Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Fever Without a Focus Differential Diagnoses

  • Author: Saul R Hymes, MD, FAAP; Chief Editor: Russell W Steele, MD  more...
 
Updated: Dec 31, 2014
 
 
 
Contributor Information and Disclosures
Author

Saul R Hymes, MD, FAAP Director, Pediatric Lyme and Tick-Borne Diseases Center, Department of Pediatrics, Division of Pediatric Infectious Diseases, Stony Brook Children’s Hospital; Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Division of Pediatric Infectious Diseases, Stony Brook University School of Medicine

Saul R Hymes, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

References
  1. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000 Dec. 36(6):602-14. [Medline].

  2. [Guideline] ACEP. Clinical policy for children younger than three years presenting to the emergency department with fever. ACEP Clinical Policies Committee; ACEP Clinical Policies Subcommittee on Pediatric Fever. Ann Emerg Med. 2003 Oct. 42(4):530-45. [Medline].

  3. Benito-Fernandez J, Raso SM, Pocheville-Gurutzeta I, SanchezEtxaniz J, Azcunaga-Santibanez B, Capape-Zache S. Pneumococcal bacteremia among infants with fever without known source before and after introduction of pneumococcal conjugate vaccine in the Basque Country of Spain. Pediatr Infect Dis J. 2007 Aug. 26(8):667-71. [Medline].

  4. Colvin JM, Muenzer JT, Jaffe DM, Smason A, Deych E, Shannon WD, et al. Detection of viruses in young children with fever without an apparent source. Pediatrics. 2012 Dec. 130(6):e1455-62. [Medline]. [Full Text].

  5. Watt K, Waddle E, Jhaveri R. Changing epidemiology of serious bacterial infections in febrile infants without localizing signs. PLoS One. 2010 Aug 27. 5(8):e12448. [Medline]. [Full Text].

  6. Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ. 2010 Apr 20. 340:c1594. [Medline]. [Full Text].

  7. Mazzi E, Bartos AE, Carlin J, Weber MW, Darmstadt GL. Clinical signs predicting severe illness in young infants (1111J Trop Pediatr</i>. 2010 Oct. 56(5):307-16. [Medline].

  8. McCarthy PL, Sharpe MR, Spiesel SZ. Observation scales to identify serious illness in febrile children. Pediatrics. 1982 Nov. 70(5):802-9. [Medline].

  9. Bonadio WA. The history and physical assessments of the febrile infant. Pediatr Clin North Am. 1998 Feb. 45(1):65-77. [Medline].

  10. Hoberman A, Wald ER, Reynolds EA. Pyuria and bacteriuria in urine specimens obtained by catheter from young children with fever. J Pediatr. 1994 Apr. 124(4):513-9. [Medline].

  11. Galetto-Lacour A, Zamora SA, Andreola B, et al. Validation of a laboratory risk index score for the identification of severe bacterial infection in children with fever without source. Arch Dis Child. 2010 Dec. 95(12):968-73. [Medline].

  12. Mintegi S, Benito J, Pijoan JI, et al. Occult pneumonia in infants with high fever without source: a prospective multicenter study. Pediatr Emerg Care. 2010 Jul. 26(7):470-4. [Medline].

  13. Manzano S, Bailey B, Gervaix A, Cousineau J, Delvin E, Girodias JB. Markers for bacterial infection in children with fever without source. Arch Dis Child. 2011 May. 96(5):440-6. [Medline].

  14. Gomez B, Bressan S, Mintegi S, Da Dalt L, Blazquez D, Olaciregui I, et al. Diagnostic value of procalcitonin in well-appearing young febrile infants. Pediatrics. 2012 Nov. 130(5):815-22. [Medline].

  15. Akintemi OB, Roberts KB. Evaluation and management of the febrile child in the conjugated vaccine era. Adv Pediatr. 2006. 53:255-78. [Medline].

  16. Andreola B, Bressan S, Callegaro S, Liverani A, Plebani M, Da Dalt L. Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. Pediatr Infect Dis J. 2007 Aug. 26(8):672-7. [Medline].

  17. Antonyrajah B, Mukundan D. Fever without apparent source on clinical examination. Curr Opin Pediatr. 2008 Feb. 20(1):96-102. [Medline].

  18. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993 Nov 11. 329(20):1437-41. [Medline].

  19. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993 Jul. 22(7):1198-210. [Medline].

  20. Bergman DA, Mayer ML, Pantell RH, Finch SA, Wasserman RC. Does clinical presentation explain practice variability in the treatment of febrile infants?. Pediatrics. 2006 Mar. 117(3):787-95. [Medline].

  21. Bonadio WA, Hagen E, Rucka J, et al. Efficacy of a protocol to distinguish risk of serious bacterial infection in the outpatient evaluation of febrile young infants. Clin Pediatr (Phila). 1993 Jul. 32(7):401-4. [Medline].

  22. Bonadio WA, Lehrmann M, Hennes H, et al. Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment. Ann Emerg Med. 1991 Sep. 20(9):1006-8. [Medline].

  23. Byington CL, Kendrick J, Sheng X. Normative cerebrospinal fluid profiles in febrile infants. J Pediatr. 2011 Jan. 158(1):33-7. [Medline]. [Full Text].

  24. Chinnock R, Butto J, Fernando N. Hot tots: current approach to the young febrile infant. Compr Ther. 1995. 21(3):109-14. [Medline].

  25. Condra CS, Parbhu B, Lorenz D, Herr SM. Charges and complications associated with the medical evaluation of febrile young infants. Pediatr Emerg Care. 2010 Mar. 26(3):186-91. [Medline].

  26. Galetto-Lacour A, Gervaix A. Identifying severe bacterial infection in children with fever without source. Expert Rev Anti Infect Ther. 2010 Nov. 8(11):1231-7. [Medline].

  27. Gomez B, Mintegi S, Rubio MC, Garcia D, Garcia S, Benito J. Clinical and analytical characteristics and short-term evolution of enteroviral meningitis in young infants presenting with fever without source. Pediatr Emerg Care. 2012 Jun. 28(6):518-23. [Medline].

  28. Grubb NS, Lyle S, Brodie JH, et al. Management of infants and children 0 to 36 months of age with fever without source. J Am Board Fam Pract. 1995 Mar-Apr. 8(2):114-9. [Medline].

  29. Herd D. In children under age three does procalcitonin help exclude serious bacterial infection in fever without focus?. Arch Dis Child. 2007 Apr. 92(4):362-4. [Medline].

  30. Ishimine P. Fever without source in children 0 to 36 months of age. Pediatr Clin North Am. 2006 Apr. 53(2):167-94. [Medline].

  31. Ishimine P. The evolving approach to the young child who has fever and no obvious source. Emerg Med Clin North Am. 2007 Nov. 25(4):1087-115, vii. [Medline].

  32. Jaskiewicz JA, McCarthy CA. Evaluation and management of the febrile infant 60 days of age or younger. Pediatr Ann. 1993 Aug. 22(8):477-80, 482-3. [Medline].

  33. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics. 1994 Sep. 94(3):390-6. [Medline].

  34. Kramer MS, Tange SM, Drummond KN. Urine testing in young febrile children: a risk-benefit analysis. J Pediatr. 1994 Jul. 125(1):6-13. [Medline].

  35. Lacour AG, Zamora SA, Gervaix A. A score identifying serious bacterial infections in children with fever without source. Pediatr Infect Dis J. 2008 Jul. 27(7):654-6. [Medline].

  36. Lee GM, Harper MB. Risk of bacteremia for febrile young children in the post-Haemophilus influenzae type b era. Arch Pediatr Adolesc Med. 1998 Jul. 152(7):624-8. [Medline].

  37. Lieu TA, Baskin MN, Schwartz JS, Fleisher GR. Clinical and cost-effectiveness of outpatient strategies for management of febrile infants. Pediatrics. 1992 Jun. 89(6 Pt 2):1135-44. [Medline].

  38. Maheshwari N. How useful is C-reactive protein in detecting occult bacterial infection in young children with fever without apparent focus?. Arch Dis Child. 2006 Jun. 91(6):533-5. [Medline].

  39. Manzano S, Bailey B, Gervaix A, Cousineau J, Delvin E, Girodias JB. Markers for bacterial infection in children with fever without source. Arch Dis Child. 2011 May. 96(5):440-6. [Medline].

  40. Manzano S, Bailey B, Girodias JB, Galetto-Lacour A, Cousineau J, Delvin E. Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: a randomized controlled trial. Am J Emerg Med. 2010 Jul. 28(6):647-53. [Medline].

  41. Massin MM, Montesanti J, Lepage P. Management of fever without source in young children presenting to an emergency room. Acta Paediatr. 2006 Nov. 95(11):1446-50. [Medline].

  42. McCarthy PL, Lembo RM, Baron MA. Predictive value of abnormal physical examination findings in ill-appearing and well-appearing febrile children. Pediatrics. 1985 Aug. 76(2):167-71. [Medline].

  43. McCarthy PL, Lembo RM, Fink HD. Observation, history, and physical examination in diagnosis of serious illnesses in febrile children less than or equal to 24 months. J Pediatr. 1987 Jan. 110(1):26-30. [Medline].

  44. Mintegi S, Benito J, Sanchez J, Azkunaga B, Iturralde I, Garcia S. Predictors of occult bacteremia in young febrile children in the era of heptavalent pneumococcal conjugated vaccine. Eur J Emerg Med. 2009 Aug. 16(4):199-205. [Medline].

  45. Murphy CG, van de Pol AC, Harper MB, Bachur RG. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007 Mar. 14(3):243-9. [Medline].

  46. Myers C, Gervaix A. Streptococcus pneumoniae bacteraemia in children. Int J Antimicrob Agents. 2007 Nov. 30 Suppl 1:S24-8. [Medline].

  47. Nozicka CA. Evaluation of the febrile infant younger than 3 months of age with no source of infection. Am J Emerg Med. 1995 Mar. 13(2):215-8. [Medline].

  48. Olaciregui I, Hernandez U, Munoz JA, Emparanza JI, Landa JJ. Markers that predict serious bacterial infection in infants under 3 months of age presenting with fever of unknown origin. Arch Dis Child. 2009 Jul. 94(7):501-5. [Medline].

  49. Oppenheim PI, Sotiropoulos G, Baraff LJ. Incorporating patient preferences into practice guidelines: management of children with fever without source. Ann Emerg Med. 1994 Nov. 24(5):836-41. [Medline].

  50. Pena BM, Harper MB, Fleisher GR. Occult bacteremia with group B streptococci in an outpatient setting. Pediatrics. 1998 Jul. 102(1 Pt 1):67-72. [Medline].

  51. Perez-Mendez C, Molinos-Norniella C, Moran-Poladura M, et al. Low risk of bacteremia in otherwise healthy children presenting with fever and severe neutropenia. Pediatr Infect Dis J. 2010 Jul. 29(7):671-2. [Medline].

  52. Perrott DA, Piira T, Goodenough B, Champion GD. Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis. Arch Pediatr Adolesc Med. 2004 Jun. 158(6):521-6. [Medline].

  53. Richardson M, Lakhanpaul M. Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance. BMJ. 2007 Jun 2. 334(7604):1163-4. [Medline].

  54. Rothrock SG, Harper MB, Green SM, et al. Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta- analysis. Pediatrics. 1997 Mar. 99(3):438-44. [Medline].

  55. Roukema J, Steyerberg EW, van der Lei J, Moll HA. Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source. J Am Med Inform Assoc. 2008 Jan-Feb. 15(1):107-13. [Medline].

  56. Seow VK, Lin AC, Lin IY, Chen CC, Chen KC, Wang TL, et al. Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome. Am J Emerg Med. 2007 Nov. 25(9):1004-8. [Medline].

  57. Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection?. JAMA. 2007 Dec 26. 298(24):2895-904. [Medline].

  58. Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011 Mar. 127(3):580-7. [Medline].

  59. Trainor JL, Stamos JK. Fever without a localizing source. Pediatr Ann. 2011 Jan. 40(1):21-5. [Medline].

  60. Vega R. Rapid viral testing in the evaluation of the febrile infant and child. Curr Opin Pediatr. 2005 Jun. 17(3):363-7. [Medline].

  61. Wasserman GM, White CB. Evaluation of the necessity for hospitalization of the febrile infant less than three months of age. Pediatr Infect Dis J. 1990 Mar. 9(3):163-9. [Medline].

  62. Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med. 2009 Mar. 16(3):220-5. [Medline].

  63. Castelblanco RL, Lee M, Hasbun R. Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infect Dis. 2014 Sep. 14(9):813-9. [Medline].

Previous
Next
 
Table. Summary of the Yale Observation Scale
Observation Items1 (Normal)3 (Moderate Impairment)5 (Severe Impairment)
Quality of cryStrong with normal tone or contentment without cryingWhimpering or sobbingWeak cry, moaning, or high-pitched cry
Reaction to parent stimulationBrief crying that stops or contentment without cryingIntermittent cryingContinual crying or limited response
ColorPinkAcrocyanotic or pale extremitiesPale or cyanotic or mottled or ashen
State variationIf awake, stays awake; if asleep, wakes up quickly upon stimulationEyes closed briefly while awake or awake with prolonged stimulationFalls asleep or will not arouse
HydrationSkin normal, eyes normal, and mucous membranes moistSkin and eyes normal and mouth slightly drySkin doughy or tented, dry mucous membranes, and/or sunken eyes
Response (eg, talk, smile) to social overturesSmiling or alert (< 2 mo)Briefly smiling or alert briefly (< 2 mo)Unsmiling anxious face or dull, expressionless, or not alert (< 2 mo)
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.