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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
Incubation period: 14 21 days
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
Incubation period: 7 17 days
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
Incubation period: 4 7 days
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%)
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