Fever without a focus in infants
Tammy BerteauAugust 6th, 2015
What is a fever?
• Rectal/Ear >38oC (>100.4oF)• Oral >37.5oC (>99.5oF)• Axillary >37.3oC (>99.1oF)
Temperature Measurement in Paediatrics, Leduc, Woods, Canadian Paediatric Society, January 2015
Classification of Fevers
• Fever with a focus• Fever without localizing signs (without a focus)• Fever of unknown origins (FUO)
TRUE OR FALSE
The response to antipyretics can distinguish between the different etiologies of fever (i.e. viral, bacterial, malignancy, autoimmune, drugs)
FALSE
MCQ
The pattern of fever can distinguish between:
a. Malignancy vs infectiousb. Bacterial vs viralc. Inflammatory vs infectiousd. Drugs vs inlammatorye. None of the above
The pattern of fever can distinguish between:
a. Malignancy vs infectiousb. Bacterial vs viralc. Inflammatory vs infectiousd. Drugs vs inlammatorye. None of the above
Case• A 2 month old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Case• A 2 month old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Case• A 2 month old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Case• A 2 month old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
What are pediatric vital signs?
What are pediatric vital signs?
DDx Fever• Infectious
– Bacterimia– Meningitis/encephalitis– SIRS– Sepsis/Septic Shock
• Inflammatory– Kawasaki disease, JIA, IBD, SLE, etc– Periodic fever syndromes
• Malignancy– Leukemia, lymphoma, neuroblastoma etc.
• Other– Dehydration, drugs & toxins, post-immunization, familial dysautonomia,
factitious disorder etc.
Don’t miss!• Infectious
– Bacterimia– Meningitis/encephalitis– SIRS– Sepsis/Septic Shock
• Inflammatory– Kawasaki disease, JIA, IBD, SLE, etc– Periodic fever syndromes
• Malignancy– Leukemia, lymphoma, neuroblastoma etc.
• Other– Dehydration, drugs & toxins, post-immunization, familial dysautonomia,
factitious disorder etc.
Bacterial Meningitis
Pathogens• Neisseria meningitidis• Streptococcus pneumonia• Haemophilus influenzae type b
***Major risk factor for meningitis is lack of immunity (younger age) and occult bacteremia
Pathogens• Neisseria meningitidis• Streptococcus pneumonia• Haemophilus influenzae type b
BM: Clinical manifestations
« Fulminant » form• Sudden onset/rapidly
progressing shock• Purpura• DIC• LOC
« Classic » form• Several days of fever• URTI or GI symptoms• Nonspecific CNS signs (i.e.
lethargy and irritability)
BM: Clinical manifestations
Non-specific findings• Fever• Anorexia/poor feeding• Headache• URTI• Myalgias/arthralgias• Tachycardia• Hypotension• Cutaneous signs (petechiae,
prupura, erythematous macular rash)
« Specific » findings• Meningeal irritation• ICP• Seizures• D mental status
Shock
Shock
Shock
SIRS
Sepsis/Septic Shock
Septic Shock:Clinical Manifestations
Initially:• Alteration in temperature
(hypo/hyperthermia)• Tachycardia• Tachypnea
« Warm » vs « Cold »
Case• A 2 month old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Further Hx
• HPI– OPQST
• >14 days (FUO vs FWF)• Pattern/height of fever*• Persistent or recurrent (? PFS or autoimmune)• No fever, only lethargy and poor feeding (? metabolic d/o)• Overbundling
– Pertinent +/-• Localizing signs (Fever with a source)• Focal neurological signs (Brain abscess, contraindication for LP,
malignancy)• Travel history, sick contacts (household, daycare, dormitories, military)
Further Hx• PMHx,
– Chronic diseases,– Hospitalization/Doctors consulted– Recent treatment w/ antibiotics, – Immunocompromised (i.e. HIV, corticosteroids, immunomodulators or
biologics, IgG deficiencies, complement defect (C5-C8)), – T-lymphocyte defects (congenital, acquired (chemotherapy), AIDS, malignancy)),– Inflammatory conditions (IBD, SLE,JIA), – Asplenia (congenital or trauma), – Sickle cell anemia, – Cochlear implants/defects, – Malignancies (chemotherapy),– Congenital or acquired CSF leak (cranial or midline facial defects, middle/inner
ear fistula, basal skull fractures).
Further Hx
• SocHx– Living conditions (crowding, poverty, black, Native
American, Inuit)• FHx– IgG deficiencies, Hereditary PFS (AR or AD), Defects in
complement or properdin system, Early infant deaths*• Pregnancy/Delivery– Preterm– Duration of neonatal hospitalization
• Development
Further Hx
• Allergies• Immunization– Conjugate vaccines (Hib, Pneumococcus,
Meningococcus)• Medications– Corticosteroids, chemotherapy, biologics,
immunomodulators
Approach to FWF (infants)
FWF: Organisms• Bacteremia
– <28 days (neonates)• GBS, E. coli, L. monocytogenes
– 1-3 months • S. pneumoniae, H. influenza, nontyphoidal Salmonella, N. meningitidis
• UTI– E. coli
• Pneumonia– S. pneumoniae, GBS, S. aureus
• Meningitis– S. pneumoniae, H. influenzae type B, GBS, N. meningitidis, HSV, enteroviruses
• Bacterial diarrhea– Salmonella spp., Shigella spp., E. coli
• Osteomyelitis• Septic arthritis
– S. aureus, GBS
Investigations
Case• A 3 week old female was brought to the ER with a hx of lethargy,
fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanel is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Case• A 8 months old female was brought to the ER with a hx of
lethargy, fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.
• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.
Bibliography
1. Nelson Textbook of Pediatrics 19th Edition, Kliegman, Stanton, St. Geme, Schor, Behrman, 2011, Elsevier Saunders.
2. The Evolving Approach to the Young Child Who Has Fever and No Obsious Source, Ishimine, P., Emergency Medicine Clinics of North America, 2007
3. Acute Fever, Pediatrics in Review, Vol. 30, No. 1, January 20094. Periodic Fever Syndromes, Pediatrics in Review, Vol. 30, No. 5,
May 20095. Temperature Measurement in Paediatrics, Leduc, Woods,
Canadian Paediatric Society, January 20156. http://www.pedscases.com/pediatric-vital-signs-reference-chart7. Toronto Notes, 2014
Important references
For Health Care• CPS• Pediatrics in Review
For parents• Caring for kids (CPS)