Pneumococcal Meningitis (R-2098).
SERIOUS BACTERIAL ILLNESS• INFANTS: 0 TO 28 DAYS OF AGE• <28 DAYS OF AGE + fever > 38.0 C are at high risk for bacterial infection. Rates = 12%.• Hospitalization the pt and continue the work up “EVEN IF THE CHILD IS WELL APPEARING” (R- 2098).• SEPSIS w/u includes cath urine and CSF studies.• “LUMBAR PUNCTURE IS INDICATED EVEN IN THE PRESENCE OF A UTI DUE TO THE RISK OF CONCOMITANT MENINGITIS (R-2098)”
SERIOUS BACTERIAL ILLNESS• Infants 0 to 28 days of age:• “All children in this age group should be admitted to the hospital on EMPIRICAL antibiotics until culture data become available( R-2098).”• Rx: Ampicillin-100mg/Kg/24hours divided into 4 doses + either: Gentamycin 5mg/Kg/24 hours divided each 8 to 12 hours OR: Cefotaxime 150mg/Kg/24 hours divided each 8 hours.• Add empiric Acyclovir for risk of HSV at 60 mg/Kg/24 hours, divided each 8 hours.
SERIOUS BACTERIAL ILLNESS• Infants 0 to 28 Days of age.• NO CEFTRIAXONE IN INFANTS UNDER 28 DAYS!• NO CEFTRIAXONE IN INFANTS<28 DAYS DUE TO A “THEORETICAL RISK” OF INDUCING ACUTE BILIRUBIN ENCEPHALOPATHY!!!• ROCEPHIN CAUSES BILIRUBIN TO BE DISPLACED FROM ITS PROTEIN BINDING SITES.
SERIOUS BACTERIAL ILLNESS• Infants 29 to 90 days of age:• May allow for an “outpatient follow up” only if the child looks “good” and lab work and possibly CSF studies are all in a normal range.• Boston criteria allows for next day follow up, with a CBC, blood culture, cath UA & spinal tap being obtained, and IM ceftrixone 50mg/Kg IV or IM prior to D/C (R-2099).
FEBRILE SEIZURES (FS)• FS= Common cause of convulsions in children less than 5 Y/O.• Definition: A seizure accompanied by a fever WITHOUT the presence of a CNS infection.• “FEBRILE SEIZURES CAN BE THE PRESENTING COMPLAINT OF INFANTS AND CHILDREN WITH CNS INFECTION SUCH AS MEMINGITIS (R-2101).”• The AAP suggests LP be “strongly considered” for Pt<12 mo old with 1st febrile seizure, or in pts with prior antibiotics, or for “worrisome” pts.
SIMPLE FEBRILE SEIZURES (T-878)• Tintinalli, 7th ED. Pub 2011, pg 878.• Simple febrile seizure: It is most important to decide if the child appears well or sick.• The definition of a SIMPLE FEBRILE SEIZURE:• -A generalized tonic-clonic seizure lasting <15 min. With a fever equal to, or higher than 38.0 C (Over 100.4 F).• Age: 6mo to 5 years old.• Only one seizure in 24 hours (p 878).
Tintinalli’s Simple Febrile Seizure• If the seizure is consistent with a simple febrile seizure, AND:• THE CHILD LOOKS WELL, Then>• The evaluation can focus on the cause of the fever, AND:• BLOOD WORK, LUMBAR PUNCTURE, AND Imaging are not mandated (p 878).
SIMPLE FEBRILE SEIZURE• Only 50% of pts <12 mo old and 30% of pts > 12 mo old will have another febrile seizure.• Having a febrile seizure DOES NOT mean a child will develop epilepsy.• Anticonvulsant therapy is not recommended for simple febrile seizures (T 878).• Children who appear “SICK” post seizure, and have petechial lesions, and/or have neck stiffness> Treat as meningitis, start decadron, and give IV antibiotics appropriate for age!!!
PEER VII TQ #262• A pt sent in by local peds, for “possible febrile seizure”. Which pt is most likely to fit the Dx?• A. 2 week old, afebrile, well appearing, generalized seizure at home < 10 min.• B. 4 Mo old, fever on arrival, generalized seizure at home,10 min, Dx with UTI in ED.• C. 19 Mo old, febrile, appears well. Generalized seizure at home, < 10 min.• D. 23 Mo old, appears well, with 2 seizures at home , each < 5 min.• E. 9 Y/O febrile, generalized seizure that started in right hand in the ED, lasted < 10 min, the pt also had a seizure at home.
PEER VII TQ # 262 ANSWERS• The ANS is C.• A “Simple Febrile Seizure” is Generalized, lasts<15 min, occurs in pts 6 Mo to 5 Y/0, 1time in 24 hours, with No evidence of CNS infection, ( cns exam is normal, NO sx of meningitis, and the child appears well).• A,B, and E are outside the acceptable age.• D & E both had more than one seizure in<24hours.
Rosen’s fever and Petechiae• Petechial Rash + Febrile illness has been associated with Meningococcal infection.• Meningococcal infection was found in 7% to 11% of pts hospitalized with a fever and petechiae (R 2101).• Diff Dx of fever + petechiae: DIC, RMSF, Pneumococcal bacteremia, ITP, HSP, LEUKEMIA, and Meningococcal Infection.
TOXIC SHOCK SYNDROMEDue to a toxin mediated clinical syndrome.Caused by: infection with S. Aureus, or Group A Strep.The toxin implicated is an exotoxin termed TSS toxin 1.The classic syndrome was originally identified with tampon use.Pts present SICK. +Fever, >38.9 C, + Hypotension/shock, Diffuse erythroderma, and 3 major organ systems involved: CNS, Renal, GI, See Table 165-3 CDC case definition (p 2102).
TINTINALLI’S TOXIC SHOCK SYNDROME 7th Ed, 2011, Ch #145, pg 999-1003• This is an excellent chapter and I recommend that everyone review it, Dr G Ekblad.• Definition: Toxic Shock Syndrome (TSS), is:• A toxin-mediated, severe, life threatening Dx.• Findings: High fever, septic shock presentation, severe hypotension, diffuse erythema, mucous membrane hyperemia, pharangitis, and diarrhea. (see Table 145- 1).• TSS vs Kawasaki DX. Kawasaki Dx does not have multi- system failure, there is no profound hypotension, and no renal failure, diarrhea and thrombocytopenia is not found. (T-1000).
Tintinalli’s TOXIC SHOCK SYNDROME• TSS is related to many risk factors.• TSS is not only related to tampon use during menses. 12% cases are from use of vaginal contraceptive sponges and diaphragms.• Causes: Toxin from S. Aureus or Streptococcal TSS.• Approx10% of pts are Male (T-999).• Mortality rate for men is 3.3X > women.
Tintinalli’s TSS• Children < 2 Y/O: TSS risk factors include burns, Non surgical skin injuries (abrasions, lacerations), Infected VARICELLA VESICLES.• (Jump question: What is VARICELLA vs VARIOLA, what are the findings between both, what are the skin findings, what are the public health issues??)
Tintinalli’s TSS: Clinical features• “Consider tss in pts with: unexplained FEBRILE illness, with ERYTHRODERMA, HYPOTENSION, AND DIFFUSE ORGAN PATHOLOGY (p 1000)”• Headache is the most common complaint.• Fever occurs 1 to 4 days prior to the presentation.• The vast majority of pts develop watery diarrhea and repeat vomiting. 50% to 75% of pts have pharangitis with a “strawberry red tongue” (p 1001).
Tintinalli’s TSS Treatment and disposition• Aggressively treat the shock and admit to ICU,• Get early Inf Disease consult (They never want to miss this one).• During the first 24 hours pts may require 4 to 20 LITERS OF IV FLUID AND FFP.• Antibiotics do not “affect the outcome of the acute illness (p1002). However they are given to eradicate the toxin producing bacteria and decrease the recurrence rate.”
Tintinalli’s TSS: TREATMENT• Antibiotic options for adults:• Nafcillin or oxacillin: 2 gms IVPB each 4 hours.• Or LINEZOLID 600mg IVPB each 12 hours.• Some recommend clindamycin 600 to 900 mg IVPB each 8 hours or LINEZOLID because they may decrease toxin production.• Vancomycin 1 gm IVPB each 12 hours for pts with possible MRSA.