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CONFERENCE

Pediatrics department, Songkhla hospital

THIS CASE
Ceftriaxone 2 gm IV OD day2
Start > Doxycycline (100) ½ x2 po pc (5mkday) x5 day
Lab investigation > Leptospirosis IgM , Scrub typhus IgM ,Dengue NS1
Paracetamol (120 mg/5ml)
8 ml po prn q 6hr (10mkdose)
5%DN/3 1000 ml/hr IV rate 65 ml/hr (MT)
FEVER WITHOUT
SOURCE IN
CHILDREN
Definition of Acute febrile illness
◦ Fever without source
◦ Core temperature > or = 38 C
◦ Duration fever < 1 week
◦ Without specific signs and symptoms
Fever without source(FWS)
Self- limited Viral infection

UTI,bacterial enteritis

AOM, sinusitis, mastoiditis

Invasive: bacteremia,meningitis

Serious bacterial
infection Osteomyelitis

Localized infection
Occult pneumonia
History
◦ Fever : onset(abrupt, gradual), Continuous vs Remittent, Duration(<7 or >7 days), with chill ?
◦ Dehydration : last void, amount of milk/food, poor appetite
◦ Localizing symptoms : rash, drowsiness, URI, diarrhea, dysuria
◦ Immunization status : Hib, PCV
◦ Prior use of medication, previous treatment
◦ Underlying : asplenia, immunocompromised
◦ In neonate : Hx of perinatal >> maternal fever/ triple I
◦ Attend day care center
◦ Sick contact : family, school
◦ Consumption of raw/ uncooked meat, milk
◦ Travel history : Scrub typhus, murine typhus, malaria, contacts animal and insect exposure
 Physical examination
◦ GA : alert, drowsiness, irritable
◦ Vital sign, SpO2, Capillary refill, pulse full? >> evaluate sepsis
◦ All organ systems
◦ >> anterior fontanelle
◦ >> HEENT : conjunctivitis, conjunctival suffusion, petechiae, jaundice, pale, TM opacity?, Bulging ?, oropharynx,
signs of mastoiditis
◦ LN
◦ Respiratory systems
◦ GI : hepatosplenomegaly
◦ Umbilicus : in neonate
◦ Skin : rash, eschar, rose spot, erythroderma, flushing face, purpura
◦ Bone and joints
◦ Neuro signs
◦ Meningeal irritation
Fever without localizing signs Different
management strategies by age group
0-28 days

1-3 months

3-36 months

>= 3 yaers
Infants 0 to 28 days of age, Temp ≥ 38 C
◦ Limitation of Clinical Assessment >> Need for admit
◦ SBI: Bacteremia, UTI, meningitis, pneumonia or bone & joint
Management of Febrile Neonates
without source
◦ All febrile neonates (age < 1 m) with fever ≥ 38 oC without localizing signs should be
admit all cases
◦ Complete septic work up: CBC, H/C, U/A, U/C
◦ LP for CSF exam and C/S for bacteria
◦ Consider other tests: CSF PCR for HSV, Enterovirus, Blood PCR for HSV, LFT, CRP
Empirical ATB of Febrile Neonates
without Source

◦ Sepsis: Ampicillin + Gentamicin/Amikin (Early onset) or Cefotaxime + Amikin (Late

onset neonatal sepsis: Age >3days)
◦ Consider Acyclovir if suspect HSV : Seizure, EncephalitisHSV lesions in neonate (skin,
eye, mucous membrane), Maternal HSV, Should suspect HSV in case febrile neonate
with high ALT and non- response to appropriate ATB
Management of Febrile children age1-
3 months without source

ื้ ในเด็กแห่ง
CPG for Management of Pediatric Acute febrile illness 2019 สมาคมโรคติดเชอ
Management of Febrile children
age3-36 months without source

ื้ ในเด็กแห่ง
CPG for Management of Pediatric Acute febrile illness 2019 สมาคมโรคติดเชอ
Yale Observation scale

<10 non-toxic
>10 moderate
>16 severe
CHILDREN > 3 YEARS
WITH FEVER
WITHOUT SOURCE
Onset and pattern of fever

Abrupt onset Insidious onset

Continuous Remittent Continuous Remittent
Dengue Leptospirosis Typhus Typhoid
Chikungunya Influenza Malaria

Septicemia
Duration of fever
< or = 7 days > 7 days

Continuous Remittent Continuous Remittent

Dengue Typhus Typhoid
Chikungunya Influenza Septicemia Malaria
Leptospirosis
 Dengue Chikungunya Influenza Lepto Scrub Typhoid Malaria
typhus
Clues ไข้สง
ู ลอย Bilateral ไอ ปวด ั ัสน้ำ
สมผ ไปสุมทุมพุม่ ถ่าย มาจาก
หน้าแดง symmetrical เมือ่ ยตาม ท่วมข ัง, ไม้, เหลว(50% endemic area
จุดเลือด polyarthralgia ต ัว ไข้สง
ู ปวดน่อง, incubation 6- ), ท้องผูก, ในชว่ ง 2-8
ออก (distal joint), ผืน
่ ตาแดง,co
21 days,
ปวดท้อง, wk, ไข้สง ุ
Plasma myalgia, ่ ั ซดี
แดงทงต ั้ ัว njunctival ประว ัติกน
ิ หนาวสน
leakage,ต ั headache,
suffusion conjunctivitis อาหารที่ เหลือง ต ับ
บโตกด ปนเปื้ อน ม้ามโต
เจ็บมปวด
ท้อง
Flushed face +++ +++ ++ + +++ - -
Skin lesions Petechiae, MP rash(ค ัน)ทว่ ั - MP rash Eschar(20- Rose -
MP rash, ทงต ่ งทีไ่ ข้
ั้ ัวชว 90%) spot(<10
Convalescent
rash MP rash %)
LN enlarge ++ ++ ++ ++ +++ - -
 Dengue Chikungunya Influenza Lepto Scrub Typhoid Malaria
typhus
UA normal normal normal Proteinuria,p Normal normal normal or
yuria,with or urobilinogen
without
(rare
nephritis) positive
hematuria

hepatomegaly +++ ++ - ++ ++ ++ ++

splenomegaly +/- +/- - ++ ++ ++ ++

LFT AST>ALT AST,ALT rising ++ Jaundice(7 AST,ALT AST,ALT AST>ALT

2%) rising rising Hemolytic Jx
 Dengue Chikungunya Influenza Lepto Scrub Typhoid Malaria
typhus
WBC D1-2: normal WBC ไม่สงู มาก WBCไม่ WBCสูง(P 1st WBCไม่ Normal WBC
>D3:WBC สูงมาก สูงมาก or leukocytosis
<5000 แต่>5000(Lเด่น) MNเด่น)ห wk:ปกติ
L,Atypเด่น แต่>5000( รือปกติ (WBC>500 แต่>5000(
Lเด่น) 0) PMNเด่น)
2nd
wk:WBCสู
ง(PMNเด่น
)
Hct Hctสูง normal normal normal normal Abnormal Anemia
in 2nd wk (hemolysis)
Plt >D3 low 50000-150000 Normal/ Normal/ Normal/ Low in 2nd low
low low low wk
Treatment supportive supportive Oseltamivir Doxycycline/
Ceftriaxone
Doxycycline/ Ciproflox/ Antimalarial
Azithromycin Ceftriaxone
drugs
SCRUB TYPHUS
Family Rickettsiaceae

◦ Genus Orientia >> Orientia tsutsugamushi ; scrub typhus

◦ GenusRickettsia >> Rickettsia typhi ; murine typhus Rickettsia prowazekii ; epidemic

typhus
Scrub typhus
◦ O. tsutsugamushi ; bite of the larval stage of infected trombiculid mites
◦ Male : Female = 3 : 1
◦ Incubation period; 1-3 weeks (common 10-12 days)
◦ Endemic in SEA, Northern Australia and Western Pacific Islands
◦ Mainly in rural agricultural areas > urban areas
◦ Common serotypes; Karp, Kato, Gilliam
◦ Overall mortality rates 2.6-15%
Clinical manifestations
◦ Non-specific symptoms : Acute fever, headache, myalgia

◦ Physical examinations : Maculopapular rash (5th day after fever), splenomegaly,

conjunctival sufusion(may be up to 70%), generalized lymphadenopathy, Pulmonary
involvement ; 50% (rare ARDS), Eschar (20-90%)
Study in Songkhla
province
Investigations
◦ CBC : Leukopenia or mild leukocytosis, Thrombocytopenia
◦ LFT : Transaminitis (common 90%)
◦ UA : normal (rare Nephritis)
 Gold standard for diagnosis of scrub
typhus [WHO 1999]
◦ Eschar
◦ Single serum : IFA for Scrub typhus
◦ IgM > 1:400 IgG > 1:1600
◦ Serology – IFA titre > 1:400 (Sensitivity 48% Specificity 96%)
◦ Serology – IFA titre > 1:200 (Sensitivity 70% Specificity 92%)
◦ Serology – IFA titre > 1:100 (Sensitivity 84% Specificity 78%)
◦ A four fold increase to a titer of > 1:200 is 98% specific and 54% sensitivity
Treatment
◦ Oral, IV : children ≤8 year: 2.2 mg/kg q 12 hr for 5-7 days
◦ Oral, IV : children >8 year (and weight > 45 kg) ,Adults : 100 mg po bid
for 5-7 days
◦ Doxycycline shortens the course of disease, and symptoms typically
resolve within 12 to 48 hours after initiation of therapy. Chloramphenicol
is an alternative drug but carries a risk of serious adverse events
LEPTOSPIROSIS
ORGANISM AND TRANSMISSION
Leptospirosis is a disease that is caused by spirochete bacteria in the genus Leptospira.
CLINICAL FEATURES
Syndrome,stage Clinical findings Specimen positive
Anicteric leptospirosis(85-
90%
1. Septicemic stage Fever,headache,myalgia,abdo Blood and CSF
minal
pain,nausea,vomitting,rash,c
onjunctiva
Suffusion
2. Immune stage Milder Urine
fever,headache,vomitting,ase
ptic meningitis
Icteric leptospirosis
Septicemic and immune stage Jaundice,hepatomagaly,renal Blood(1st wk)
(Weil’s syndrome) failure,hypotension,hemorrh CSF(1st wk)
age,ARDS,CHF Urine(2bd wk)
Confirmatory Diagnostic Tests

1. Microscopic agglutination test (MAT)

2. Immunofluorescent assay (IFA)
3. Latex agglutination (LA)
4. Enzyme linked immunosorbent assay (ELISA)
TREATMENT
1.Supportive and symptomatic treatment
2.ATB
Mild form >> Doxycycline, Amoxicillin, Azithromycin
Moderate to severe form >> Ceftriaxone, Doxycycline, PGS
TYPHOID FEVER
CLINICAL FEATURES

The organism classically responsible for the enteric fever syndrome is

Salmonella enterica serotype Typhi (formerly S. typhi). Other Salmonella
serotypes, particularly S. enterica serotypes Paratyphi A, B, or C.
Intubation period : 10-20 days
Transmission : Fecal-oral route
INVESTIGATION
1. CBC : normochromic normocytic anemia, Leukocytosis/Leukopenia,
Thrombocytopenia
2. UA : Proteinuria
3. Liver Function test : Transaminitis
4. Confirm test
4.1 Culture : Blood / Stool
4.2 Serology : ELISA
TREATMENT
◦ Ciprofloxacin 30 MKD bid for 7-10 days
◦ Ceftriaxone 50-100 MKD bid for 7-10 days
REFERENCE
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