Fever without a focus in infants

Tammy BerteauAugust 6th, 2015

What is a fever?

• Rectal/Ear >38oC (>100.4oF)• Oral >37.5oC (>99.5oF)• Axillary >37.3oC (>99.1oF)

Temperature Measurement in Paediatrics, Leduc, Woods, Canadian Paediatric Society, January 2015

Classification of Fevers

• Fever with a focus• Fever without localizing signs (without a focus)• Fever of unknown origins (FUO)

TRUE OR FALSE

The response to antipyretics can distinguish between the different etiologies of fever (i.e. viral, bacterial, malignancy, autoimmune, drugs)

FALSE

MCQ

The pattern of fever can distinguish between:

a. Malignancy vs infectiousb. Bacterial vs viralc. Inflammatory vs infectiousd. Drugs vs inlammatorye. None of the above

The pattern of fever can distinguish between:

a. Malignancy vs infectiousb. Bacterial vs viralc. Inflammatory vs infectiousd. Drugs vs inlammatorye. None of the above

Case• A 2 month old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Case• A 2 month old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Case• A 2 month old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Case• A 2 month old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

What are pediatric vital signs?

What are pediatric vital signs?

DDx Fever• Infectious

– Bacterimia– Meningitis/encephalitis– SIRS– Sepsis/Septic Shock

• Inflammatory– Kawasaki disease, JIA, IBD, SLE, etc– Periodic fever syndromes

• Malignancy– Leukemia, lymphoma, neuroblastoma etc.

• Other– Dehydration, drugs & toxins, post-immunization, familial dysautonomia,

factitious disorder etc.

Don’t miss!• Infectious

– Bacterimia– Meningitis/encephalitis– SIRS– Sepsis/Septic Shock

• Inflammatory– Kawasaki disease, JIA, IBD, SLE, etc– Periodic fever syndromes

• Malignancy– Leukemia, lymphoma, neuroblastoma etc.

• Other– Dehydration, drugs & toxins, post-immunization, familial dysautonomia,

factitious disorder etc.

Bacterial Meningitis

Pathogens• Neisseria meningitidis• Streptococcus pneumonia• Haemophilus influenzae type b

***Major risk factor for meningitis is lack of immunity (younger age) and occult bacteremia

Pathogens• Neisseria meningitidis• Streptococcus pneumonia• Haemophilus influenzae type b

BM: Clinical manifestations

« Fulminant » form• Sudden onset/rapidly

progressing shock• Purpura• DIC• LOC

« Classic » form• Several days of fever• URTI or GI symptoms• Nonspecific CNS signs (i.e.

lethargy and irritability)

BM: Clinical manifestations

Non-specific findings• Fever• Anorexia/poor feeding• Headache• URTI• Myalgias/arthralgias• Tachycardia• Hypotension• Cutaneous signs (petechiae,

prupura, erythematous macular rash)

« Specific » findings• Meningeal irritation• ICP• Seizures• D mental status

Shock

Shock

Shock

SIRS

Sepsis/Septic Shock

Septic Shock:Clinical Manifestations

Initially:• Alteration in temperature

(hypo/hyperthermia)• Tachycardia• Tachypnea

« Warm » vs « Cold »

Case• A 2 month old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanelle is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Further Hx

• HPI– OPQST

• >14 days (FUO vs FWF)• Pattern/height of fever*• Persistent or recurrent (? PFS or autoimmune)• No fever, only lethargy and poor feeding (? metabolic d/o)• Overbundling

– Pertinent +/-• Localizing signs (Fever with a source)• Focal neurological signs (Brain abscess, contraindication for LP,

malignancy)• Travel history, sick contacts (household, daycare, dormitories, military)

Further Hx• PMHx,

– Chronic diseases,– Hospitalization/Doctors consulted– Recent treatment w/ antibiotics, – Immunocompromised (i.e. HIV, corticosteroids, immunomodulators or

biologics, IgG deficiencies, complement defect (C5-C8)), – T-lymphocyte defects (congenital, acquired (chemotherapy), AIDS, malignancy)),– Inflammatory conditions (IBD, SLE,JIA), – Asplenia (congenital or trauma), – Sickle cell anemia, – Cochlear implants/defects, – Malignancies (chemotherapy),– Congenital or acquired CSF leak (cranial or midline facial defects, middle/inner

ear fistula, basal skull fractures).

Further Hx

• SocHx– Living conditions (crowding, poverty, black, Native

American, Inuit)• FHx– IgG deficiencies, Hereditary PFS (AR or AD), Defects in

complement or properdin system, Early infant deaths*• Pregnancy/Delivery– Preterm– Duration of neonatal hospitalization

• Development

Further Hx

• Allergies• Immunization– Conjugate vaccines (Hib, Pneumococcus,

Meningococcus)• Medications– Corticosteroids, chemotherapy, biologics,

immunomodulators

Approach to FWF (infants)

FWF: Organisms• Bacteremia

– <28 days (neonates)• GBS, E. coli, L. monocytogenes

– 1-3 months • S. pneumoniae, H. influenza, nontyphoidal Salmonella, N. meningitidis

• UTI– E. coli

• Pneumonia– S. pneumoniae, GBS, S. aureus

• Meningitis– S. pneumoniae, H. influenzae type B, GBS, N. meningitidis, HSV, enteroviruses

• Bacterial diarrhea– Salmonella spp., Shigella spp., E. coli

• Osteomyelitis• Septic arthritis

– S. aureus, GBS

Investigations

Case• A 3 week old female was brought to the ER with a hx of lethargy,

fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Fontanel is bulging and her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Case• A 8 months old female was brought to the ER with a hx of

lethargy, fever and poor feeding. The child was born at term following an uncomplicated pregnancy and seems to have been growing well until now. She is breastfed.

• The clinical examination reveals a lethargic baby with a temperature of 38.5oC rectally. The HR 190, RR60, bp 90/50. Her cap refill <2sec and warm extremities. Her neck is supple. Her chest had good air entry bilaterally. Heart sounds are normal. Her abdomen is soft with no organomegaly or masses palpable. Her musculoskeletal and skin exams are unremarkable. Her pupils are equal and reactive and her neurological exam is non-focal.

Bibliography

1. Nelson Textbook of Pediatrics 19th Edition, Kliegman, Stanton, St. Geme, Schor, Behrman, 2011, Elsevier Saunders.

2. The Evolving Approach to the Young Child Who Has Fever and No Obsious Source, Ishimine, P., Emergency Medicine Clinics of North America, 2007

3. Acute Fever, Pediatrics in Review, Vol. 30, No. 1, January 20094. Periodic Fever Syndromes, Pediatrics in Review, Vol. 30, No. 5,

May 20095. Temperature Measurement in Paediatrics, Leduc, Woods,

Canadian Paediatric Society, January 20156. http://www.pedscases.com/pediatric-vital-signs-reference-chart7. Toronto Notes, 2014

Important references

For Health Care• CPS• Pediatrics in Review

For parents• Caring for kids (CPS)