puo

APPROACH TO A CHILD WITH FEVER OF UNKNOWN ORIGIN

BY DR MANDAR HAVALDCH.DNB

BEST DEFINED ASFEVER WITHOUT OBVIOUS

SOURCE ON CLINICAL EXAMINATION

ORAL

RECTAL

FEVERTEMPERATURE >38 .0 degree C (>100.4 degree F)

RECTAL TEMPRATURE

ORAL – 0.6 C LESS

AXILLARY IS 1.1 C LESS

What is a PUO?1956 Age > 14

T > 37.4°C x3 or 38°C x1 Fever - predominant symptomInsufficient symptoms / signs to localise

1961 Days > 21, T > 38.3°C1/52 hospital investigation

1968 Days > 14No clear diagnosis

Reid

Petersdorf & Beeson

Dechovitz & Moffet

What is a PUO now?

Now+

2 hospital visits, orHospital investigations for 3 days

Neutropenic PUO

Neutrophils < 1.0Diagnosis not clear at 3 days

Nosocomial PUO

Admission infection screen negativeDiagnosis not clear at 3 days

HIV PUO HIV infected, fever for 4 weeksDiagnosis not clear after 3 days

TYPES OF PUOACUTE ONSET (<7 DAYS)

PROLONG (> 7 to 10 DAYS)

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.

The answer is ..A..The commonest cause of PUO IS …Common disease presenting ATYPICALLY

ETILOGYINFECTION CONTRIBUTE TO 40

TO 50% OF FUO

COLLAGEN VASCULAR DISEASE 15-20%

MALIGNANCY 5-10%

Causes of PUOBacteria Tuberculosis, Salmonellosis, Brucellosis,

Mycoplasma, Campylobacter

Viruses Cytomegalovirus, Hepatitis, Infectious Mononucleosis, HIV

Parasitic Disease

Amebiasis, Toxoplasmosis, Malaria, Visceral Larva Migrans

Spirochetes Leptospirosis, Lyme Disease, Relapsing Fever, SyphilisChlamydia Lymphogranuloma VenereumLocalised Infections

Abscess, Endocarditis, Pyelonephritis, Sinusitis

Causes of PUO – Contd..Connective Tissue Disorders

Juvenile Rheumatoid Arthritis, Rheumatic fever, Systemic lupus erythematosus, Polyarteritis Nodosa, Hypersensitivity Pneumonia

Malignancies Hodgkin disease, Leukemia, Neuroblastoma, Wilms tumor

Granulomatous Disease

Crohn’s Disease, Sarcoidosis

Hypersensitivity Disease

Drug fever, Hypersensitivity PneumonitisPancreatitis

Miscellaneous Causes Kawasaki Disease, Pulmonary Embolism, Thyrotoxicosis, Diabetes Insipidus, Factitious fever

AGE GROUPNEONATE ( 0-28 days)

YOUNG INFANT ( 1-3 months)

OLDER INFANT TO TODDLER (3 month To 36 month)

NEONATEALL TOXIC – APPEARING INFANTS

AND ALL FEBRILE INFANTS LESS THAN 28 DAYS SHOULD BE HOSPITALIZED FOR EVALUATION AND INITIATION OF PROMPT PARENTAL ANTIBIOTIC THERAPY AFTER SENDING BLOOD CULTURE

FLOW CHART AGE<28 days ORCLINICALLY TOXIC CHILD

YES NOINVESTIGATIONINCLUDE LPIV ANTIBIOTICSHOSPITALIZATION

INVESTIGATECONSIDER LP

NORMAL LABAND X RAY

REACESS 24 HRS LATER CLINICALLY

ABNORMAL LABSOR CXR

IV ANTIBIOTICS HOSPITALIZATION

WHY NEONATE ARE AT HIGH RISKHIGH RISK OF DEVELOPING SBI

MAINLY BACTERIAL ( GRAM NEGATIVE)

WHICH NEONATE ARE TOXIC

Fever in young infants (1-3 months)Low riskWell appearingWBC count 5000-

15000/cmmBand : Neutrophil

≤0.2Centrifuged urine

<10 WBC/HPFNo bacteria on Gram

stain-urineCSF <8 WBC/cmm

High riskIll lookingWBC count <5000

or >15000/cmmBand : Neutrophil

>0.2Centrifuged urine

>10 WBC/HPFBacteria + on gram

stain- urineCSF >8 WBC/cmm

Risk for SBI

TAKE HOME MESSAGEANY NEONATE LESS THAN 28

DAYS HAS TO BE REFERRED OR ADMITTED

AGE 28 DAYS TO 60 DAYS 5 – 10% INCEDENCE OF HIGH

RISK INFECTION

UNFORTUNATE ABOUT FEVER IN THESE AGE GROUP

ROCHESTER CRITERIA

APPROACHTOXIC OR NON TOXIC

NO YES

(EXAMINATIONINVESTIGATION)

REPEATED EVALUATION ADMIT OR

REFERRED

INVESTIGATIONPERIPHERAL BLOOD COUNTCRPURINE ANALYSISBLOOD CULTUREURINE ANALYSIS/CULTURECHEST X RAYCSF

AGE 3MONTHS TO 36 MONTHSIN THIS SUB GROUP

TEMPERATURE MORE THAN 39 degree C IS DEFINED AS FEVER

TEMP > 39 C

YES NO

TOXIC

YES

NO

ADMITINVESTIGATIONPARENTAL ANTI.

INVESTIGATEWITH

TC, DCURINE XRAY

OCCULT UTI

OCCULT BACTEREMIA

PNEUMONIA

LAB CRITERIATLC (5 – 15000)

ABSOLUTE BAND CELL COUNT (<1500/mm)

<10 WBC PER HIGH POWER FIELD IN SPUN URINE SEDIMENT

<5 WBC PER HIGH POWER FIELD IN STOOL SAMPLE

LP – PRESENCE OF WBC IN CSF/ GRAM STAINING

2 D ECHO – HELPS IN DIAGNOSING IE, MYOCARDITIS

CT SCAN / MRI

Management of Fever – Contd..Oral antipyretics – Well tolerated , effectiveParenteral antipyretics not indicatedRectal suppositories – In intractable vomiting ,

post-operative state Inform parents that antipyretics do not cure

Fever may persist despite antipyretics , especially in first 2-3 days of even in self-limiting viral infection

ANTIBIOTIC PREFFERED LESS THAN 3 MONTHS

AMPICILLIN + GENTAMYCIN

CIFTRIAXONE

CEFOTAXIME

MORE THAN 3 MONTHCIFTRIAXONE

CEFUROXIME

TAKE HOME MSG..ALL FEBRILE INFANTS WHO ARE LESS

THAN 36 months WHO HAVE TOXIC MANIFESTATION HAS TO BE REFERRED

LESS THAN 28 DAYS HAS TO BE REFERRED FOR PARENTRAL ANTIBIOTIC

NO LAB TEST OR ANTIBIOTIC ARE NEEDED IN CHILD OVER 3 MONTHS WHO HAS TEMP LESS THAN 39 C.

QUESTIONS?

THANK YOU