APPROACH TO CHILD

WITH FUO
Anuja Jacob
 FEVER OF UNKNOWN ORIGIN
• Fever (rectal temperature >38ºC) documented by a health-care personnel
for which no cause is identifiable after 3 weeks of outpatient evaluation and
after 1 week of evaluation as an inpatient that includes a careful history,
physical examination and initial laboratory assessment.
 ETIOLOGY

1.INFECTIONS
Bacterial Tuberculosis, typhoid, paratyphoid, brucellosis,
Campylobacter, meningococcemia, relapsing fever
Viral Infectious mononucleosis, HIV, hepatitis,
cytomegalovirus
parasitic Malaria, kala azar, amoebic abscess, giardiasis,
toxoplasmosis, trypanosomiasis, visceral larva migrans
Rickettsia Scrub typhus, Q fever, Rocky mountain spotted fever
Fungal Histoplasmosis, blastomycosis, disseminated
candidiasis, cryptococcosis
2. Connective tissue and
autoimmune disorders
3. Hypersensitivity disorder
4. Malignancies
5. Granulomatous diseases
6. Familial and hereditary
diseases
7. Miscellaneous
SLE, juvenile idiopathic arthritis, rheumatic fever,
juvenile dermatomyositosis, Behcet disease,
polyarteritis nodosa
Drug fever, serum sickness, hypersensitivity
pneumonitis, Weber-Christian disease
Hodgkins disease, leukemia, lymphoma,
pheochromocytoma, neuroblastoma, Wilms
tumor
Inflammatory bowel disease, sarcoidosis,
granulomatous hepatitis
Anhidrotic ectodermal dysplasia, familial
dyautonomia, familial Mediterranean fever,
ichthyosis
Addison disease, thyrotoxicosis, Kawasaki
disease, hemophagocytic histiocytosis, Kikuchi
disease
 APPROACH TO DIAGNOSIS
• HISTORY
• PHYSICAL EXAMINATION
• LABORATORY EVALUATION
 HISTORY
• Characteristics of fever : onset, intensity, duration, frequency,
response and nonresponse to therapy, recurrence and associated
symptoms
• Recent exposures like vaccination or animal/insect bites or receipt
of any blood transfusion or biological products
• Exposure to any family member with fever or any infectious disease,
past history of any significant illnesses such as TB, UTI, CHD
• Any history of travel to specific disease endemic areas in recent
past
• Any exposure to heavy metals or poisonous fumes
• History of any underlying chronic disease and medications
• Information about Genetic background
 PHYSICAL EXAMINATION
• A detailed clinical examination should be repeated frequently
• General appearance of child should be assessed
• Particular attention should be paid to evaluation of skin, fundus, throat,
lymph nodes, genitalia and sinuses
• Detailed eye inspection (cornea, conjunctiva, orbit, uveal tract and retina)
SITE PHYSICAL FINDING DIAGNOSIS
Head Sinus tenderness Sinusitis
Temporal artery Nodules, reduced pulsations Temporal arteritis

Oropharynx Ulceration Disseminated histoplasmosis, SLE, IBD,

Behcet syndrome, periodic fever syndromes
Hyperemia of pharynx Streptococcal, EBV,CMV, Toxoplasma or
Salmonella infection
Fundi or conjunctivae Choroid tubercle Disseminated Granulomatosis
Petechiae, Roth spot Endocarditis
Thyroid Enlargement, tenderness Thyroiditis
Heart Murmur Infective endocarditis
Abdomen Enlarged iliac crest lymph nodes Lymphoma, disseminated granulomatosis,
Splenomegaly endocarditis
Rectum Perirectal lymphadenopathy, Deep pelvic abscess, iliac adenitis
tenderness
Skin Petechiae, splinter hemorrhage, Vasculitis, endocarditis
s/c nodules, clubbing
 LABORATORY EVALUATION
• PRELIMINARY INVESTIGATIONS
• SECOND LINE INVESTIGATIONS
 PRELIMINARY INVESTIGATIONS
• Complete blood count (anemia, thrombocytosis, TLC)
• ESR (>30 mm/hr ), C-reactive protein
• Peripheral smear, Malarial parasite
• Widal test
• Blood culture
• Urinalysis and culture
• Tuberculin test
• LFT
• Serum electrolytes, BUN, creatinine
• Chest X-ray, USG abdomen
 SECOND LINE INVESTIGATIONS
• HIV ELISA
• Contrasted enhanced CT of chest and abdomen, MRI
• CT of the paranasal sinuses
• 2D echocardiogram
• Compliment level
• ANA and Rh factor
• Bone marrow histology and cultures
• Tissue biopsies
• Serology (EBV, CMV, Toxoplasma, Brucella)
 MANAGEMENT
• Ultimate treatment depends on underlying diagnosis
• Empirical treatment with anti-inflammatory agents or antibiotics should be
avoided (exceptions are there)
• Disease specific interventions should be started soon after a diagnosis is
established
 PROGNOSIS
• Children with FUO have better prognosis than adults
• In many cases no diagnosis can be established and fever resolve
spontaneously
• In about 25% children in whom fever persists the cause will remain unclear
even after thorough evaluation
THANK YOU