OUTLINE
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.
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FEVER IS PRESENT IF
rectal temperature is 38 degrees Celsius oral temperature is 37.5 degrees Celsius axillary temperature is 37.2 degrees Celsius
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)
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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).
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INFECTIONS
1.
Bacterial
UTI and Pyelonephritis Enteric fever Partially treated meningitis. Abscesses- perinephric, retroperitonial, subdiaphragmatic, lung, liver Tuberculosis (miliary TB) . Osteomyelitis. Infective endocarditis
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INFECTIONS
2. Viral.
HIV. Hepatitis A, B, C, D, E and G. EBV. CMV. Coxasackie virus group B infections
3. Protozoa.
Malaria. Amoebiasis. Toxoplasmosis.
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INFECTIONS
4. Helminthes.
Strongyloides especially in the immuno-compromised
5. Fungal.
Aspergillosis . Coccidioidomycosis. Blastomycosis.
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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.
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COMMON CAUSES
GRANULOMATOUS DISEASES
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THERMOREGULATORY DISORDERS
MISCELLANEOUS Drugs.
e.g. Antibiotic fever - betalactam antibiotics, procainamide, isoniazid, alpha-methyldopa, quinidine, and diphenylhydantoin
COMMON CAUSES
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IDIOPATHIC
Despite todays sophisticated diagnostic tools, not all fevers are specifically diagnosed.
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MANAGEMENT
History
Physical examination
Investigations
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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.
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HISTORY (CONT.)
Presenting complaints Headache Malaise Convulsions Weight loss Chills Sweating Poor feeding
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HISTORY (CONT.)
Pattern of fever Duration of 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)
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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
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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
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PHYSICAL EXAMINATION
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GENERAL EXAMINATION
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LYMPHADENOPATHY
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Petechial rashmeningococcal dx
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Murmur (rheumatic carditis, infective endocarditis) Pulse (Relative bradycardia in Typhoid) Chest indrawing
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Nervous system
Hyperactive deep tendon reflexes suggest thyrotoxicosis.
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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
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Oral examination
Fever blisters on the mouth are common in malaria, pnemococcal and streptococcal infections. Examine pharynx and teeth (dental abscess).
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INVESTIGATIONS
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Laboratory Studies: CBC count: anaemia, leukocytosis (occult bacterial infexn, malaria) Urinalysis: UTI, malignant tumors Serum chemistry: LFT, AFP Cultures: Serologies: HIV, CMV, Toxoplasmosis
when TB is
TREATMENT
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TREATMENT
Two pronged approach
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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.
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Anti pyretics do not bring the temperature down to normal unless it was a low grade fever to begin with.
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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.
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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.
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SUMMARY
Prolonged fever may arise from atypical manifestation of common diseases. Diseases common to the location must first be taken into account.
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THANK YOU
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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
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