Lec .

45

Pediatrics

Dr. Hasanen
Fever of unknown origin

Lec. 4
18th April. 2017

Done by: Zainab Abdul Ghany.

2016-2017
‫مكتب آشور لالستنساخ‬
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Fever without a focus (Pediatric Mystery)
Introduction
 One of the most challenging problems a physician faces in practice is the evaluation of a
patient with prolonged pyrexia - a truly significant test of his clinical skills.
 “Humanity has three great enemies: Fever, famine and wars. Of these by far the greatest,
by far the most terrible is fever” - Sir William Osler (1849-1919).

DEFINITIONS
 Fever: A rectal temperature of ≥38 C. It fluctuates in degree and timing.
 FWLS (Fever without localising sign): Fever of acute onset, with duration of <1 wk and
without localizing signs.
 FUO (Fever of unknown origin): Fever documented by a health care provider and for which
the cause could not be identified after 3 wk of evaluation as an outpatient or after 1 wk of
evaluation in the hospital.

The commonest cause of PUO is:

A- A common disease presenting in an atypical way.
B- A rare disease presenting in atypical way.
C- A common disease presenting typically.
D- A rare disease presenting typically.

Continuous: Temperature remains above normal throughout

the day and does not fluctuate more than 1 °C in 24 hrs
Typhoid, lobar pneumonia,
Remittent: Temperature remains above normal throughout
the day and fluctuates more than 1 °C in 24 hours
SBE
Intermittent: The temperature elevation is present only for a
certain period, later cycling back to normal
Kala Azar
Undulant: fever is typically undulant, rising and falling like a
wave Brucellosis
Relapsing: multiple episodes of fever occur and each may
last up to 3 days. Individuals may be free of fever for up to 2
weeks before it returns. Tick borne

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• A 10 - year old female, presented to the outpatient clinic with a 4 - week history of fever
(38.3 C – 39.5 C) and easy fatigability. She underwent a good primary work up by the family
physician prior to referral with failure to reach a diagnosis. She is sitting now with her
worried parents in the desk next to you and ready to receive your questions and actions.
1- How you define this complaint in view of duration?
2- Put a differential diagnosis inside a general frame?
3- What shall you ask in the context of history?
4- What are the general and special sites you look for in physical examination?
5- Set a panel of investigations you are planning to perform?
6- Start a treatment plan?

CAUSES
1- Infections:
Bacterial
Systemic: Brucellosis, Salmonella, Tuberculosis
Localized infections: Osteomyelitis, Pneumonia and Sinusitis
Viruses: CMV, Hepatitis viruses ,HIV, IM (Epstein-Barr virus)
Parasitic Diseases: Malaria ,Toxoplasmosis
Fungal diseases

2- Rheumatologic diseases
JRA, Rheumatic fever, SLE and drug fever.

3- Neoplasms
Leukemia, Lymphoma, other malignancies.

4- Miscellaneous
Familial Mediterranean fever, Kawasaki disease.

5- Undiagnosed

Always look for

Abscesses: Abdominal, brain, dental, hepatic, pelvic, perinephric, rectal, subphrenic, psoas

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APPROACH
The Best Approach
“There is no substitute for observing the patient, talking to him and thinking about him”

HISTORY
Fever specifications, sweating, antipyretics use and response, appearance, other complaints
(CNS, urinary,,,,), pain (severity, site), rash and distribution, arthralgia / arthritis, travel, contact,
animals, medications, hospitalization, immunizations, ethnicity, exposure to contaminated
food or water.

CAREFUL PHYSICAL EXAMINATION

General appearance and vital signs (heart rate, pressure, respiratory, temperature), pallor,
jaundice, clubbing, skin and scalp, eyes, sinuses, oropharynx, LN, abdomen, musculoskeletal,
genitourinary.

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INVESTIGATIONS
Level 1:
CBC differentials, ESR, CRP, metabolic panel (RFT, LFT, elects), GUE, stool, C/S, LP,
CXR, US, TB, EBV, CMV, cultures.

Level 2:
Echo, CT, Bone scan, Serology, Autoimmune, Bone marrow.

Level 3:
Tissue biopsy, Endoscopy.

 Avoid indiscriminately ordering a large battery of tests.

Approach

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Treatment

In general,

NONE
Until diagnosis…

You should know that

1. Most children will get better
2. Most children have common illnesses
3. It hasn’t killed them yet! So do not rush to antibiotic treatment.

Admit
1- Reliability
2- Toxicity
3- Invasive investigations

Empirical therapy (little or no role in cases of classic fever of unknown origin) is indicated only
in:
1- Non-steroidal agents in presumed JIA
2- Anti-tuberculosis drugs in critically ill children with possible disseminated TB
3- Clinically deteriorating with suspicion of bacteremia or sepsis.
4- Immunocompromised
Antibiotics if used should be at targeted disease rather than blanket therapy with 4-5
antibiotics.

Take home message

 FUO is more likely to be an unusual presentation of a common disorder than a common
presentation of a rare disorder.
 Giving antibiotics to a child with FUO is like shooting a gun into dark room

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Hints
o As the duration of fever increases, infectious etiology decreases
o Malignancy and factitious fever should be considered with more prolonged fever
o The most critical features of the evaluation of a patient with FUO is to take a carefully
history and to reassess the patient frequently.
o The Best Approach is “there is no substitute for observing the patient, talking to him and
thinking about him”
o It is important to look for uncommon presentation of common disease and to perform a
detailed physical examination
o Clinically challenging - get expert help! Clinical balance between trial antimicrobial (often
anti tuberculosis regimen) or corticosteroid trial.
o Avoid indiscriminately ordering a large battery of tests.

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 THANK YOU
Edited by: Zainab Abdul Ghany