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FEVER OF UNKNOWN ORIGIN - PEDIATRICS

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FUO , NELSON , PUO , PEDIATRICS , PYREXIA OF UNKNOWN ORIGIN

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FEVER OF UNKNOWN ORIGIN - PEDIATRICS

  1. 1. FEVER OF UNKNOWN ORIGIN - Dr.Apoorva.E PG,DCMS
  2. 2. NORMAL BODY TEMPERATURE • The hypothalamus is the heat-regulating center of the body • The normal body temperature ranges from 37.0 degree C and 37.5 degree C • Evening temperatures being 0.5 degree C higher than in the morning. • Rectal temperature>oral temperature (0.4 degree C) >axillary temperature (1 degree C)
  3. 3. • A rectal temperature with a glass- mercury or digital-electronic thermometer is considered the gold standard for taking temperatures • Liebermeisters rule -The pulse rate rises about 15 beats/min for each degree centigrade rise of fever
  4. 4. FEVER • Fever is a controlled increase in body temperature above the normal hypothalamic set point • A rectal temperature of 38 degree C or more (100.4 degree F) • A temperature of 40 degree C or more is termed as hyperpyrexia
  5. 5. PATHOGENESIS OF FEVER
  6. 6. PATTERNS OF FEVER Intermittent fever - Fever that touches the baseline for a few hours during the day. • Seen in malaria, acute pyelonephritis, local boils,furuncles,kala azar,sepsis
  7. 7. • Types of intermittent fever : - Quotidian fever, with a periodicity of 24 hours, typical of Plasmodium falciparum - Tertian fever,with a 48 hour periodicity,typical of Plasmodium vivax or Plasmodium ovale -Quartan fever,with a 72 hour periodicity,typical of Plasmodium malariae
  8. 8. Remittent fever - Fever that fluctuates by more than 1.5 degree F but never touches the baseline in 24 hours • Seen in infective endocarditis
  9. 9. Continuous fever - Fever that never touches the baseline in 24 hours and fluctuates by less than 1.5 degree F in a day. • Seen in enteric fever,lobar pneumonia,brucellosis,typhus.
  10. 10. Pel-ebstein fever - Fever lasting for 3-10 days followed by an afebrile period of 3-10 days • Seen in hodgkins lymphoma
  11. 11. CLASSIFICATION OF FEVER Fever with focus Fever without focus Fever without localizing signs Fever of unknown origin ( refers to a rectal temperature of 38 degree C or higher as the sole presenting feature)
  12. 12. FEVER OF UNKNOWN ORIGIN • 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
  13. 13. CLASSIFICATION • 4 categories : 1. Classic FUO 2. Health care associated FUO 3. Immune deficient FUO 4. HIV – related FUO
  14. 14. CLASSIC FUO • Definition: fever of > 38 degree 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
  15. 15. • Examination emphasis : 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
  16. 16. HEALTH CARE ASSOCIATED FUO • Definition : Fever of > 38 degree 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
  17. 17. • 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 .
  18. 18. IMMUNE DEFICIENT FUO • Definition : Fever of > 38 degree 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
  19. 19. • 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 .
  20. 20. HIV – RELATED FUO • Definition : Fever of >38 degree 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
  21. 21. • 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
  22. 22. CAUSES OF PUO •Infectious causes • Non infectious causes Infectious causes -> Bacterial – salmonella,brucellosis,meningococcal,mycoplasma pneumonia,TB,actinomycosis -> Sphirochaetal -B burgdorferi ,leptospirosis ,relapsing fever,syphillis -> Parasitic- amoebiasis,giardiasis,toxoplasmosis,babesiosis,malaria -> Fungal-blastomycosis,histoplasmosis,coccidiodomycosis
  23. 23. -> Chlamydial -lym venereum,psittacosis -> Rickettsial -Q fever,tick borne typhus,rocky mountain spotted fever -> Viruses –CMV,HIV,hepatitis -> Local septic infection -dental abscess,subphrenic abscess,sinusitis,tonsillitis,hepatic abscess,bronchiectasis,mastoiditis -> Local infection without pus formation - UTI,ulcerative colitis ,diverticulitis,phlebitis,regional enteritis
  24. 24. Non infectious causes -> Collagen vascular disorders -JRA ,SLE ,behcets disease,juvenile dermatomyosis -> Neoplastic -leukaemia ,lymphoma,neuroblastoma,wilms tumour -> Metabolic - gout,porphyria -> Endocrine - thyrotoxicosis ,addisons disease -> HS reactions - serum sickness -> Misc - liver cirrhosis ,familial mediterannean fever ,poisoning ,sarcoidosis ,whipples disease ,factitious fever
  25. 25. 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
  26. 26. • 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
  27. 27. HOPI • ONSET
  28. 28. • GRADE
  29. 29. • DURATION fever
  30. 30. • 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-Pneumonia ,uti -> Remittent-Viral, collagen vascular diseases -> Intermittent - Malaria , Brucellosis -> Step ladder fever-Typhoid. • Associated with -> Chills and rigors- Malaria,brucellosis ,otitis media Myalgia- brucellosis,dengue,bartonellosis Sweating-Meningitis , TB ,Bacteraemia ,Malaria
  31. 31. • 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
  32. 32. • 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
  33. 33. 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, subctaneous nodules
  34. 34. Eye -> Anemia- malaria, kala azar ,ALL , SABE -> Icterus – infectious hepatitis, malaria, weil’s disease,liver abscess -> Proptosis – orbital tumor , thyrotoxicosis, orbital infection , wegener granulomatosis , metastases(neuroblastoma) -> Roth’s spots – infective endocarditis -> Uveitis – sarcoidosis, SLE, kawasaki disease,vasculitis -> Chorioretinitis – CMV, toxoplasmosis , syphilis
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. NO INDOLENT BACTERIAL INFECTION SEVERE BACTERIAL INFECTION
  39. 39. BLOOD SMEAR -> WITH GIEMSA OR WRIGHT STAIN MALARIA TRYPANOSOMIASIS RELAPSING FEVER BABESIOSIS
  40. 40. ESR >30 mm -> inflammation -> further evaluation ESR >100 mm -> TB/malignancy/autoimmune/ kawasaki disease
  41. 41. • 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 – of sinuses,mastoid,GIT,chest • SEROLOGIC TESTS – widal test,ANA,RF, for inf mononucleosis,cmv,brucellosis,toxoplasmosis
  42. 42. • 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
  43. 43. 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 months of age . • Etiology and evaluation of this type depends upon age of the child • 3 age groups are considered : I. Neonates II. Infants > 1 month to 3 months of age . III. Children > 3 months to 3 yrs of age .
  44. 44. NEONATES • Neonates having fever without focus show limited signs of infection -> difficult to clinically distinguish between a serious bacterial infection & self limited viral illness • Every febrile neonate has to be hospitalized • 7% risk of having serious bacterial infection (sepsis,meningitis,UTI,enteritis,osteomyelitis, pneumonia,septic arthritis) • Organisms responsible - Group B streptococcus & Listeria(Late onset sepsis & meningitis) , Ecoli,HSV,Enterovirus
  45. 45. • Blood ,urine ,CSF should be cultured • CSF study should include cell counts, glucose, protein levels,gram stain & culture • HSV & Enterovirus polymerase chain reaction • Stool culture,chest radiograph • Combination antibiotics- ampicillin and cefotaxime is recommended, acyclovir if HSV is suspected.
  46. 46. 1 MONTH TO 3 MONTHS • Majority of the cases are of viral origin • Respiratory syncytial virus and influenza A in winter season • Entero virus in summer
  47. 47. • Also suspect serious bacterial infections • Common bacteria : Group B streptococci,listeria,salmonella enteritis,ecoli,pneumococus,meningococcus, hiB,staph aureus • Common conditions : Pyelonephritis > Otitis media > Pneumonia > Skin and soft tissue infections • Based on blood ,urine ,CSF cultures,these infants are classified in to low and high risk groups
  48. 48. •With out antibiotics under close observation • Empirical antibiotic therapy • Ampicillin plus either ceftriaxone/ cefotaxime • If CSF shows abnormal findings, vancomycin included against penicillin resistant S.Pneumoniae LOW RISK HIGH RISK
  49. 49. 3 MONTHS TO 36 MONTHS • 30% of these infants with fever have no localizing signs of infection • Majority are viral but serious bacterial infection do occur • Pathogens are same as in 1 to 3 months of age • S.pneumoniae,meningococcus,salmonella,hiB account for most of occult bacteremia
  50. 50. • Risk factors indicating occult bacteremia 1.temperature >39° c 2.WBC count >15000/micro litre 3.elevated ANC,band count 4.elevated CRP 5.elevated ESR • It may resolve spontaneously without sequelae or can lead to localized infections like meningitis, pneumonia etc
  51. 51. • Management : Child 3-36 mo and temperature 38-39 ° C Reassurance that diagnosis is likely self-limiting viral infection, but advise return if fever persists,temperatures > 39 ° C and new signs / symptoms Child 3-36 mo and temperature > 39 ° C -Hospitalization and prompt antimicrobial therapy based on the blood, urine ,CSF cultures • Immunize against Hib and S.pneumoniae with conjugate vaccine
  52. 52. THANK YOU

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