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Fever of unknown origin

Fever of unknown origin. Dr Rafat Mosalli. Different body sites. Rectal standard Oral 0.5-0.6  lower Axillary 0.8-1.0 lower Tympanic 0.5-0.6  lower Documented: In the absence of antipyretics In ED or office or by hx from reliable parents/adults.

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Fever of unknown origin

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  1. Fever of unknown origin Dr Rafat Mosalli

  2. Different body sites • Rectal standard • Oral 0.5-0.6 lower • Axillary 0.8-1.0 lower • Tympanic 0.5-0.6 lower Documented: • In the absence of antipyretics • In ED or office or by hx from reliable parents/adults

  3. Fever Without Source • “An acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination.” Baraffet al, Pediatrics 1993; 92:1-12

  4. Fever of Unknown Origin 1. Fever of 38C or greater which has continued for a 2 to 3 weeks 2. Absence of localizing clinical signs 3. Negative simple investigations

  5. Occult bacteremia • “…a positive blood culture in the setting of well appearance and without focus (e.g. no pneumonia) • Fleisher et al, J Pediatrics 1994

  6. Serious Bacterial Infection • “…Include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and enteritis” Baraffet al, Pediatrics 1993; 92:1-12

  7. Frequency of febrile illness • 35% of unscheduled ambulatory care visits • 65% of kids see doc before age 2y • Majority (75%) for T < 39 C • 13% T > 39.5

  8. Epidemiology • Incidence of bacteremia in febrile infants in post-Hib era • 2-3% if < 2 months, T > 38C • < 2% if 3-36 months, T >39C

  9. Occult bacteremia organisms • Streptococcus pneumonia > 85% • Neisseria meningitidis 3-5% • Others: • S. aureus • S. pyogenes (GAS) • Salmonella species • Haemophilus influenzae type B (now rare – previously 10%)

  10. Outcomes of occult bacteremia without antibiotics • Persistent fever 56% • Persistent bacteremia 21% • Meningitis 9% • S. pneumonia 6% • H. Influenzae 26% (now rare)

  11. Should fever be treated? • Pros • Decrease discomfort • Calm the family • Extreme (>41C) may cause permanent brain damage rare,rare,rare • Decrease risk of febrile convulsions in prone kids??

  12. Should fever be treated? • Cons • Adverse effect of antipyretic may outweigh benefits • May obscure diagnostic/prognostic signs • Fever usually short-lived and benign • Fever is normal and adaptive physiologic response

  13. What is the eventual etiology of fever in children with FUO?

  14. How should a child with FUO be evaluated? • FUO is more likely to be an unusual presentation of a common disorder than a common presentation of a rare disorder. • detailed history and thorough physical examination • avoid indiscriminately ordering a large battery of tests.

  15. Causes

  16. Evaluation options [ ] CBC [ ] blood culture [ ] urinalysis [ ] urine culture [ ] CXR [ ] LP [ ] Nothing

  17. Management options [ ] Admit [ ]Treat empirically, or [ ]Observe, no treatment [ ] Send home, follow-up within 24 hours [ ]Treat empirically, or [ ]No treatment

  18. Treatment options [ ] Oral [ ]Amoxicillin [ ]Amoxicillin/clavulanate [ ]Other [ ] Intravenous [ ]Ceftriaxone [ ]Other

  19. Fever Without SourceAge 3 – 36 Months • Risk of occult bacteremia • 3-11%, mean 4.3% for T>39C • Risk greater with • Higher temperatures • WBC > 15,000 (13%vs2.6%) • Risk of pneumococcal meningitis (w/o abxtx) 0.21% (1:500)

  20. FWS – age 3-36 months:Consensus Recommendations • CHILD APPEARS TOXIC: • ADMIT to hospital • Sepsis w/u • Parenteral abx

  21. FWS – age 3-36 months:Consensus Recommendations • CHILD NON-TOXIC, T < 39C • No diagnostic tests or antibiotics • Acetaminophen 15 mg/kg prnfor fever • Return if fever persists > 48 hours or clinical condition deteriorates

  22. Heptavalent conjugate pneumococcal vaccine • very efficacious • Likely to make most of the foregoing pneumococcal in 3-36 month group obsolete • Finally become routine by MCH Given at 2,4,6 month and 12-15m

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