2. DEFINITION
Children with fever, documented by a health care provider, for
which cause could not be identified even after 3 weeks of
evaluation as an outpatient or after 1 week of evaluation in the
hospital
3. CLASSIFICATION
4 categories :
1.Classic FUO
2. Health care associated FUO
3. Immune deficient FUO
4. HIV – related FUO
4. CLASSIC FUO
Definition: fever of > 380 C ,lasted for > 3 wks, >2 visits or
1 wk in hospital
Patient location : community , clinic or hospital
Leading causes : cancer , infections , inflammatory
conditions, undiagnosed , habitual hyperthermia
History emphasis : H/O travel , contacts , animal & insect
exposure , medications , immunization , family history ,
cardiac valve disorder
5. Examination emphasis :fundi, oropharynx , temporal artery ,
abdomen , lymph nodes , spleen , joints , skin , nails , genitalia
, lower limb deep veins .
Investigation emphasis : Imaging , biopsies , erythrocyte
sedimentation rate , skin test
Management : Observation , outpatient temperature chart ,
investigations , avoidance of empirical drug treatment
Time course of disease : For months
6. HEALTH CARE ASSOCIATED FUO
Definition : Fever of > 380 C ,lasted for > 1 week , not
present or incubating on admission
Patient location : Acute care hospital
Leading causes : Hospital acquired infections , post-
operative complications , drug fever
History emphasis : Operation & procedures , devices
used , anatomic considerations , drug treatment
7. Examination emphasis :Wounds , drains , devices
, sinuses , urine
Investigation emphasis : Imaging , bacterial
cultures & other microbiological investigations
Management : Depends upon situation
Time course of disease : Lasts for weeks .
8. IMMUNE DEFICIENT FUO
Definition : Fever of > 380 C , lasted for > 1 wk & negative
culture after 48 hrs
Patient location : Hospital or clinic
Leading causes : Majority are due to infections but cause
has been documented in only 40-60%
History emphasis : Stage of chemotherapy , drugs
administered , underlying immunosuppressive disorders
9. Examination emphasis : Skin folds , IV sites , lungs,
perianal area
Investigation emphasis : Chest radiograph , bacterial
cultures
Management : Antimicrobial treatment
Time course of disease : Lasts for days .
10. HIV – RELATED FUO
Definition : Fever of >38 C , >3 wks for outpatients ,
>1 wk for inpatients & HIV infection confirmed
Patient location : Community , clinic or hospital
Leading causes : HIV (primary infection) , typical &
atypical mycobacteria , CMV , toxoplasmosis ,
cryptococcosis , lymphomas , immune reconstitution
inflammatory syndrome (IRIS)
History emphasis : drugs,exposures,risk
factors,travel,contacts,stage of hiv infection
11. Examination emphasis : Mouth , sinuses , skin , lymph
nodes , eyes , lungs,perianal area.
Investigation emphasis : Blood & lymphocyte count ,
serologic tests , chest X-ray , stool examination, biopsies of
lung , bone marrow & liver for cultures and cytologic tests ,
brain imaging
Management : Antiviral & antimicrobial protocols , vaccines
, revision of treatment regimen , good nutrition
Time course of disease : Lasts for weeks to months
18. HISTORY
History should be taken from the child or reliable informant
AGE
-> 1-5 yrs - common causes are RTI,UTI,diarrhoea and
osteomyelitis
->5-10 yrs-measles,mumps,chicken pox,typhoid
->10yrs-TB, typhoid ,rheumatic fever
GENDER -> Females-urinary tract infections,pelvic infections
-> Males-allergic fever(hay fever), typhoid ,
tuberculosis,malaria
19. ADDRESS -> endemic regions for malaria and japanese
encephalitis,epidemics,out breaks in that area
CHIEF COMPLAINTS -> History of fever and other symptoms
should be taken in chronological order,give clue towards
system involved
eg:-
fever,dysuria ,loin pain –UTI
fever ,drowsiness ,convulsions - meningitis, encephalitis
23. PROGRESSION ->Viral fever peaks in 2 days and declines
-> Bacterial fever worsens day by day without treatment
-> Parasite fever like malaria shows cyclical cold,hot and
sweating stages.
TYPE -> Continuous-viral
- Remittent-enteric fever , collagen vascular diseases
-Intermittent - Malaria , Brucellosis, filarial fever
Step ladder fever-Typhoid
Saddle back fever – dengue
Pelebstein fever – Hodgkin lymphoma
Undulant fever - brucellosis
24. Associated with ->
Chills and rigors- Malaria,brucellosis ,otitis media , UTI ,
follicular tonsillitis, filaria
Myalgia- brucellosis,dengue,bartonellosis
Sweating-Meningitis ,TB ,Bacteraemia ,Malaria
Remission
Abrupt – malaria
Remission like a wave - brucellosis
25. History of travel to endemic areas,how long,any
precautions.
Epidemics in resident area
Pets - toxoplasmosis,visceral larva migrans
Contact with animals – leptospirosis,brucellosis
Tick bites-relapsing fever, Q fever
Blood transfusion - malaria,hepatitis-B
Migrating joint pains - Rheumatic fever
Loss of weight-malignancies
History of recurrent fever,oral thrush -
immunocompromised
Joint pains,rash,photosensitivity - autoimmune
26. Past history - of surgeries(occult infection)
Family history - similar complaints suggest
infectious disease,genetic background-familial
dysautonomia(recurrent hyperpyrexia)
Personal history - diet -> unpasteurized
milk(brucellosis,TB),raw egg (salmonella)
Loss of appetite - malignancies ,TB
Immunization history - vaccination induced fever.
e.g,DPT,measles
Treatment history - drug induced fever
27. PHYSICAL EXAMINATION
Careful and complete examination
Repetitive examination to pick up subtle or new signs
Look for the child’s general appearance, built and nourishment,
for temperature pattern ,
pulse rate –relative bradycardia in typhoid, meningitis ,dengue,
Skin – look for rashes , petechiae, splinter hemorrhages,
subcutaneous nodules
30. Tenderness to tapping over sinus – sinusitis
Oral cavity - Hyperemia of pharynx
Tender tooth –> periapical abscess
Recurrent oral candidiasis –> disorder of immune system
Neck - Enlargment or tenderness of thyroid gland –> thyroiditis
Heart- Murmur –> infective endocarditis
Abdomen –
Splenomegaly –> malaria, kala azar , CML
Abdominal tenderness -> pelvic abccess
Loin tenderness -> pyelonephritis
Hepatomegaly- > liver abscess , primary or metastatic malignancy
31. Muscle and bone –
Point tenderness- occult osteomyelitis or bone marrow invasion
from neoplasms
Painful and swollen joints – arthritis –> rheumatic fever
Rectal examination – pelvic abscess,adenitis
32.
33. INVESTIGATIONS
On IP or OP basis,
determined on a case by case
basis,
OP if chronic
CBC,DC
Urine analysis
Blood smear
ESR
Serologic tests
Tuberculin test
Blood and urine culture
Bone marrow examination(
aspiration and biopsy)
Xray ,2D ECHO,USG,CT , MRI ,
Radionuclide scans
35. ESR >30 mm -
inflammation -> further evaluation
ESR >100 mm -TB/malignancy/autoimmune/
kawasaki disease
36. BLOOD CULTURES –
- Normally aerobic culture is done as anaerobic culture gives low
yield
- Repeated culture done in case of infective endocarditis and
osteomyelitis
- Poly microbial infection suggests GI infection.
RADIOLOGICAL EXAMINATION – sinuses,mastoid,GIT,chest
SEROLOGICTESTS – widal test,ANA,RF, for infectious
mononucleosis,cmv,brucellosis,toxoplasmosis
37. RADIONUCLEIDE SCANS - These are mainly helpful in detecting abdominal
abscess & osteomyelitis and in multifocal disease.
ECHOCARDIOGRAPHY - detects vegetations on valve leaflets in infective
endocarditis
ULTRASONOGRAPHY detects intra- abdominal abscesses of liver and spleen
CT SCAN AND MRI - detection of neoplasms,CT scan guided aspiration and
biopsy,MRI for detecting osteomyelitis
38.
39.
40. TREATMENT
Emphasis in patients with classic FUO is on continuous observation
and examination with avoidance of empiricaltherapy
Indication of empirical therapy is vital signs instability and
neutropenia
The ultimate treatment of FUO is tailored to the underlying diagnosis.
Fever and infection in children are not synonymous; antimicrobial
agents should not be used as antipyretics, and empirical trials of
medication should generally be avoided.
41. An exception may be the use ofantituberculous
treatment in critically ill children with suspected
disseminatedtuberculosis.
Empirical trials of other antimicrobial agents may be
dangerous and can obscure the diagnosis of infective
endocarditis,meningitis, parameningeal infection, or
osteomyelitis
42. TAKE HOME MESSAGE
FUO may represent uncommon manifestation of common disease.
work-up should be cost effective and thoughtful and clinically appropriate.
Empirical treatment sometimes may be justified, however one should
remember that treatment should not be worse than disease.
In India infections notably extra pulmonary tuberculosis is the most common
cause of FUO.
Noninfectious causes like collagen vascular disease and neoplasms are
becoming important differential diagnosis.
Patience, compassion, equanimity, vigilance and intellectual flexibility are
indispensable attributes for the clinician in dealing successfully with FUO.
43. REFERENCES
NELSONTEXTBOOK OF PAEDIATRICS SOUTH ASIAN 1ST EDITION
IAPTEXTBOOK OF PEDIATRIC INFECTIOUS DISEASES 1ST EDITION
IAPTEXTBOOK OF PEDIATRICS 6TH EDITION
Editor's Notes
Is a term applied to……….Petersdorf and Beeson Criteria- Fever higher than 38.3oC on several occasions.Duration of fever – 3 weeks.Uncertain diagnosis after one week of study in hospital
