Fever (Case 8)

Chapter 36 Fever (Case 8)



Justin F. Lynn, MD, MPH




Case


A 24-month-old with fever of 38.8° C (102° F) for 24 hours who is cranky and not feeding or sleeping well




Differential Diagnosis













Upper respiratory infection Acute otitis media Acute bacterial sinusitis
Bronchiolitis and pneumonia Viral syndrome Urinary tract infection


Speaking Intelligently


Fever is generally defined as a body temperature greater than 38° C (100.4° F). Recognize that fever is common in children and by itself is not a diagnosis. It is a reset of the body’s thermostat in response to a stimulus, and the goal of evaluation is to find the stimulus. If the exact cause is not identified, serious causes need to be excluded. Using both the history and physical examination, it is helpful to take the outside-in approach and start with a general sense of the child’s well-being and then narrow in on specific signs or symptoms. Most children with fever have a benign self-limited viral illness or a bacterial cause identified on examination. Antipyretics will decrease the temperature but are not always necessary, and treatment of the underlying condition (if possible) is the priority. In the office setting, the extent of laboratory evaluation is guided by the child’s age, immunization status, overall appearance, and the physician’s ability to make a clinical diagnosis.1 (See Chapter 46, Neonatal Fever).



Patient Care



Clinical Thinking



• Does the child’s appearance raise concern for serious bacterial infection? Does the child look significantly better after a dose of antipyretics and/or fluids?

• Are there localizing signs or symptoms that can lead to diagnosis?

• Is there specific treatment, such as penicillin for group A streptococcal pharyngitis?

• What caregiver education is needed for supportive care and need for follow-up?

• Is additional testing such as urine, blood, or chest radiograph indicated?

• Season may be important: Coxsackie hand-foot-and-mouth disease and Lyme disease occur in spring/summer, whereas bronchiolitis and influenza have a fall/winter occurrence.


History



• Is there history of exposure to other febrile children? Does the child attend day care or school?

• A child with normal activity level and oral intake has a decreased likelihood of a serious infection.

• Are vaccinations current?

• Prolonged fever may indicate an unresolved infection or an inflammatory disease.

• Poor linear growth and weight gain may occur with inflammatory disease.

• Change in mental status is concerning for meningitis/encephalitis.

• A fever developing once an illness has started is concerning for secondary bacterial infection, such as acute otitis media with upper respiratory infection (URI).

• Fever and tachypnea may indicate pneumonia if tachypnea persists after administration of an antipyretic and decreased temperature.


Physical Examination



• Note general sense of well-being. Is the child toxic, somnolent, or irritable appearing?

• Vital signs: Note tachypnea or tachycardia out of proportion to fever. Include pulse oximetry if respiratory symptoms.

• Note hydration status: Assess activity level, oral intake, urine output, presence of tears, and fluid losses from vomiting or diarrhea.

• Is there rhinorrhea?

• Bulging fontanelle occurs in infants with meningitis; classic meningeal signs occur in older children. See Chapter 46, Neonatal Fever, and Chapter 49, Meningitis.

• Bulging tympanic membrane with inflammation and acute onset of symptoms occur in acute otitis media.

• On lung examination, note overall aeration, respiratory rate, and retractions as well as auscultation findings.

• A careful skin examination for rashes may provide diagnostic clues. Distribution and pattern may suggest an etiology. Petechiae below the nipple line should raise concern about meningococcemia, generalized erythroderma with toxin-mediated bacteremia, a discrete fine maculopapular sandpaper rash in group A streptococcal infection, and a polymorphous rash in viral exanthems.


Tests for Consideration



• Complete blood count (CBC): Leukocytosis with a left shift supports bacterial etiology, though early on viral processes may be neutrophil predominant. $116

• Urinalysis: Nitrites and leukocyte esterase indicate infection; infants may only have increased microscopic white blood cell count. $95

• Urine culture: Confirms infection. $148

• Blood culture: If toxic appearing. $152

• Erythrocyte sedimentation rate (ESR): Marked elevation with bacterial infection; can be used to follow response to treatment. $85

• C-reactive protein: Elevated with infection and inflammation. $69

• Metabolic panel: If concern for dehydration, renal function, or hepatitis. $174

• Rapid respiratory panel: Respiratory syncytial virus (RSV), influenza, parainfluenza, adenovirus, human metapneumovirus. $325

• Rapid antigen for Rotavirus. $170


Imaging Considerations














Sinus computed tomography (CT) scan: In refractory cases or if concern for underlying anatomic abnormality $1716
Chest radiograph: If concern for pneumonia $231
Bone scan: In select cases with fever of unknown source to check for osteomyelitis $1512
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Fever (Case 8)

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