fever of unknown origin dr rafat mosalli. different body sites rectal standardrectal standard...
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Fever of unknown Fever of unknown originorigin
Dr Rafat MosalliDr Rafat Mosalli
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Different body sitesDifferent body sites
• RectalRectal standardstandard• OralOral 0.5-0.60.5-0.6 lowerlower• AxillaryAxillary 0.8-1.00.8-1.0 lowerlower• Tympanic 0.5-0.6Tympanic 0.5-0.6 lowerlower
Documented:Documented:• In the absence of antipyreticsIn the absence of antipyretics• In ED or office or by hx from reliable In ED or office or by hx from reliable
parents/adultsparents/adults
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Fever Without SourceFever Without Source
• ““An acute febrile illness in which An acute febrile illness in which the etiology of the fever is not the etiology of the fever is not apparent after a careful history apparent after a careful history and physical examination.”and physical examination.”
Baraff et al, Pediatrics Baraff et al, Pediatrics 1993; 92:1-121993; 92:1-12
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Fever of Unknown Fever of Unknown OriginOrigin
1. 1. Fever of 38Fever of 38C or greater which C or greater which has has continued for a 2 to 3 weeks continued for a 2 to 3 weeks
2. 2. Absence of localizing clinical Absence of localizing clinical signssigns
3. 3. Negative simple investigationsNegative simple investigations
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Occult bacteremiaOccult bacteremia
• “…“…a positive blood culture in the a positive blood culture in the setting of well appearance and setting of well appearance and without focus (e.g. no pneumonia)without focus (e.g. no pneumonia)
• Fleisher et al, J Pediatrics 1994Fleisher et al, J Pediatrics 1994
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Serious Bacterial Serious Bacterial InfectionInfection
• “…“…Include meningitis, sepsis, bone Include meningitis, sepsis, bone and joint infections, urinary tract and joint infections, urinary tract infections, pneumonia and enteritis”infections, pneumonia and enteritis”
Baraff et al, Pediatrics 1993; 92:1-Baraff et al, Pediatrics 1993; 92:1-1212
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Frequency of febrile Frequency of febrile illnessillness
• 35% of unscheduled ambulatory 35% of unscheduled ambulatory care visitscare visits
• 65% of kids see doc before age 2y65% of kids see doc before age 2y• Majority (75%) for T < 39 Majority (75%) for T < 39 C C • 13% T > 39.513% T > 39.5
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EpidemiologyEpidemiology
• Incidence of bacteremia in febrile Incidence of bacteremia in febrile infants in post-Hib erainfants in post-Hib era
• 2-3% 2-3% if < 2 months, T > 38if < 2 months, T > 38CC
• < 2% if 3-36 months, T >39< 2% if 3-36 months, T >39CC
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Occult bacteremia Occult bacteremia organismsorganisms
• Streptococcus pneumoniaStreptococcus pneumonia > 85% > 85%
• Neisseria meningitidisNeisseria meningitidis 3-5% 3-5%
• Others:Others:• S. aureusS. aureus• S. pyogenesS. pyogenes (GAS) (GAS)• SalmonellaSalmonella species species• Haemophilus influenzaeHaemophilus influenzae type B type B
(now (now rarerare – previously 10%) – previously 10%)
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Outcomes of occult bacteremia Outcomes of occult bacteremia without antibioticswithout antibiotics
• Persistent feverPersistent fever 56%56%• Persistent bacteremiaPersistent bacteremia 21%21%• MeningitisMeningitis 9%9%
• S. pneumoniaS. pneumonia 6% 6%• H. InfluenzaeH. Influenzae 26% (now rare) 26% (now rare)
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Should fever be Should fever be treatedtreated??
• ProsPros• Decrease discomfortDecrease discomfort• Calm the familyCalm the family• Extreme (>41Extreme (>41C) may cause C) may cause
permanent brain damage permanent brain damage rare,rare,rarerare,rare,rare
• Decrease risk of febrile convulsions in Decrease risk of febrile convulsions in prone kids??prone kids??
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Should fever be Should fever be treatedtreated??
• ConsCons• Adverse effect of antipyretic may Adverse effect of antipyretic may
outweigh benefitsoutweigh benefits• May obscure diagnostic/prognostic May obscure diagnostic/prognostic
signssigns• Fever usually short-lived and benignFever usually short-lived and benign• Fever is normal and adaptive Fever is normal and adaptive
physiologic responsephysiologic response
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What is the eventual What is the eventual etiology of fever in etiology of fever in children with FUOchildren with FUO??
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How should a child with How should a child with FUO be evaluatedFUO be evaluated??
• FUO is more likely to be an unusual FUO is more likely to be an unusual presentation of a common disorder presentation of a common disorder than a common presentation of a than a common presentation of a rare disorder. rare disorder.
• detailed history and thorough detailed history and thorough physical examinationphysical examination
• avoid indiscriminately ordering a avoid indiscriminately ordering a large battery of tests. large battery of tests.
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CausesCauses
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Evaluation optionsEvaluation options
[ ] CBC[ ] CBC[ ] blood culture[ ] blood culture[ ] urinalysis [ ] urinalysis [ ] urine culture[ ] urine culture[ ] CXR[ ] CXR[ ] LP[ ] LP[ ] Nothing[ ] Nothing
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Management optionsManagement options
[ ] Admit[ ] Admit[ ]Treat empirically, or[ ]Treat empirically, or
[ ]Observe, no treatment[ ]Observe, no treatment
[ ] Send home, follow-up within 24 [ ] Send home, follow-up within 24 hourshours
[ ]Treat empirically, or[ ]Treat empirically, or
[ ]No treatment[ ]No treatment
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Treatment optionsTreatment options
[ ] Oral [ ] Oral
[ ]Amoxicillin[ ]Amoxicillin[ ]Amoxicillin/clavulanate[ ]Amoxicillin/clavulanate[ ]Other[ ]Other
[ ] Intravenous[ ] Intravenous
[ ]Ceftriaxone[ ]Ceftriaxone[ ]Other[ ]Other
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Fever Without SourceFever Without SourceAge 3 – 36 MonthsAge 3 – 36 Months
• Risk of occult bacteremia Risk of occult bacteremia
• 3-11%, mean 3-11%, mean 4.3%4.3% for T>39 for T>39CC
• Risk greater withRisk greater with• Higher temperaturesHigher temperatures• WBC > 15,000 (WBC > 15,000 (13%13% vs vs 2.6%2.6%))
• Risk of pneumococcal meningitis (w/o Risk of pneumococcal meningitis (w/o abx tx) abx tx) 0.21% (1:500)0.21% (1:500)
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FWS – age 3-36 months:FWS – age 3-36 months:Consensus RecommendationsConsensus Recommendations
• CHILD APPEARS TCHILD APPEARS TOXIC:OXIC:
• ADMIT to hospitalADMIT to hospital• Sepsis w/uSepsis w/u• Parenteral abxParenteral abx
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FWS – age 3-36 months:FWS – age 3-36 months:Consensus RecommendationsConsensus Recommendations
• CHILD NON-TOXIC, T < 39CHILD NON-TOXIC, T < 39CC
• No diagnostic tests or antibioticsNo diagnostic tests or antibiotics• Acetaminophen 15 mg/kg prn for Acetaminophen 15 mg/kg prn for
feverfever• Return if fever persists > 48 hours or Return if fever persists > 48 hours or
clinical condition deterioratesclinical condition deteriorates
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Heptavalent conjugate Heptavalent conjugate pneumococcal vaccinepneumococcal vaccine
• very efficaciousvery efficacious• Likely to make most of the foregoing Likely to make most of the foregoing
pneumococcal in 3-36 month group pneumococcal in 3-36 month group obsoleteobsolete
• Finally become routine by MCHFinally become routine by MCH
Given at 2,4,6 month and 12-15mGiven at 2,4,6 month and 12-15m
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