CLINICAL CONSIDERATIONS & MGT OF A CHILD WITH PROLONGED FEVER

OUTLINE

Introduction Pathogenesis of fever Definition Causes Management Summary

INTRODUCTION

Fever (pyrexia) is a medical sign defined as a regulated elevation of body temperature above the customary set point. Fever is a body defence mechanism. It is one of the body's immune responses that attempts to neutralize a bacterial or viral infection. A fever can be caused by many different conditions ranging from benign to potentially serious.
3

FEVER IS PRESENT IF
rectal temperature is 38 degrees Celsius oral temperature is 37.5 degrees Celsius axillary temperature is 37.2 degrees Celsius

GRADES OF FEVER (AXILLARY TEMP)

Collapse (hypothermia) Subnormal < 35C 35C - 36.2C

Normal
Pyrexia Low grade pyrexia Moderate pyrexia High grade pyrexia Hyperpyrexia

36.2C - 37.2C
>37.2C 37.2C - 38.2C 38.2C - 39.4C 39.4C - 40.5C > 40.5C

PATHOPHYSIOLOGY

DEFINITIONS
Prolonged fevera single illness in which duration of fever exceeds that expected for clinical diagnosis (principles and practice of paediatric infectious disease, 3rd edtn, chp 17, page 127) Fever of unknown origina single illness of at least 3 weeks duration in which fever > 38.3 is present on most days and diagnosis remains uncertain after 1 week intense evaluation (principles and practice of paediatric infectious disease, 3rd edtn, chp 17, page 127)
7

DEFINITION

There are very few true FUO's" in paediatric practice. Most of them turn out to be atypical cases of common diseases. Usually the cause is found and treated. Diagnosis & treatment of prolonged fever, and classification of FUO depends on certain factors. As technology advances further and better diagnostic equipment are designed, cases of FUO are on the decline (every fever has a cause, we just cannot always tell what that cause is).
8

COMMON CAUSES OF PROLONGED FEVER

Infections . Neoplasms. Collagen vascular/ hypersensitivity diseases. Granulomatous diseases. Metabolic diseases. Thermoregulatory disorders. Miscellaneous conditions. Idiopathic.

INFECTIONS
1.

Bacterial
UTI and Pyelonephritis Enteric fever Partially treated meningitis. Abscesses- perinephric, retroperitonial, subdiaphragmatic, lung, liver Tuberculosis (miliary TB) . Osteomyelitis. Infective endocarditis

10

INFECTIONS
2. Viral.
HIV. Hepatitis A, B, C, D, E and G. EBV. CMV. Coxasackie virus group B infections

3. Protozoa.
Malaria. Amoebiasis. Toxoplasmosis.

11

INFECTIONS
4. Helminthes.
Strongyloides especially in the immuno-compromised

5. Fungal.
Aspergillosis . Coccidioidomycosis. Blastomycosis.

12

COMMON CAUSES
NEOPLASMS

COLLAGEN VASCULAR DX

Acute lymphocytic leukemia. Acute myeloid leukemia. Lymphomas (Hodgkins and Non-Hodgkins). Neuroblastoma.

Rheumatic fever. Juvenile rheumatoid arthritis. SLE. Kawasaki disease. Dermatomyositis. Scleroderma.

13

COMMON CAUSES
GRANULOMATOUS DISEASES

METABOLIC DISORDERS Hyperthyroidism. Adrenal insufficiency.

Inflammatory bowel disease. Sarcoidosis. Crohns disease

14

THERMOREGULATORY DISORDERS

Brain tumors. Hypothalamic dysfunction. Encephalitis. CVA e.g. pontine hemorrhage.

MISCELLANEOUS Drugs.

e.g. Antibiotic fever - betalactam antibiotics, procainamide, isoniazid, alpha-methyldopa, quinidine, and diphenylhydantoin

COMMON CAUSES
15

IDIOPATHIC
Despite todays sophisticated diagnostic tools, not all fevers are specifically diagnosed.

16

MANAGEMENT

History
Physical examination

Eliciting supporting signs for diagnosis

Investigations

Targeted at suspected diagnoses

Treatment General and Specific

17

HISTORY

Demography
Children

less than 6yrs are more likely to have respiratory, genitourinary tract infection, localized abscess. Adolescents are likely to have lymphoma or inflammatory bowel disease. Boys more commonly affected in ALL.

18

HISTORY (CONT.)

Presenting complaints Headache Malaise Convulsions Weight loss Chills Sweating Poor feeding
19

HISTORY (CONT.)
Pattern of fever Duration of fever

Intermittent fever with wide variations(Stopping and starting at regular/irregular intervals)

Deep seated or systemic infection Abscess Malignancy Drug fever TB Viral

Salmonella
20

Remittent fever (periods of diminished severity)

Persistent step ladder fever

HISTORY (CONT.)
Past medical and surgical History Dental work Recent surgery Unusual, severe or chronic illness Malignancy Blood transfusions Drug history Is child on any medication e.g. cytotoxics, antibiotics, immunosuppressive therapy. Partial treatment e.g. malaria, meningitis, Tb. Partial drug resistance (patient does not quite recover)

21

HISTORY (CONT.)
Pregnancy and Birth History History of chronic infections? PROM mode of delivery and any trauma during delivery Immunisation history Ask if it is up to date e.g. BCG (against TB). Nutritional history Drinking of unpasteurized milk . Severe malnutrition and risk of atypical or prolonged infections
22

HISTORY (CONTD.)
Family history Hx of inheritable aetiologies Social history Place of residence, Contact with any livestock (brucellosis, toxoplasmosis) Any contact with TB infection Impact on childs health and activity

23

PHYSICAL EXAMINATION

24

GENERAL EXAMINATION

Wasting (TB, thyrotoxicosis, malignacy) Pallor (Malaria, ALL, Chronic sepsis)

Jaundice with Fever (Infective hepatitis, Malaria, Liver abscess, infectious mononucleosis) Lymphadenopathy (lymphomas, HIV, TB, 2o Syphilis, lymphocytic leukemia)

25

LYMPHADENOPATHY

26

GENERAL EXAMINATION CTD

Maculopapular rashviral, Kawasaki dx, drug reaction

Petechial rashmeningococcal dx

Clubbing of fingersTB, lung abscess, Bronchiectasis, SBE, liver absces

27

CVS & Respiratory System

Murmur (rheumatic carditis, infective endocarditis) Pulse (Relative bradycardia in Typhoid) Chest indrawing

28

PHYSICAL EXAMNINATION (CONT.)

Abdomen Suprapubic tenderness, renal angle tenderness in UTI, masses Rectal or pelvic examination This may reveal tenderness suggesting deep pelvic abscess, iliac or mesenteric adenitis, or pelvic osteomyelitis.

29

PHYSICAL EXAMNINATION (CONT.)

Musculoskeletal system
Local tenderness (osteomyelitis) Generalized muscle tenderness (dermatomyositis, polyarteritis or mycoplasma infection.) Joint tenderness (Rheumatic fever, SBE, septic arthritis, leukemia.)

Nervous system
Hyperactive deep tendon reflexes suggest thyrotoxicosis.

30

PHYSICAL EXAMINATION (CONT.)

Ophthalmic Examination
Red weeping eyes: collagen vascular disease Palpebral conjunctivitis: viral infection such as measles or adenovirus. Petechial and conjunctival hemorrhage: endocarditis. Uveitis: sarcoidosis, SLE. Proptosis: orbital tumor, thyrotoxicosis , neuroblastoma , orbital infection etc

31

PHYSICAL EXAMINATION (CONT.)

Oral examination
Fever blisters on the mouth are common in malaria, pnemococcal and streptococcal infections. Examine pharynx and teeth (dental abscess).

Examine the ear for signs of otitis media.

32

INVESTIGATIONS

33

Laboratory Studies: CBC count: anaemia, leukocytosis (occult bacterial infexn, malaria) Urinalysis: UTI, malignant tumors Serum chemistry: LFT, AFP Cultures: Serologies: HIV, CMV, Toxoplasmosis

Imaging Studies: Radiographic examination: of the chest, sinuses,

mastoids, or gastrointestinal tract may be indicated by specific historical or physical findings.

Abdominal ultrasonography: Ultrasonography may

identify intra-abdominal abscesses of the liver, subphrenic space, pelvis, or spleen.

MRI / CT scanning: CT and MRI are helpful in identifying

lesions of the head, neck, chest, retroperitoneal spaces, liver, spleen, intraabdominal and intrathoracic lymph nodes, kidneys, pelvis, and mediastinum. MRI is particularly useful for detecting osteomyelitis if there is concern about a specific limb.

Other Tests: Endoscopic examination: Bronchoscopy, laparoscopy,

gastrointestinal endoscopy may provide direct visualization and biopsy material when organ-specific manifestations are present. This is indicated (e.g. when imaging techniques are nondiagnostic)

Echocardiography: this technique is highly sensitive in

diagnosing endocarditis.

Tuberculin skin testing: a more specific test usually

suspected.

when TB is

TREATMENT

37

TREATMENT
Two pronged approach

Treat symptoms associated with fever.

Treat the cause of the fever.

38

TREATMENT
Adequate rehydration is necessary and tepid sponging may be applied. Paracetamol and/or Ibuprofen may be administered. Ibuprofen has been shown to be a more effective antipyretic.

39

Anti pyretics do not bring the temperature down to normal unless it was a low grade fever to begin with.

40

DEFINITIVE TREATMENT
Directed at the cause of the fever. Empirical therapy should be started before the cause has been found. When investigations point to a specific condition then the patient is treated specifically for that disease.

41

DEFINITIVE TREATMENT
However if it does not point to any specific diagnosis then revisit the hx and examination and carry out new but relevant investigation based on any new developments. Antibiotics are adjusted according to the results of the cultures taken. Refer appropriate cases.

42

SUMMARY
Prolonged fever may arise from atypical manifestation of common diseases. Diseases common to the location must first be taken into account.

43

THANK YOU

44

REFERNCES

Principles and practice of paediatric infectious disease. chp 13, pg 127 David A. Perrott, PhD et al Arch Pediatr Adolesc Med. 2004;158:521526. Nelson textbook of paediatrics Kleigman et al 18th edition Hospital care for children WHO 2005, chp6, pg 133 British medical journal 30 aug 1975, pg 504

45