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Case 1030: The Febrile child
Authors and Affiliations
Anthony Trimboli MBBS
University of Notre Dame Australia
A/Professor Joe McGirr
Associate Dean
Rural School of Medicine
Wagga Wagga
Case Overview
Fever in a child can be a diagnostic challenge for the emergency doctor as the source can be difficult to
identify.
Learning Objectives
With regards to the paediatric population, the graduating student should know and understand:
the
possible causes of fever
the
most important sources of fever
how
to appropriately investigate the source of fever
the
common presentation of urinary tract infections
the
appropriate management of the febrile child, in particular, urinary tract infections
Question 1 : MS
Question Information:
It is 11pm, you are the intern in a regional hospital in New South wales and it is your first overnight shift
in the emergency department. You are asked to see Jack, a 9 month old boy with his very concerned
mother. Jack has had a fever †œhigher than 38†• for 2 days and is not acting like himself. He is off
his food, is irritable and is not interested in playing with his toys. He has been a previously well child,
developing appropriately, is fully immunised and there are no sick contacts at home. Before you begin
your assessment, you try to think of the signs of symptoms that are considered high risk of a serious
illness.
Question:
Which of the following signs or symptoms are considered to be high risk of a serious illness?
Choice 1: Respiratory rate > 60 per minute Score : 2
Choice Feedback:
Correct, this is a high risk sign for serious illness.
An increased respiratory rate with increased work of breathing are positive signs for a serious illness.
Choice 2: Reduced urine output Score : 1
Choice Feedback:
Partially correct, this is an intermediate sign of risk for serious illness.
Choice 3: Grunting Score : 2
Choice Feedback:
Correct, this is a high risk sign of serious illness
.
Choice 4: No response to social cues Score : 2
Choice Feedback:
C
orrect, this is a high risk sign for serious illness.
Choice 5: Pale/mottled skin Score : 2
Choice Feedback:
Correct, this is a high risk sign for serious illness.
Choice 6: Increased screaming Score : -1
Choice Feedback:
Incorrect. This is not a sign of a serious illness but rather of a child who is slightly distressed.
Choice 7: Decreased activity Score : 1
Choice Feedback:
Partially
correct, this is an intermediate sign for serious illness.
Choice 8: Poor feeding Score : 1
Choice Feedback:
Partially correct, this is an intermediate sign for serious illness.
Choice 9: Rash Score : 0
Choice Feedback:
If this is a non-blanching rash then it is not a serious symptom. However, caution should be exercised
for a purpuric rash.
Question 2 : FT
Question Information:
After taking a further history and performing a clinical examination, you find out more information. Jack
felt warm two days ago, his temperature was recorded (by axillary thermometer) as 38.1 0C and has
remained elevated. He has no coryzal symptoms, cough, vomiting or diarrhoea. He is eating half of
what he usually does, is not sleeping well, and is generally restless and is crying constantly. He has not
had as many wet nappies as usual.
He has no sick contacts, no recent travel, and has had an unremarkable past medical history, except for
an episode of bronchiolitis at 4 months for which he was hospitalised for a night. He is on no
medications, and has no allergies.
On examination Jack looks unwell. He is lethargic with a lack of interest in his environment. His capillary
refill is 4 seconds, has dry mucous membranes, but feels warm to touch. He has no rash, neck
stiffness, increased work of breathing, swelling of joints, or bulging fontanelles. Tympanic membranes
are normal. Heart sounds are dual with no murmur, chest is clear to auscultation.
Vitals:
Blood
pressure - 70mmHg systolic
Respiratory
Heart
rate †“ 45/min
rate †“ 160/min
Temperature
Oxygen
†“ 38.50C
saturations †“ 98% on room air
After your examination, Jack†™s mother informs you that she is very concerned that he might have
†˜ meningococcal†™. After considering your findings, you tell the mum that it is very unlikely that
Jack has meningococcal infection.
Question:
Describe the classic signs and symptoms of meningococcal disease that need to be recognised early.
Choice 1: null Score : 0
Choice Feedback:
Meningococcal disease needs to be considered in any child with a fever and non-blanching rash,
especially if any of the following features are present:
An
ill looking child (hypotensive, shock-like symptoms)
Lesions
greater than 2mm in diameter (purpura)
Capillary
Neck
refill of greater than 3 seconds
stiffness
Bulging
fontanelle
(NICE guidelines 2013 feverish child)
Question 3 : MS
Question Information:
You are concerned about Jack. From your assessment, you have placed him into the moderate to high
risk category. You then consider ordering some investigations to help you try and establish the cause of
his fever.
Question:
Which of the following investigations should be ordered?
Choice 1: Full blood count Score : 2
Choice Feedback:
Correct. This is considered a first line investigation.
Choice 2: Blood culture
Score : 2
Choice Feedback:
Looking for a bacteraemia is an important investigation for a febrile child. Must be conducted prior to
starting antibiotics.
Choice 3: Chest X-ray
Score : -1
Choice Feedback:
A chest X-ray is not indicated in this patient. There are no focal respiratory signs, and due to the
radiation exposure, it is currently not required. If a source of infection cannot be found with the initial
examinations, a chest X-ray would be considered
Choice 4: Urinalysis Score : 2
Choice Feedback:
Urine infections are common in paediatric patients. This is an important investigation to help determine
the source of a febrile child. This is compulsory if no obvious focus of infection is found.
Choice 5: Nasopharyngeal aspirate Score : -1
Choice Feedback:
There is no indication for a nasopharyngeal aspirate as there are not any signs of an upper respiratory
tract infection.
Choice 6: Abdominal ultrasound
Score : -1
Choice Feedback:
Incorrect. There is no indication for abdominal ultrasonography at this stage of investigations.
Choice 7: Lumbar puncture
Score : 1
Choice Feedback:
Although a difficult investigation to perform, this child has signs of high risk disease. It would be prudent
to perform a lumbar puncture in order to help rule out serious conditions such as meningitis. It should
be considered but may be difficult to perform in a 9 month old child. It is essential in a patient less than
3 months of age.
Choice 8: Stool culture Score : -1
Choice Feedback:
The child has no history of diarrhoea, so it is not necessary to perform a stool culture.
Choice 9: CRP/ESR Score : 1
Choice Feedback:
A rise in the acute phase reactants may help your diagnosis.
Choice 10: CT head Score : -1
Choice Feedback:
Incorrect. There is no indication for conducting a CT and unnecessarily exposing the patient to
radiation.
Question 4 : FT
Question Information:
You realise that Jack is quite unwell and you will need to call the consultant for advice. You decide to
order the following tests before calling the consultant to help clarify your thoughts.
Full
blood count
Urinalysis
Urine
and blood cultures
After 10 minutes of waiting for a clean catch urine, Jack is not being very helpful, and you decide that
you will have to use another means of collecting the urine.
Question:
Other than a clean catch urine, describe the other means of collecting a urine sample for urinalysis.
Choice 1: null Score : 0
Choice Feedback:

Suprapubic aspirate (gold standard - SPA) †“ this involves inserting a catheter in the midline, lower
abdominal crease, under the guidance of ultrasound to help visualise the bladder. Insert the needle and
aspirate, placing the urine in a sterile jar.

Bag collection †“ after the skin has been cleaned, a bag is applied and secured to the perineum
securely. The bag should be removed as soon as urine and passed, and the specimen collected from
the base of the bag. Although less invasive than other means, there is a greater chance of a
contaminated sample.

In-out catheter †“ useful if SPA fails. This involves placing a catheter in the urethra, allowing urine to
pass, and then removing the catheter.
Question 5 : FT
Question Information:
The results of the investigations return;
Full
Hb
Hct
blood count:
†“ 140
†“ 0.51
MCV
†“ 80
Leucocytes
†“ 11 x 109
Neutrophils
†“ 4.0 x 109
Urinalysis
WBC
†˜ s: ++
RBCâ€
™s: +
Nitrites
++
Electrolytes
unremarkable
Urine and blood cultures - pending
You are still unsure if you need to perform a lumbar puncture to rule out infection of the CNS and you
will check when you call the consultant. Since admission, Jack's condition has changed and he now has
a tachycardia and tachypnoea. You check your watch, it's 12.30 am. You gather your thoughts, and
prepare what you will say to the consultant when you call.
Question:
Considering all of the information you now have regarding Jack, what would you say when calling the
consultant, using the ISBAR format as a guide.
Choice 1: null Score : 0
Choice Feedback:
The ISBAR for clinical handover might go something as follows:
Introduction:
Hi
Dr Jones, its Dr John Smith, the intern working in the ED tonight, sorry to bother you at this time of
night, do you have a moment to discuss a patient?
Situation:
I
have a 9 month old boy, with a suspected urinary tract infection who doesn†™t look well at all.
Background:
He
has been brought in by his parents with no significant past history of note, other than an
admission for bronchiolitis at 4 months of age for one night.
Assessment:
His
mother reports he has been febrile for 3 days. On examination he is lethargic, irritable and looks
dehydrated. He currently has a temperature of 38.5 and is tachycardic and tachypnoeic. His urinalysis
is positive for white blood cells and nitrates, consistent with a UTI. I†™ve started some fluids and have
him on oxygen.
Recommendation:
Would
you like me to perform a lumbar puncture? Or start empirical antibiotics?
Question 6 : MS
Question Information:
You are relieved that the consultant does not being woken and relieved that the call goes smoothly particularly as you are able to provide a brief and succinct account. The consultant is glad that you
called and agrees that the diagnosis is likely that of a urinary tract infection (UTI). However, considering
how unwell the child sounds, she will come to the hospital and perform a lumbar puncture as having a
UTI does not necessarily rule out meningitis.
Within 10 minutes, the consultant arrives and performs a lumbar puncture. The CSF looks clear and
nothing is seen on the immediate Gram stain. The fluid is sent off for biochemistry and culture. The
consultant is satisfied with a UTI being the most likely diagnosis and instructs you to continue with fluids
and oxygen, begin empirical antibiotics and admit the child for monitoring, and then leaves the room as
quickly as she came.
In considering which antibiotics to give, you think about which pathogens are most likely to cause a UTI
in children.
Question:
Which of the following are the four most common pathogens that cause urinary tract infections in the
paediatric population?
Choice 1: Campylobacter jejuni Score : -1
Choice Feedback:
Incorrect. This is more often associated with gastroenteritis.
Choice 2: Escherichia coli Score : 1
Choice Feedback:
Correct. This is the commonest organism causing UTI†™s in the paediatric population, responsible for
approximately 85% of all UTI†™s.
Choice 3: Citrobacter Score : -1
Choice Feedback:
Incorrect. Although a gram negative bacterium that is responsible for UTI†™s, it is not one of the
commonest. Citrobacter are responsible for
Choice 4: Klebsiella spp Score : 1
Choice Feedback:
Correct. Klebsiella spp. are responsible for approximately 2-3% of UTI†™s in children.
Choice 5: Streptococcus pneumoniae.
Score : -1
Choice Feedback:
Incorrect. Strep pneumonia is a gram positive bacterium that is often associated with pneumonia.
Choice 6: Neisseria meningitides Score : -1
Choice Feedback:
Incorrect. Neisseria is not usually associated with UTI†™s. It can cause meningoccal disease such as
meningococcemia that can cause sepsis, or meningitis.
Choice 7: Proteus spp Score : 1
Choice Feedback:
Correct. Proteus spp make up approximately 3-5% of UTI†™s in the paediatric population. It is the
second most common pathogen associated with UTI†™s.
Choice 8: Enterococcus spp Score : 1
Choice Feedback:
Correct. Enterococcus account for 3-5% of UTI's in the paediatric population.
Choice 9: Staph epidermidis Score : -1
Choice Feedback:
Incorrect. Staph epidermidis is a common contaminant from the skin.
Choice 10: Candida albicans Score : -1
Choice Feedback:
Incorrect. This is not a source of infection for a UTI.
Question 7 : SC
Question Information:
You begin to administer empirical antibiotics for Jack on the basis that he has a serious urinary tract
infection.
Question:
Which one of the following is the most appropriate emipirical antibiotic regimen?
Choice 1: Amoxycillin only Score : 0
Choice Feedback:
Incorrect.
Choice 2: Vancomyocin and gentamicin Score : 0
Choice Feedback:
Incorrect.
Choice 3: Benzylpenicillin only Score : 0
Choice Feedback:
iIcorrect.
Choice 4: Benzylpenicillin and gentamicin Score : 1
Choice Feedback:
Correct.
Choice 5: Vancomyocin only Score : 0
Choice Feedback:
Incorrect.
Synopsis
Feverish illness is common in children, with between 20-40% of parents reporting their child having at
least one event per year. (1) It is often difficult to identify a source, much to the worry of the parents.
Most commonly, the illness is due to a self limiting viral infection, but as fever is a common presenting
symptom of serious bacterial infections such as pneumonia or meningitis, the importance of determining
the source cannot be overstated. The most common sources of a fever in a child include;
Upper
respiratory viral infections
Gastroenteritis
Urinary
Fever
tract infections
of unknown origin
The most concerning and threatening to life include;
Meningococcal
disease
Meningitis
Encephalitis
Pneumonia
Septicaemia
Osteomyelitis
Urinary
tract infection
Kawasaki
disease
Like many conditions, prompt diagnosis and management of the condition will result in the most
favourable outcomes. This is particularly important in the paediatric population, due to the rapid pace in
which they can deteriorate.
The investigation for the source of infection can often be difficult, and frustrating to the doctor, child and
parents alike. As always, the history and examination are the essential first step in the management. It
is important to note that various methods of temperature assessment can yield differing results. For
infants less than 4 weeks old, body temperature should be measured with an electronic thermometer in
the axilla. For children aged 4 weeks to 5 years, either of the following devices can be used;
Electronic
Chemical
Infra-red
thermometer in the axilla
dot thermometer in the axilla
tympanic thermometer
When determining the source of the fever, your investigations are guided by various factors elucidated
by your history and examination.
As a guide, the following investigations should be ordered as a minimum, and others added depending
on the clinical picture:
Full
blood count
Blood
culture
Urine
culture/urinalysis
Electrolytes
Lumbar
+
puncture
or †“ chest x-ray, liver function tests, stool culture, naso-pharyngeal aspirate
Urinary tract infections are a common source of fever in children. The incidence varies with age and
gender. Up to 10% of girls will have a UTI by adulthood, with few of these cases occurring before the
age of 2. Boys have UTI†™s much less frequently, with only 2-3 % being diagnosed in childhood, with
the majority of these occurring before 2 years of age.
Risk factors for UTI†™s in children include previous UTI†™s, recurrent fever of unknown origin,
anomalies of the urinary tract, voiding dysfunction, kidney stones, urinary catheterisation and family
history of UTI and VUR [3]. Once a child has a UTI, it is likely that they will have another, with
recurrence rates being around the 15-40% mark. The factors that increase this risk include; first UTI at
a young age, urinary tract anomalies ie vesicoureteric reflux and voiding dysfunction. [3]. Up to 80% of
UTI†™s are caused by E.coli, with other, mostly gram negative pathogens such as proteus spp,
klebsiella, enteroccoi, citrobacter and pseudomonas spp contributing to the remaining 20%.
Presentation ranges from mild irritative urinary symptoms, to very unwell children. If the child has a
febrile urinary tract infection, a renal ultrasound should be considered if the infection appears to be
more severe, or is atypical. This is done to identify structural abnormalities leading to obstruction, for
example, vesico ureteric reflux. A DMSA scan (radionucleotide, dimercaptosuccinic acid) can also be
performed to assess renal morphology, if other renal pathology such as acute pyeolonephritis or renal
masses are suspected.
References:
NICE
guidelines. Urinary tract infection in children. Diagnosis, treatment and long term management.
2007
NICE
guidelines Feverish illness in children. Assessment and initial management in children younger
than 5 years. 2013.
The
Royal Children†™s Hospital Urinary Tract infection Guideline. 2011.
Kennedy
S. UTI in children †“ part 1. How to treat. Australian Doctor 2009