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Download Fevers and chills in childhood - Medicine is an art
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Dr. Osama Kentab, MD, FAAP, FACEP Assistant Professor of Paediatrics and emergency Medicine King Saud Bin Abdulaziz university for Health sciences Riyadh Epidemiology Very common sign and symptom of illness in childhood May be indicative of an infection that is local or systemic; benign or invasive & life threatening Normal body physiological reaction to pyrogen ( infective, inflammatory) Implications of body temperature Is it beneficial? Rate of bacteraemia is 2-3% in all febrile infants < 2months (Baker 1999; Kadesh et al 1998) Infants < 2 months differ are less immunocompetent unique group of bacteria (GBS, Gram. Neg bacteria & listeria) Young infants show relative inability to demonstrate clinical evidence of illness Assessment: Relevant history Duration of fever Pattern of fever: intermittent or continuous Hx of contact: family members, friends, school mates Hx travel abroad: country visited Malaria endemic regions, enteric fever (Africa, Asia) Travel immunization, malaria prophylaxis Travel to mountainous region, camping in forest (Rickettsial infection, Lyme disease) Hx of Immunization Relevant symptoms Systemic symptoms: Resp, ENT, Renal, GI Rash: Pattern/type (macular, papular, ulcerative, erythematous, blanching) Distribution (mucosal involvement-conjuctivitis, mucositis, buttocks and extremities(HSP) Oral ulcers (aphthous, herpes gingivostomatitis) Relevant clinical signs Unwell – Toxic Haemodynamic instability Rash Lower Respiratory signs Joint involvement: Arthritis/ Athralgia: Reactive viral arthritis, Septic arthritis, HSP, Rheumatic fever, Chronic arthritis of childhood Organomegaly: Hepatomegaly, Splenomegaly, +/Anaemia: Systemic illness, Septicaemia, Lymphoproliferative disorders Causes of febrile illnesses in childhood Common causes URTI (viral or bact.) LRTI Gastroenteritis UTI Oral (dental abscess, hyperangina, herpetic gingivitis, mumps) MSS (septic arthritis, osteomyelitis, cellulitis Serious causes URTI (epiglottitis, croup, retropharyngeal abscess) LRTI GI (appendicitis) CNS (Meningitis, encephalitis) Systemic (meningococcaemia, toxic shock syndrome Management of fever in young children Protocols for Identification of Low Risk Infants Rochester 1985-1988 Boston 1992 Philadelphia 1993-1999 Pittsburgh 1999-2000 28-89 29-56 0-60 - No known immundef. Rochester 38.0 38.0 38.0 Yes Yes no <20,000 <15,000 <5>15 <1.5x10/L <0.2 BNR no Yes Yes <8 wbc Yes 5 10WBC/hpf - 10WBC/hpf EUA 9 5 wbc/hpf - - <5 - - Yes Neg if sx Age(days) 0-60 Past health >37 wk,home with or before mom,no susequent hosp,no prenatal, post,or current ATB,no treatment for unexplained hyperbole,no chronic diseases Temp C Infant Obs.score WBC Bands/BNR LP urine Stool(if diarrhea) CXR 38.0 no 5-15,000 No ATB(Ceftrx) No Yes No 34.7%?? SBI in low risk Pts (%) 1.1 5.4 0 0 NPV(%) 98.9 94.6 100 100 Sens (%) 92.4 Not stated 100 100 8 Age < 29 days CBCD,glucose,BUN,Creat,lytes, +/- cap.gasses Blood culture Urine cath (microscopy and culture) LP (if infant unstable defer) CXR (suspected respiratory disease) NPW (suspected viral respiratory disease) Stool for WBC, culture and heme test (suspected eneteric infection) Management of fever in young children 9 Age < 29 days Cont’d Supportive care Antibiotics: Ampicillin AND Gentamycin OR Ceftriaxone/Cefotaxime Consider Acyclovir Admit Management of fever in young children 10 29 to 60 days CBCD, BNR Blood culture LP (if infant unstable defer) Urine cath (microscopy and culture) CXR (suspected respiratory disease) Stool for WBC, heme test and culture (suspected enteric infection) Management of fever in young children 11 29-60 days Low risk Past history Born >37 wks Home with or before the mother No subsequent admission No prenatal,postnatal,or current antibiotics No treatment for unexplained hyperbilirubinemia No known immune deficiency Management of fever in young children 12 29-60 days Low risk P/E Appears generally well (non-toxic) No evidence of skin,soft tissue,bone, joint,or ear infection Management of fever in young children 13 29-60 days Low risk Laboratory WBC >5k <15k ANC <10K or band/neutrophil ratio < 0.2 Urine <10 WBC/hpf, spun and negative Gram stain CSF: Non-bloody ,< 8 WBC , normal glucose, protein, negative Gram stain and latex agg.test Normal CXR (if it was done) Stool (if diarrhea) <5 wbc/hpf Management of fever in young children 14 29-60 days Low Risk Option I No antibiotics Admit for observation OR Re-evaluate in 24 & 48 hours Discharge only if: Reliable caregiver Has nearby telephone Adequate transportation Management of fever in young children Option II Ceftriaxone 50 mg/kg IV or IM Re-evaluate in 24 hours and 48 hours Optional second dose of ceftriaxone at second visit 15 61-90 days Low Risk Option I No LP No antibiotics Admit for observation OR Re-evaluate in 24 hours Discharge only if: Reliable caregiver Has nearby telephone Adequate transportation Management of fever in young children Option II LP & if normal: Ceftriaxone 50 mg/kg (IV or IM) OR NO antibiotics Admit for observation. OR Re-evaluate in 24 hours 16 29-90 days High risk Toxic Positive labs Concerning history /social factors Admit Supportive care Meningitis Ceftriaxone and Vancomycin Non-meningitis Ampicillin and Ceftriaxone OR Gentamycin Management of fever in young children 17 3-36 months Toxic looking Fever, meningeal signs, lethargic, limb, mottled Admit, septic work-up, parenteral antibiotics Focal bacterial infection OM, pharyngitis, sinusitis, etc (excluding SBI). Oral/parenteral antibiotics, outpatient care Well looking Risk for occult bacteremia and serious bacterial infection Previous decision analysis( Pre-H. flu immunization) Current decision analysis Management of fever in young children 18 3-36 months High risk/toxic Admit Supportive care Septic work-up IV antibiotics Meningitis---->Vanco + Ceftriaxone Non-meningitis ----> Ceftriaxone Management of fever in young children 19 3-36 months Non-toxic If <3 yrs,temp >39 : Obtain CBC,Blood culture,Urinalysis & culture Stool culture,CXR as indicated If WBC>15k --->Empiric antibiotics (Ceftriaxone,Clavulin,Biaxin, omnicef or Suprax ) If urine is positive treat as UTI If WBC normal ,urine is negative no therapy needed Management of fever in young children 20 3-36 months Cont’d IF Temp < 39, Non-toxic, No focus of infection NO INVESTIGATIONS ARE REQUIRED Follow up all in 24 hours Management of fever in young children 21 Management of fever in children with underlying illness Management of fever in young children 22 Oncology patients At risk of overwhelming sepsis CBC, CXR, blood culture, urine culture, and LP when clinically indicated Neutropenic patients at risk for Pseudomonas and other gram negative Broad spectrum antibiotics Management of fever in young children 23 Acquired Immunodeficiency Syndrome Repeated risk of infection with common bacterial pathogens, risk of Pneumocytsis carinii, mycobacterial infections, cryptococcosis, CMV, Ebstein-Barr virus. Low CD4; septic work up and broad spectrum antibiotic Management of fever in young children 24 Sickle Cell Anemia Functional asplenia susceptible to overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu Parvovirus can cause aplastic crisis Osteomyelitis should be suspected in fever and bone pain CBC, retics,blood culture, stool culture, and urine culture recommended Ceftriaxone Hospitalization recommended Management of fever in young children 25 Congenital Heart Diseases Children with valvular heart disease are at risk for endocarditis Fever without obvious source with a new or changing murmur; hospitalization, serial blood cultures, echo, antibiotics against: S.viridans, S aureus, S. fecalis, S. pneumo, enterococci, H. flu, and other gram neg rods Suggested antibiotics include Vancomycin and Gentamycin until cultures are known Management of fever in young children 26 Ventriculoperitoneal shunts Must be evaluated for shunt infection esp if patient displays headache, stiff neck, vomiting, or irritability Shunt reservoir should be aspirated and examined for pleocytosis and bacteria Most common pathogen is S. epidermidis CT head also warranted Management of fever in young children 27 Febrile Seizures 455 children with simple febrile seizure -1.3% with bacteremia -5.9% UTI - 12.5% with abnormal chest x-ray -Normal CSF in all who had an LP (135) Trainor J, et al: Clin Pediatr Emerg Med 1999 Management of fever in young children 28 Febrile Seizures 486 children with bacterial meningitis -complex seizures present in 79% -93% of those with seizures were obtunded -of the few with “normal” LOC, 78% had nuchal rigidity Green SM, et al: Pediatrics 1993 Management of fever in young children 29 Febrile Seizures Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile seizures LP strongly considered in the first seizure in infants less than 12 month because signs and symptoms of meningitis may be absent in this age group 12-18 months LP should be considered because sign of meningitis may be subtle in this age group 18+ months LP only if signs and symptoms of meningitis (Peditrics 1999) Management of fever in young children 30 Febrile Seizures Routine lab (CBC, lytes, Ca, phos, Mg, or glucose) should not be performed in simple febrile seizure Neuro-imaging should not be performed routinely on simple febrile seizure EEG is not performed in a neurologically healthy child with simple febrile seizure Anticonvulsant therapy is not recommended in simple febrile seizure Management of fever in young children 31 DDx Fever with rash Viral exanthems Streptococcal infection Staphylococcal scalded skin syndrome / Toxic shock syndrome Kawasaki disease Meningococcal disease Henoch Schonlein purpura (HSP) Measles paramyxo virus Spread by respiratory droplets Incubation period: 7 – 12 days CF: prodromal period (fever, conjuctivitis, coryza, dry cough, koplik spots +/- lymphadenopathy) florid maculopapular rash appearing over head and neck spreading to cover the whole body X 3-4 days Infectious from the prodromal period until 4 days after rash appeared Dx: Measles Antibodies in saliva or serum Complications: OM, pneumonia, encephalitis, subacute sclerosing pan encephalitis Chicken pox (Varicella) varicella zoster DNA virus Incubation period 14 – 21 days Fever & malaise X 5-6 days followed by crops of skin lesions that go through stages of macules, papules, vesicles, and crusting Infectious 2 days before rash until vesicles dry/crust Complications: Secondary bact. Infection of lesions, haemorrhagic varicella, pneumonia, encephalitis, ataxia at 7-10 days after rash Severe illness in immunocompromised adults, preg. Women & neonates Rubella (german measles) RNA rubella virus Incubation period: 14 – 21 days Fever, rash, posterior cervical lymph node Complications: Deafness,encephalitus, Congenital rubella syndrome Rx: Symptomatic Roseola infantum (Human herpes virus type 6) Roseola infantum Caused by Human herpes DNA virus type 6 & 7 Many children already infected by 2 years Incubation period: 5- 15 days CF: short febrile illness x 3- 5 days and an erythematous rash Complication: Meningoencephalitis & Sz Fifth Disease Erythema infectiosum (Fifth ds/ Slapped cheek ds) Human parvo virus B19 Incubation period: 7 – 17 days Head ache & malaise rash on face ( slapped cheek app.) spreading to the trunk and limbs with maculopapular lesion evolving to a lace- like reticular pattern Complications: Aplastic crisis with underlying chronic haemolytic anaemia, Aseptic meningitis, Hydrops fetalis Hand, Foot & Mouth disease Caused by coxsackie A16, A19 and Enterovirus 71 RNA viruses Incubation period: 4 – 7 days CF: fever, malaise , head ache, pharyngitis, vesicular lesions on the hands and feet including palms & soles May be complicated by chronic recurrent skin lesions Rx: Symptomatic Infectious mononucleosis (Glandular fever) Ebstein Barr (DNA) virus CF: fever, lymphadenopathy, tonsillitis, headache, malaise, myalgia, splenomegaly, petechiae on soft palate, rash (macular, maculopapular, urticarial or erythema multiforme) DX: EBV specific IgM; Paul Bunnell test Complication: Splenic rupture, ataxia, facial nerve palsy, aplastic anaemia, interstitial pneumonia Rx: Symptomatic UTI in childhood UTI is common VUR is assoc with renal scarring particularly in the 1st year pf life chronic renal failure Neonates – irritability, refusal of feeds, vomiting, FTT, prolonged NNJ, toxic/extremely unwell Pre-school: vomiting, poor wt. Gain, fever, malaise, freq, dysuria, enuresis, haematuria, loin pain UTI (2) Inv: Urine m/c/s x 2 (or 1 SPA urine sample) – mid stream, clean catch, bag, SPA urine sample Pyuria, organism on microscopy Significant bacteruria > 10 5 org/ml or and growth from SPA Treatment: Antibiotics PO or iv Commence low dose prophylactic antibiotic Refer to the Paediatrician for further investigations Meningococcal disease Gram neg. diplococci Nasopharyngeal carriage in 25% Invasive disease in 1% carriers 15% meningitis; 60% Septicaemia + endotoxaemia; fulminant septicaemic shock with circulatory failure & wide spread purpura Rx: Antibiotics; management of shock, anticipate ventilatory failure Transfer to PICU and contact public health dept Prognosis: Poor if <1 year, better if evolution of ds slower; overall mortality approx. 30% Kawasaki disease Systemic vasculitis of early childhood 80% cases < 4 years & M:F ratio = 1.5:1 No single diagnostic test; 5/6 clinical criteria fever >5 days Changes in the mucous membrane of URT Changes in the peripheral extremities (oedema, desquamation Polymorphous rash (urticarial, maculopapular, multiforme) Cervical lymph adenopathy Exclusion of staphylococcal & streptococcal infection & others (Measles, drug reaction, JCA) Coronary aneurysm +fever + 3 / 4 criteria Kawasaki disease (2) Other features: irritability, arthritis, aseptic meningitis, hepatitis, hydropic gall bladder 20-30% Myocarditis, pericarditis, arthymia, cardiac failure, coronary aneurysm Rx: High dose IV Ig 2g/Kg over 12-18 hrs High dose Aspirin 30mg/Kg/day until fever resolves then 3-5mg/Kg/day Cardiac echo for coronary aneurysm Investigation According to the differential diagnosis Indicated if child is unwell and or no cause identified full infection screen Urinalysis & Urine m/c/s where no focus of infection All children <2 years where S&S of UTI is non specific and diagnosis has implication for future management With urinary symptoms Before starting antibiotics Complete Infection Screen FBC & blood film; WBC differential, band neutrophil ratio CRP Throat swab: virology, m/c/s Urine m/c/s Blood c/s Blood for PCR and rapid antigen screen: meningococcal, pneumococcal, Stool m/c/s & virology CXR LP for CSF analysis: protein, glucose, m/c/s Treatment Temp control: antipyretics (paracetamol, Ibuprofen) exposure & avoid dehydration Sick / deteriorating child: supportive mx with best guess antimicrobial therapy Specific cause Indication for referral to paediatric team Unwell/ toxic Unknown source or cause of fever particularly in early childhood Associated systemic symptoms & signs Fever > 14 days (PUO)
