FEVER WITHOUT SOURCE

IN CHILDREN > 3 MONTHS

Dr. Tiroumourougane Serane. V

MBBS, MD (Ped), DNB, MNAMS, MRCPCH (UK)

Senior Consultant Neonatologist & Pediatrician

Head, CANVIJ Neonatal Services

A.G.Padmavati’s Hospital Ltd

 FEVER SCENARIO
• Fever in the neonate
• Fever with localizing signs
• Fever without source (FWS)
• Fever of unknown origin (FUO)
 HEAT ILLNESS

• Different from fever

• Unregulated rise in body temperature

• Normal hypothalamic set point

• Result of excessive heat production or inadequate heat

dissipation.

• Results in multiorgan dysfunction and death

• Restoration of normal body temperature - mandatory

 FEVER WITHOUT SOURCE
• Recent onset of fever with no obvious historical or physical
explanation for the fever
• Most are self-limited viral illness
• Bacterial pathogens account for a small but clinically
significant number of cases.
• Risk of bacterial infection decreases with increasing age
and is highest for infants less than 3 months of age
 HEAT ILLNESS

• Excessive Heat Production • Diminished Heat Dissipation

• Heat stroke (exertion)
• Malignant hyperthermia
• Tetanus
• Status epilepticus
• Hyperthyroidism
• Drugs
• Heat stroke
• Occlusive dressings
• Dehydration
• Anhidrotic ectodermal
dysplasia
• Anticholinergic-like drugs
Autonomic neuropathy
• Possible overbundling
 FEVER: TEMPERATURE MEASUREMENT

• Gold standard for children < 3 years - Rectal temperature

• Rectal temperature > 38°C (100.4°F) or higher.
• Oral thermometry - older than 4-5 years of age
• Other Options
• Axillary temperature
• Temporal artery temperature
• Tympanic membrane temperature - unreliable
 FEVER WITHOUT SOURCE - CHALLENGE

• To identify children having fever caused by

• Bacterial pathogens
• Other pathogens requiring treatment
 FEVER WITHOUT SOURCE - CHALLENGE

• When to suspect Bacterial infection?

• Immunocompromised – Severe Acute Malnutrition,
Recent Measles, Immunodeficiency disorders,
Chemotherapy
• Those with central lines or shunts
• High fever (105F) and rigors
• Exceptions - influenza and adenoviral infections
 FEVER WITHOUT SOURCE - APPROACH
• History
• Onset and duration
• Degree of temperature
• Medications given
• Associated symptoms
• Ill contacts
• Immunizations
• Travel
• Background Illness
 FEVER WITHOUT SOURCE - APPROACH
• Examination
• Ill or well
• Lethargic or irritable
• Signs of shock - weak peripheral pulses, tachycardia,
poor perfusion
• Respiratory distress
• Mottling
• Cyanosis
• Decreased mental status
 FEVER WITHOUT SOURCE - APPROACH
• Acute Illness Observation Scale
• 6 item predictive model
• For identifying serious illness
• Most useful in children < 24-36 months
 FEVER WITHOUT SOURCE
ACUTE ILLNESS OBSERVATION SCALE
 FEVER WITHOUT SOURCE - APPROACH
• Examination
• Throat – Pus, Membrane, Ulcers
• Otoscopy
• Work of Breathing
• Hepatosplenomegaly
• Pus any where
• Skin lesions – Eschar, Papulovesicular lesions
 FEVER WITHOUT SOURCE - APPROACH
• Examination
• Common Sanctuary Sites
• Urinary Tract Infection
• Otitis Media
• Pneumonia
• Deep Seated Pus
 FEVER WITHOUT SOURCE
DIFFERENTIAL DIAGNOSIS
• Mostly Viral (76%)
• Adenovirus
• Human herpesvirus 6 (HHV-6: roseola)
• Enterovirus
• Parechovirus
• Respiratory syncytial virus
• Parainfluenza viruses
• influenza viruses
• Varicella (chickenpox),
• Human metapneumovirus
• Parvovirus (fifth disease/erythema infectiosum)
• Measles, mumps, and rubella
• Swine Flu
 FEVER WITHOUT SOURCE
DIFFERENTIAL DIAGNOSIS
• Most viral infections do not have simultaneous co-infection
with a bacterial pathogen
• Exceptions
• Croup due to parainfluenza - predispose to tracheitis
• Influenza - predispose to bacterial pneumonia
• Respiratory syncytial virus - predispose to otitis media

• Many viral illnesses are biphasic

 FEVER WITHOUT SOURCE
DIFFERENTIAL DIAGNOSIS
Bacterial Infection Viral Infection
• Generally Unwell , toxic • Reasonably well, particularly
during afebrile period
• Fever with chills/ rigor - Rare
• Fever with chills/ rigor -
Common
• Coryza – Rare • Coryza – Common
• Conjunctivitis – Rare • Conjunctivitis – Common
• Change in Voice – Rare • Change in Voice – Common
 URINARY TRACT INFECTIONS

• Most common serious bacterial infection in children < 36

months presenting with FWS
• Almost always occult in children < 24 months
• When to suspect?
• Fever greater than 39°C
• Boys with fever > 2 days and girls > 1 day
 URINARY TRACT INFECTIONS

• Urine Examination
• History of UTI
• History of urinary tract anomalies or VUR
• Infants younger than 2 months
• Girls younger than 12-24 months
• Uncircumcised boys < 12 months
• Circumcised boys < 6 months
 OCCULT BACTEREMIA

• Presence of a positive blood culture for pathogenic bacteria

in a febrile patient who does not appear extremely ill and
who has no focus of infection
• Organisms
• Escherichia coli - most common cause
• Pneumococcus
• Salmonella – Nontyphoidal & Typhoid
• Staphylococcus aureus
• Group A streptococcus
 INVESTIGATIONS

• Complete Blood Count

• Most commonly used test.
• > 15,000/mm3 - Useful in Pneumococcal illness
• Other Markers of Inflammation
• C - reactive protein (CRP)
• Procalcitonin
 INVESTIGATIONS

• Blood Culture
• Gold standard for determination of bacteremia
• Urine Culture
• Pyuria (5 WBCs/HPF) or Positive leukocyte esterase on
dipstick)
• Positive urine culture for uropathogen in appropriately
collected specimen
• Stool Culture
• Only if bacterial enteritis is suspected
 INVESTIGATIONS

• Lumbar puncture
• Only if the patient < 28 days
• Diagnosis of systemic sepsis, meningitis, or encephalitis,
regardless of the child’s age
 INVESTIGATIONS

• Chest radiographs
• Not always necessary
• Pleural effusion
• Complications of pneumonia
 TREATMENT

• Ill looking child

• Initial evaluation
• During follow-up

• Admit to the hospital

• Appropriate laboratory evaluation
• Parenteral antibiotics - Third generation Cephalosporin
 Narrow Spectrum
 TREATMENT

• Well looking child

• Screen for UTIs based on risk factors
• History of UTI
• History of urinary tract anomalies or VUR
• Infants younger than 2 months
• Girls younger than 12-24 months
• Uncircumcised boys < 12 months
• Circumcised boys < 6 months
 TREATMENT
• Well looking child
• Reassurance - likely self-limited viral infection
• Risk Factors
• Persistence of fever
• Temperatures > 39°C (102.2°F)
• New signs and symptoms
• Symptomatic
• Antipyretics
• NO antibiotics
• NO Antivirals
 TAKE HOME MESSAGES

• Fever without Source – mostly self –limiting

• Key is to identify children with bacterial infections
• Urine examination is must in majority of children
• Unwell children will need hospitalization
• Avoid unnecessary antibiotic use