Paediatrics Tutorial

EVALUATION OF FEVER IN CHILDREN

FEBRILE CONVULSIONS
PYREXIA OF UNKNOWN ORIGIN

06/10/2021

Rabiu Musa Abdullahi 092

Sani khalid Muhammad 093

Moderators: Dr Sadiku
Dr Abemi
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 EVALUATION OF FEVER
IN CHILDREN

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Synopsis
• Introduction
• The patterns of Fever
• Approach to a patient with a fever

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Introduction
• Fever is one of the most common presenting features of illnesses in
children and a major concern to parents and caregivers.

• It is the hallmark of the body's response to infection or inflammation.

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Introduction cont'd
• Fever is an increase in the core body temperature above the daily
range for an individual

• Optimal range of the core body temperature is 37°C +/- 0.5

• Rectal temperature is generally regarded as the gold standard

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Pathophysiology of fever

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The patterns of fever
• Fever can reveal a characteristic pattern in some diseases and this
pattern of rise and fall of temperature may be a clue for diagnosis.

• May be useful indicator for decisions on emperical treatment in

settings where diagnostic facilities are inadequate or investigations
fail to resolve the cause of the FUO

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The patterns of fever

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Definition of some terms
• Hyperpyrexia

• Hyperthermia

• Fever phobia

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Approach to a patient with a fever
• History

• Examination

• Investigations

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History taking
• HPC: Onset, duration of the fever, pattern, characteristic should all be
described. Ask wether the patient has taken any medication.

• Past medical history: diabetes, rheumatic heart disease, previous TB.

Ask about underlying diseases such as HIV, medications such as
steroids or chemotherapy or a history of splenectomy.

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History taking cont'd
• Recent hospitalisation

• Surgery

• Blood transfusions

• Radiation exposure

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History of behaviours and exposures
• contact with anyone having similar symptoms

• Access to clean water and sanitation

• Proximity to animals or rodents

• Vaccination history

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Systemic history
• Respiratory: Upper respiratory tract infection is suggested by
rhinorrhea, nasal stuffiness, sneezing, sore throat, cough and a hoarse
voice.

• Otitis: ear pain, ear discharge with or without deafness

• Lower respiratory tract infections present with cough, shortness of

breath, wheeze or chest pain

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Systemic history cont'd
• Genitourinary: presents with a combination of dysuria, frequency,
change in smell and colour of urine. Plus loin pain in upper UTI

• Digestive system: gastroenteritis, hepatitis, cholecystitis, bowel

perforation and peritonitis, all have their peculiarities.

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Systemic history cont'd
• Central Nervous system: In neonates and young children the
symptoms of infection are mostly non-specific.

• Skin and soft tissue: the presence of a rash is more likely to suggest a
systemic than localised condition. Example of localised infections
include; impetigo, cellulitis, NF

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Systemic history cont'd
• Musculoskeletal system
• Joint infections
• Bone infection

• Cardiovascular system

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General Examination
• Temperature
• Pulse
• Respiratory rate
• Blood pressure
• Lymph nodes
• Eyes
• Ears

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Examination cont'd
• Mouth
• Skin
• Hands and nails

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Systematic assessment
• Respiratory system
• Cardiovascular system
• Genitourinary system
• Digestive system
• Nervous system
• Musculoskeletal system

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Investigations
• FBC with diffential and film
• Platelets
• Inflammatory markers
• Basic biochemistry tests
• Microbiology and virology
• Immunological
• Histopathology
• +Radiology

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 Febrile Convulsion

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Outline
• Definition
• Classification
• Epidemiology
• Risk factors
• Causes
• Differential diagnosis
• Diagnosis
• Management
• Prognosis
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Definition
• Febrile convulsions are convulsions occurring in a child between
6month to 5year of age due to temperature >/=38 °C (101°F) which is
not resulting from a CNS infection or any metabolic imbalance and
the child is otherwise neurologically normal

• A diagnosis of exclusion

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Epidemiology
• The most common neurologic disorder of infants and young children
• Age dependent phenomenon
• Occurs between the age 6month to 5years
• Occurring in 2-4% of children <5
• Peak incidence 12-18months
• Male: female 1.6:1

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Classification
Simple febrile seizure Complex febrile seizure

Generalized tonic- clonic focal

Lasts <15min Lasts >15min

Does not reoccur within a 24H period Reoccurs within a 24H period

More common Less common

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Risk Factors
• Age
• High grade fever
• Infections
• Genetic susceptibility

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Causes
• Upper Respiratory tract infections
• Roseola infantum HHV6
• Gastroenteritis
• Urinary tract infections
• Epilepsy syndromes

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Pathogenesis
• Exact mechanism not known

• Fever

• Hyperventilation (Respiratory Alkalosis)

• Cytokines (IL-1B)

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Differential diagnosis
• CNS infections
• GEFS or Dravet syndrome
• Shaking chills
• Metabolic imbalances
• Drug ingestion

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Management
• History
• Physical Examination
• ?Investigations
• Treatment
• Follow up

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History
• Type, duration and number of episodes
• Clerk fever
• Recent antibiotic use
• Seizure neurological problems developmental delay
• Family history /epilepsy
• Recent vaccination

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Examination
• Sought the underlying cause
• Often reveals otitis media, pharyngitis, exanthem
• Full neurological examination
• Serial evaluation of neurologic status

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?Investigations
• Blood studies
• Lumber puncture
• EEG

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Treatment
• Most cases abort spontaneously before reaching hospital

• First aid very essential

• Left lateral position
• Don’t give anything orally
• Ensure safe environment

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Treatment
• Hospital
• Abort seizure
• ABC
• Very brief history and physical examination
• Abort seizure
IM paraldehyde 0.1ml/kg or 1ml/year to a maximum of 5mls
Rectal or IV diazepam 0.1-0.3mg/kg in double dilution given slowly

• Control fever
Tepid sponging, exposure

• Treat underlying disease

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Follow up
• To rule out seizure disorder

• Parental counselling

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Complication
• Recurrence
• Biting of oneself
• Aspiration
• Injury from falling down or bumping into objects
• Residual neurological deficits
• Risk of development of epilepsy
• Side effects of medications used to treat and prevent seizures

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Risk factors for recurrence
• Major
• Age
• Duration <24h
• Fever 38-39˚C
• Minor
• Family history of febrile convulsion
• Family history of epilepsy
• Complex febrile convulsion
• Male gender
• Hyponatremia

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Recurrence
• Febrile seizure recur in:
• 30% after 1st episode
• 50% after 2 or more episodes

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Prognosis
• Not anything frightening is life threatening
• Very good prognosis
• NO Effect on school performance and intelligence, academic progress

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 Pyrexia of Unknown Origin

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Outline
• Introduction
• Definition
• Classification
• Causes
• Management
• Prognosis
• Conclusion

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Introduction
• One of the most challenging problems a physician faces in practice

• A truly significant test of skill

• A thorough and detailed history with a good clinical examination and

relevant investigations are necessary

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Definition
• A temperature greater than 38.3° C (101° F) on several occasions

• More than 3 weeks of illness

• Failure to reach a diagnosis after a week of inpatient management

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Definition(modified)
• Uncertain diagnosis after 3 days of hospital stay or more than 2
outpatient visits

• A daily rectal temperature greater than 38.3° C (101° F) of 2 weeks

duration for which history, thorough physical examination and
routine investigations fail to reveal a focus of infection

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Classification
• Classic

• Nosocomial

• HIV related

• Neutropenic

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CLASSIFICATION
• CLASSIC FUO
Temperature >38.3°C
Lasting for 3 or more weeks as an outpatient.
Lasting for > 1 week as an inpatient.
Causes include: infections, malignancies, collagen vascular diseases.

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CLASSIFICATION
• NOSOCOMIAL
Temperature >38.3°C
Develops 24 hours or more after hospitalization.
Fever not present on admission.
Causes include: thrombophlebitis, sinusitis, enterocolitis, drug-
induced.

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CLASSIFICATION
• NEUTROPENIC
Temperature >38.3°C
Neutrophil count ≤500/mm3
Causes include: opportunistic bacterial infections, aspergillosis,
candidiasis,herpes virus.

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CLASSIFICATION
• HIV ASSOCIATED
Temperature > 38.3° C (101° F)
HIV infection confirmed.
Duration > 4 weeks for outpatients and 3 days for inpatients.
Causes include: Mycobacterium avium intracellulare complex,
Pneumocystis carinii pneumonia, CMV.

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Causes
• Infectious 28%
• Inflammatory 21%
• Malignancy 17%
• Miscellaneous
• No diagnosis at time of discharge

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Infectious
• Tuberculosis
• Abscesses
• Endocarditis
• Osteomyelitis

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Inflammatory
• Rhematotoid arthritis

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Malignancy
• Leukemia
• Lymphoma

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Miscellaneous
• Facticious
• Drug induced

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Approach to PUO
• Establish fever
• Exclusion criteria

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MANAGEMENT
• History
• Physical examination
• Investigations
• Treatment

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MANAGEMENT
• HISTORY
Detailed history of fever
Pattern should be documented
Associated symptoms
Recent travel
Contact with patients exhibiting similar symptoms
Contact with pets and other animals
Detailed drug history

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MANAGEMENT
Past medical history
Previous surgeries
Immunization history
Nutritional history

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MANAGEMENT
• PHYSICAL EXAMINATION
General physical examination: eyes, skin, lymph nodes.
Abdominal examination: organomegaly, masses.
Ear, nose, and throat examination.
CVS: murmurs
Respiratory system examination.

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MANAGEMENT
• INVESTIGATIONS
Full blood count and differentials.
Liver function tests
Urea ,electrolytes, and creatinine.
Urinalysis
Culture: blood, CSF, peritoneal fluid, pleural fluid stool, sputum.
Blood smear
Serological tests

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MANAGEMENT
Tuberculin skin test
Chest radiograph
Abdominal ultrasound
CT scan
MRI
Endoscopy
Biopsy

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MANAGEMENT
• TREATMENT
Treat the underlying cause
Empirical treatment has little or role in cases of classic FUO.
There are few suggested exceptions to the rule. These include:
Cases that meet criteria for culture-negative endocarditis
Features suggestive of disseminated TB.

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 Prognosis
• Good in children
• Depend on underlying disease: malignances have
poorest prognosis
• Delay diagnosis worsen prognosis in conditions like
miliary Tb, intra-abdominal infection, disseminated
fungal infection
• Undiagnosed after extensive evaluation have good
prognosis
• Most cases regress spontaneously.

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CONCLUSION
• FUO is usually a diagnostic dilemma for the physician. Appropriate
investigations guided by findings on history and physical examination
goes a long way in solving majority of the cases.
• In some cases however, no diagnosis can be established and the fever
resolves spontaneously.

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 THANK YOU

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References
• Dorothy ESANGBEDO and Christopher ESEZOBOR Pyrexia of Unknown Origin. Paediatrics and
child health in the tropical region by Azubuike and Nkanginneme 3rd edition 615-618
• Caryn Rosmarin and Ali Jawad Patients with Fever. Hutchisons clinical methods 2017;147-166

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