MTS_Fever and Chills in Children

7/29/2019 MTS_Fever and Chills in Children

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Fever and chills in children

mts darmawan


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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)


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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


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Assessment: Relevant history

Duration of fever

Pattern of fever: intermittent or continuous

Hx of contact: family members, friends, schoolmates

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


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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)


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Relevant clinical signs

Unwell Toxic

Haemodynamic instability

Rash

Lower Respiratory signsJoint involvement: Arthritis/ Athralgia:

Reactive viral arthritis, Septic arthritis, HSP,

Rheumatic fever, Chronic arthritis of

childhood

Organomegaly: Hepatomegaly,

Splenomegaly, +/- Anaemia: Systemic illness,

Septicaemia, Lymphoproliferative disorders


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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,

retropharyngealabscess)

LRTI

GI (appendicitis)

CNS (Meningitis,encephalitis)

Systemic(meningococcaemia,toxic shock syndrome


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DDx Fever with rash

Viral exanthems (exanthema subitum ~ Roseola

infantum)

Streptococcal infection

Staphylococcal scalded skin syndrome / Toxic

shock syndrome

Kawasaki disease

Meningococcal diseaseHenoch Schonlein purpura (HSP)


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Rash maculopapuler


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Measlesparamyxo virus

Spread by respiratory droplets

Incubation period: 7 12 days

CF: prodromal period (fever, conjuctivitis, coryza,

dry cough, koplik spots +/- lymphadenopathy) floridmaculopapular rash appearing over head and neckspreading to cover the whole body X 3-4 days

Infectious from the prodromal period until 4 days

after rash appearedDx: Measles Antibodies in saliva or serum

Complications: OM, pneumonia, encephalitis,subacute sclerosing pan encephalitis


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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 crustingInfectious 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


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Rubella (german measles)

RNA rubella virus


Fever, rash, posterior cervical lymph node

Complications: Deafness,encephalitus,

Congenital rubella syndrome

Rx: Symptomatic


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Roseola infantum

(Human herpes virus type 6)


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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


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Fifth Disease


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Erythema infectiosum

(Fifth ds/ Slapped cheek ds)

Human parvo virus B19


Head ache & malaiserash on face ( slapped cheek app.) spreadingto the trunk and limbs with maculopapularlesion evolving to a lace- like reticular pattern

Complications: Aplastic crisis with underlyingchronic haemolytic anaemia, Asepticmeningitis, Hydrops fetalis


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Hand, Foot & Mouth disease

Caused by coxsackie A16, A19 andEnterovirus 71 RNA viruses


CF: fever, malaise , head ache, pharyngitis,vesicular lesions on the hands and feetincluding palms & soles

May be complicated by chronic recurrent skin

lesionsRx: Symptomatic


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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


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UTI in childhood

UTI is commonVUR is assoc with renal scarring particularlyin 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


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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


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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 failureTransfer to PICU and contact public health dept

Prognosis: Poor if


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Kawasaki disease

Systemic vasculitis of early childhood80% 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


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Kawasaki disease (2)

Other features: irritability, arthritis, asepticmeningitis, 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


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Investigation

According to the differential diagnosisIndicated if child is unwell and or no cause

identified

full infection screenUrinalysis & Urine m/c/s

where no focus of infection

All children


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Complete Infection Screen

FBC & blood film; WBC differential, bandneutrophil ratio

CRP

Throat swab: virology, m/c/s

Urine m/c/sBlood 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


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Treatment

Temp control: antipyretics (paracetamol,Ibuprofen) exposure & avoid dehydration

Sick / deteriorating child: supportive mx withbest guess antimicrobial therapy

Specific cause

Indication for referral to paediatric team Unwell/ toxic

Unknown source or cause of fever particularly inearly childhood

Associated systemic symptoms & signs

Fever > 14 days (PUO)


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Febrile convulsion

Occurs in 3 5% children

Peak age incidence 6 months to 6 years

Sz: gen convulsion; < 15mins; may be complex

focal (4-18%) or prolonged (4-30%), repeatedwithin same illness or leave residual focal sign

(Todds paresis

Rx: diagnose & treat cause of fever;

counsel parents for 1st aid management of fever


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Febrile convulsion (2)

Prognosis: Good, < 3% epilepsy

Guarded with prolonged & atypical Sz

40% have 2nd seizure & 15% have a 3rd

Epilepsy: children< 1 year; complex initial

convulsion & neurological sign; febrile

convulsion in 1st degree relativ; prolonged

fits> 30 mins; > 3 episodes (10%)

MTS_Fever and Chills in Children

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