Systematic Approach to a Child with Fever

This is a class presentation.

1. Approach to a Child with Fever Facilitator : Assist. Prof. Dr . S.N Suwal Presenter: Dr. Sunil Timilsina 1 st year resident Department of General Practice and Emergency Medicine NAIHS

2. Definition Neonate < 56 Days ≥ 38.0°C or 100.4°F Children > 56 Days of Age ≥ 38.5°C or 101.3°F Patients with Underlying Immunocompromised State ≥ 38.5°C once ≥ 38.0°C three times in a 24-hour period, 1 hour apart or  any clinical concern Fever of Unknown Origin (FUO) Patients with daily fever ≥ 38.3°C or 101°F ≥ 8 days

3. Pathophysiology of Fever

4. Diagnostic considerations Infectious Bacterial Enteric fever, Escherichia coli (UTI), Klebsiella , CONS, Tuberculosis , Staphylococcus, Chlamydia, Mycoplasma Viruses Hepatitis, Dengue fever, Measles, COVID, Adenovirus, Epstein barr virus, HIV, Cytomegalo Virus. Fungus Blastomycosis , Coccidioidomycosis , Histoplasmosis Spirochetes Leptospirosis , Borrelia burgdorferi ( Lyme disease), Syphilis Rickettsiae Scrub typhus, Q fever, Tick borne typhus Parasites Amebiasis , Giardiasis , Malaria, Toxoplasmosis

5. Autoimmune Rheumatic fever Juvenile dermatomyositis Juvenile Idiopathic arthritis SLE Kawasaki disease IBD Vasculitis ( Polyarteritis nodosa ) Malignancies Leukemia Hodgkin Lymphoma Neuroblastoma Wilms tumor Diagnostic considerations

6. Familial (Rare) Anhidrotic ectodermal dysplasia Familial dysautonomia Familial Mediterranean fever Sickle cell crisis Miscellaneous Addison disease Diabetes Insipidus Drug fever Factitious fever Poisoning Pulmonary embolism Thrombophlebitis Thyrotoxicosis Immunodeficiencies Diagnostic considerations

7. Approach 1. History Age Duration (common causes) Short (< 2 weeks) Prolonged ( >2 weeks) Respiratory infections Viral Infections UTI Malaria Meningitis TB Autoimmune: JRA, SLE Malignancy Chronic Kalazar / Malaria

8. Character Continuous fever : Daily fluctutation in the temperature do not exceed 1 C /24 hr and never touches baseline. Eg - Enteric fever, Pneumonia Remittent fever : Daily fluctuations exceed 1 C and never touches baseline. Intermittent fever : Temperature touches baseline in between febrile phases. Quotidian fever: Occurs daily eg - P. falciparum Tertian fever : Occurs alternate day eg - P. vivax , P . malaria Quartan fever : Occurs every third day eg - Plasmodium malariae

9. Fever with associated symptoms Provisional diagnosis Rhinorrhoea , congested eyes, Sore throat Viral URTI ( Rhino virus, Adenovirus) Ear discharge Acute otitis media Postural Headache, Post nasal drip Acute sinusitis Hoarseness of voice Acute Laryngitis, Croup SOB, Noisy breathing, Cough Pneumonia, Bronchiolitis , TB Feed intolerance, feeding diaphoresis, recurrent LRTI, suck rest suck cycle Congenital heart disease, CCF Pain abdomen AGE, Dysentry , Instussusception , Acute appendicitis, Liver abscess, Pyelonephritis Burning micturation UTI, Cystitis

10. Fever with associated symptoms Provisional diagnosis Rash Chickenpox, Measles, Dengue, Rubella, Typhoid, Kawasaki disease, Drug rash, SLE Jaundice Acute viral hepatitis, Enteric hepatitis Joint pain Septic arthritis, JIA, Dengue, Chikungunya , Kawasaki disease, Rheumatic fever Pallor, bleeding spots, nodular swellings Leukemia, Lymphoma, Wilms tumor Excessive sweating, Palpitation, proptosis Thyrotoxicosis Polyuria , Polydipsia Diabetes insipidus

11. Past history of febrile episodes Geographical location of residence History of Contact with other febrile individuals Drugs use and their effect Travel history

12. Fever with Physical findings Provisional diagnosis General condition: Relative bradycardia Tachypnea Weight loss Lack of sweating Lymphadenopathy Enteric fever, Leptospirosis , Dengue Pneumonia, TB Diabetes insipidus , IBD , Malignancy Ectodermal dysplasia Kawasaki disease, Tuberculosis, Malignancy, JIA , Suppurative lymphadenitis Skin: - Petechiae Eschar Erythema migrans Rose spot Salmon pink rash Malar erythema Palpable purpura -Infective endocarditis , Leukemia, Rickettsial infection Scrub typhus Lyme disease Enteric fever JIA SLE Vasculitis 2. Physical examination

13. Physical Findings Provisional diagnosis Proptosis Orbital tumour & infection, thyrotoxicosis , Wegners granulomatosis Tender sinuses Rhinosinusitis Congested Tympanic membrane Acute otitis media Oral ulcers IBD, SLE Hyperemia of Pharynx Streptococcal, EBV Crackles on chest auscultation Pneumonia New onset cardiac murmur Infective endocarditis

14. Physical findings Provisional diagnosis Hepatomegaly Viral hepatits , Liver abscess, Enteric fever, Dengue , Scrub typhus, Leukemia, Lymphoma Splenomegaly Malaria, Kalazar , Enteric fever, Spleenic abscess, Infective endocarditis , Leukemia Musculoskeletal : -Bone tenderness - Generalized muscle tenderness - Osteomyelitis , Bone marrow invasion - Dermatomyositis , Trichinosis, Kawasaki Genitourinary: Perirectal fluctuance , tenderness Genital ulcers, urethral discharge Perianal fistulae, skin tags, fissures Abscess Sexually transmitted infection Inflammatory bowel disease Splinter hemorrhage over nails, clubbing , petechiae Vasculitis , endocarditis

15. 3. Laboratory Evaluation CBC Urine analysis ESR CRP Blood Culture Urine Culture Tuberculin skin test Serological studies

16. Investigation findings Provisional diagnosis Anemia Malaria, TB, Infective endocarditis , JIA, SLE, IBD Cytopenia , Immature cells Leukemia Leukocytosis Severe bacterial infection, drug fever Neutropenia Dengue fever, HIV , SLE Eosinophilia Parasitic or fungal infection, allergic disorder, immunodeficiency Thrombocytopenia Dengue, EBV, HIV, SLE Elevated ESR and CRP Inflammation Hypernatremia Diabetes insipidus , dehydration Hyponatremia Leptospirosis Increased BUN, Creatinine Renal impairment (SLE) Elevated hepatic enzymes Hepatitis, Leptospirosis , adenovirus, JIA

17. Investigation findings Provisional diagnosis Urinanalysis Pyuria : UTI Sterile Pyuria : Genitourinary TB, Kawasaki disease Hematuria : Infective endocarditis Proteinuria : SLE Low Urine osmolality : Diabetes insipidus Specific tests Serology for suspected infections. Stool examination Guaiac test Bone/Joint imaging ANA Serum immunoglobulin concentrations Bone marrow examination

18. Imaging Right upper lobe pneumonia Hilar lymphadenopathy

19. Renal abscess

20. Splenic abscess

21. Infective Endocarditis

22. Management To be done as per underlying diagnosis “Antimicrobial agents” should only be used when when there is evidence of infection with avoidance of empirical trials of medication Exception is use of anti tubercular drugs in suspected disseminated TB

23. References Kliegman , R. and Nelson, W., 2007. Nelson textbook of pediatrics. 21st ed. Philadelphia: Saunders. Ghai OP. Ghai Essential Pediatrics. New Delhi, India: CBS Publishers & Distributors; 2010 . Fever Pathway; Children’s Hospital of Philadelphia, USA Up to date