puo
TRANSCRIPT
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APPROACH TO A CHILD WITH FEVER OF UNKNOWN ORIGIN
BY DR MANDAR HAVALDCH.DNB
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BEST DEFINED ASFEVER WITHOUT OBVIOUS
SOURCE ON CLINICAL EXAMINATION
ORAL
RECTAL
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FEVERTEMPERATURE >38 .0 degree C (>100.4 degree F)
RECTAL TEMPRATURE
ORAL – 0.6 C LESS
AXILLARY IS 1.1 C LESS
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What is a PUO?1956 Age > 14
T > 37.4°C x3 or 38°C x1 Fever - predominant symptomInsufficient symptoms / signs to localise
1961 Days > 21, T > 38.3°C1/52 hospital investigation
1968 Days > 14No clear diagnosis
Reid
Petersdorf & Beeson
Dechovitz & Moffet
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What is a PUO now?
Now+
2 hospital visits, orHospital investigations for 3 days
Neutropenic PUO
Neutrophils < 1.0Diagnosis not clear at 3 days
Nosocomial PUO
Admission infection screen negativeDiagnosis not clear at 3 days
HIV PUO HIV infected, fever for 4 weeksDiagnosis not clear after 3 days
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TYPES OF PUOACUTE ONSET (<7 DAYS)
PROLONG (> 7 to 10 DAYS)
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The commonest cause of PUO is:
a) A common disease presenting in an atypical way.
b) A rare disease presenting in atypical way.
c) A common disease presenting typically.
d) A rare disease presenting typically.
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The answer is ..A..The commonest cause of PUO IS …Common disease presenting ATYPICALLY
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ETILOGYINFECTION CONTRIBUTE TO 40
TO 50% OF FUO
COLLAGEN VASCULAR DISEASE 15-20%
MALIGNANCY 5-10%
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Causes of PUOBacteria Tuberculosis, Salmonellosis, Brucellosis,
Mycoplasma, Campylobacter
Viruses Cytomegalovirus, Hepatitis, Infectious Mononucleosis, HIV
Parasitic Disease
Amebiasis, Toxoplasmosis, Malaria, Visceral Larva Migrans
Spirochetes Leptospirosis, Lyme Disease, Relapsing Fever, SyphilisChlamydia Lymphogranuloma VenereumLocalised Infections
Abscess, Endocarditis, Pyelonephritis, Sinusitis
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Causes of PUO – Contd..Connective Tissue Disorders
Juvenile Rheumatoid Arthritis, Rheumatic fever, Systemic lupus erythematosus, Polyarteritis Nodosa, Hypersensitivity Pneumonia
Malignancies Hodgkin disease, Leukemia, Neuroblastoma, Wilms tumor
Granulomatous Disease
Crohn’s Disease, Sarcoidosis
Hypersensitivity Disease
Drug fever, Hypersensitivity PneumonitisPancreatitis
Miscellaneous Causes Kawasaki Disease, Pulmonary Embolism, Thyrotoxicosis, Diabetes Insipidus, Factitious fever
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AGE GROUPNEONATE ( 0-28 days)
YOUNG INFANT ( 1-3 months)
OLDER INFANT TO TODDLER (3 month To 36 month)
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NEONATEALL TOXIC – APPEARING INFANTS
AND ALL FEBRILE INFANTS LESS THAN 28 DAYS SHOULD BE HOSPITALIZED FOR EVALUATION AND INITIATION OF PROMPT PARENTAL ANTIBIOTIC THERAPY AFTER SENDING BLOOD CULTURE
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FLOW CHART AGE<28 days ORCLINICALLY TOXIC CHILD
YES NOINVESTIGATIONINCLUDE LPIV ANTIBIOTICSHOSPITALIZATION
INVESTIGATECONSIDER LP
NORMAL LABAND X RAY
REACESS 24 HRS LATER CLINICALLY
ABNORMAL LABSOR CXR
IV ANTIBIOTICS HOSPITALIZATION
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WHY NEONATE ARE AT HIGH RISKHIGH RISK OF DEVELOPING SBI
MAINLY BACTERIAL ( GRAM NEGATIVE)
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WHICH NEONATE ARE TOXIC
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Fever in young infants (1-3 months)Low riskWell appearingWBC count 5000-
15000/cmmBand : Neutrophil
≤0.2Centrifuged urine
<10 WBC/HPFNo bacteria on Gram
stain-urineCSF <8 WBC/cmm
High riskIll lookingWBC count <5000
or >15000/cmmBand : Neutrophil
>0.2Centrifuged urine
>10 WBC/HPFBacteria + on gram
stain- urineCSF >8 WBC/cmm
Risk for SBI
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TAKE HOME MESSAGEANY NEONATE LESS THAN 28
DAYS HAS TO BE REFERRED OR ADMITTED
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AGE 28 DAYS TO 60 DAYS 5 – 10% INCEDENCE OF HIGH
RISK INFECTION
UNFORTUNATE ABOUT FEVER IN THESE AGE GROUP
ROCHESTER CRITERIA
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APPROACHTOXIC OR NON TOXIC
NO YES
(EXAMINATIONINVESTIGATION)
REPEATED EVALUATION ADMIT OR
REFERRED
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INVESTIGATIONPERIPHERAL BLOOD COUNTCRPURINE ANALYSISBLOOD CULTUREURINE ANALYSIS/CULTURECHEST X RAYCSF
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AGE 3MONTHS TO 36 MONTHSIN THIS SUB GROUP
TEMPERATURE MORE THAN 39 degree C IS DEFINED AS FEVER
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TEMP > 39 C
YES NO
TOXIC
YES
NO
ADMITINVESTIGATIONPARENTAL ANTI.
INVESTIGATEWITH
TC, DCURINE XRAY
OCCULT UTI
OCCULT BACTEREMIA
PNEUMONIA
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LAB CRITERIATLC (5 – 15000)
ABSOLUTE BAND CELL COUNT (<1500/mm)
<10 WBC PER HIGH POWER FIELD IN SPUN URINE SEDIMENT
<5 WBC PER HIGH POWER FIELD IN STOOL SAMPLE
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LP – PRESENCE OF WBC IN CSF/ GRAM STAINING
2 D ECHO – HELPS IN DIAGNOSING IE, MYOCARDITIS
CT SCAN / MRI
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Management of Fever – Contd..Oral antipyretics – Well tolerated , effectiveParenteral antipyretics not indicatedRectal suppositories – In intractable vomiting ,
post-operative state Inform parents that antipyretics do not cure
Fever may persist despite antipyretics , especially in first 2-3 days of even in self-limiting viral infection
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ANTIBIOTIC PREFFERED LESS THAN 3 MONTHS
AMPICILLIN + GENTAMYCIN
CIFTRIAXONE
CEFOTAXIME
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MORE THAN 3 MONTHCIFTRIAXONE
CEFUROXIME
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TAKE HOME MSG..ALL FEBRILE INFANTS WHO ARE LESS
THAN 36 months WHO HAVE TOXIC MANIFESTATION HAS TO BE REFERRED
LESS THAN 28 DAYS HAS TO BE REFERRED FOR PARENTRAL ANTIBIOTIC
NO LAB TEST OR ANTIBIOTIC ARE NEEDED IN CHILD OVER 3 MONTHS WHO HAS TEMP LESS THAN 39 C.
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QUESTIONS?
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THANK YOU