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Pediatrics, Fever: Differential Diagnoses & Workup
Updated: Aug 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Workup
Laboratory Studies
- Guidelines have been applied to neonatal emergency medicine. Traditionally, a febrile neonate (temperature 100.4°F [>38.0°C]) undergoes a full sepsis workup, eg, CBC, 1 blood culture, urinalysis, and urine culture (obtained by using a catheter), and diagnostic lumbar puncture (LP) for CSF analysis.14,15
- The age group that is defined for this workup may vary. At minimum, the guideline is applied to neonates younger than 28 days, and, in some institutions or regions of the country, it may be applied to other infants as old as 60 days.
- Older children (2-24 mo) who present with a higher temperature (>102.9°F [39.4°C]), and who are under immunized, may be at risk for occult bacteremia. By definition, occult means no other signs or symptoms suggesting the etiology of the temperature elevation. Higher temperatures are associated with increased rates of occult bacteremia. These situations are most common in unimmunized or immunosuppressed children.
- Prior to routine use of the pneumococcal vaccine, occult bacteremia occurred with an incidence of 3-5% in children younger than 24 months with fever. Studies in the 1980s-1990s showed the rate of occult bacteremia was as high as 5%. In the 21st century, studies show a decline in the rates to as low as 0.5-1%. This change is most likely due to the increasing rates of pneumococcal vaccinations.16
- Before pneumococcal vaccinations, approximately 60-70% of all cases of occult bacteremia were caused by Streptococcus pneumoniae. S pneumoniae is the most prevalent and certainly the most significant cause of morbidity and mortality related to occult bacteremia. The routine use of pneumococcal vaccine has essentially made this a classic historical discussion.17
- Before routine use of the HIB vaccine, HIB accounted for 20% of occult illness, but this cause has also decreased in frequency after the vaccination became routine in the 1990s.
- Other less common etiologic agents are Neisseria meningitides and (especially in patients with sickle cell disease) Salmonella species.18
- Herpes and community-acquired MRSA are now emerging as more common pathogens in neonate.19,20
- Before the routine use of the pneumococcal vaccine, a WBC count >15,000/mm3 had been reported to be 70% sensitive for predicting occult bacteremia from pneumomoccus.14
- An increase in the total band count or erythrocyte sedimentation rate (ESR) is not more predictive of occult pneumococcal bacteremia than the elevated WBC count alone.
- Diarrhea in children is commonly caused by viral organisms and usually not considered a major source of fever. Diarrhea with blood or mucus is an indication for further testing for fecal leukocytes, which suggests invasive bacterial etiologies.
- If fecal leukocytes (>5 per high-powered field) are present, a bacterial etiology is suggested and cultures are indicated. This finding may indicate infection with species of Salmonella, Campylobacter, Shigella, Yersinia, and toxic strains of Escherichia coli. The final diagnosis can be made only by obtaining stool cultures.
- During winter months, children presenting with low-grade fever, vomiting, and diarrhea should be considered possibly infected with rotavirus. Children in daycare centers are at increased risk for rotavirus infection. Rotavirus vaccine may change the incidence of this clinical etiology as well.
- During summer months, children with fever and no other signs may have an enterovirus infection. Some studies report the incidence as high as 50% in febrile children in the ED. Enteroviral infection is a clinical diagnosis for the emergency physician. No specific laboratory testing is indicated.
- Boys younger than 6 months with fever have an increased rate of UTIs. Several groups report an incidence of approximately 7%. For this reason, urinalysis and urine culture (obtained by catheterization) are recommended in male infants without another source of fever.21
- Girls younger than 12 months have about an 8% incidence in UTIs. Urinalysis and urine culture (obtained by catheterization) should be performed in febrile girls younger than 12 months if no other focus of fever is discovered. Fecal and skin contamination make the urine bag inadequate for obtaining specimens for culture. Bladder catheterization is required for culture.22
- Children younger than 24 months presenting with the clinical syndrome of bronchiolitis are at a lower risk of bacteremia and UTIs. Therefore, routine urine and blood culturing in previously healthy children presenting with fever and bronchiolitis is usually not indicated; extreme fever or ill appearance may be indications to obtain a blood culture. Rates of UTI may be lower in those with bronchiolitis than those without any fever source.23
- The febrile child older than 24 months (who has been previously fully immunized) is primarily evaluated by obtaining a history and performing a physical examination. Specific workup and/or treatment is based on the clinical findings and suspicion of disease.24,25,26
Imaging Studies
- Chest radiography
- In febrile neonates and young infants, a chest radiograph may not be part of a routine sepsis workup in the absence of respiratory complaints (neonates) or lower respiratory tract findings/tachypnea (infants).
- An increased respiratory rate is the earliest indicator of respiratory distress and should be considered in the overall decision to obtain a chest radiograph.
- In febrile children aged 3-24 months, pneumonia may be present even in the absence of definite auscultatory signs. Abnormal respiratory rate or pulse oximetry should alert the emergency physician to the need for a chest radiograph. Chest radiography is indicated if the child shows signs of respiratory distress, such as tachypnea; grunting, flaring, or retractions; or hypoxia, as determined with pulse oximetry.
- In children older than 2 years, chest radiography is not routinely ordered unless a specific indication is present.
- Tachypnea on physical examination remains the most sensitive indicator of lower respiratory tract infection.
- Infants who present with fever and signs of respiratory syncytial viral (RSV) bronchiolitis may be diagnostically challenging. Studies have shown they are at lower risk for serious bacterial illness. Testing of the nasal secretions for a viral etiology may be helpful.
Procedures
- In young children, the classic signs of meningismus, such as Kernig or Brudzinski signs, may be absent, even in the presence of CNS infection.
- Diagnostic LP is suggested for ill-appearing patients with associated persistent vomiting, irritability, lethargy, full anterior fontanelle, complex febrile seizure (<12 mo), or petechial rash.
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 Differential Diagnoses & Workup: Pediatrics, Fever |
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References
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Further Reading
Keywords
fever in children, fever in kids, high temperature, febrile, pyrexia, feverish, febrile child, febrile infant, infant with fever, child with fever, infection, meningitis, bacteremia or sepsis, enteritis, pneumonia, pericarditis, osteomyelitis, septic arthritis, cellulitis, otitis media, pharyngitis, sinusitis, urinary tract infections, enteritis, appendicitis, viral illnesses, upper respiratory infections, bronchiolitis, enteroviral exanthems, gastroenteritis, flulike illnesses
