Fever Without a Focus Clinical Presentation

Updated: Nov 07, 2016
  • Author: Saul R Hymes, MD, FAAP; Chief Editor: Russell W Steele, MD  more...
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Presentation

History

Obtaining an accurate history from the parent or caregiver is important when assessing fever without a focus; the history obtained should include the following information:

  • Fever history: What was child's temperature prior to presentation and how was temperature measured? Consider fever documented at home by a reliable parent or caregiver the same as fever found upon presentation. Accept parental reports of maximum temperature.
  • Fever at presentation: If the physician believes the infant has been excessively bundled, and if a repeat temperature taken 15-30 minutes after unbundling is normal, the infant should be considered afebrile. Always remember that normal or low temperature does not preclude serious, even life-threatening, infectious disease.
  • Current level of activity or lethargy
  • Activity level prior to fever onset (ie, active, lethargic)
  • Current eating and drinking pattern
  • Eating and drinking pattern prior to fever onset
  • Appearance: Fever sometimes makes a child appear rather ill
  • Vomiting or diarrhea
  • Ill contacts
  • Medical history
  • Immunization history (especially recent immunizations)
  • Urinary output: Inquire as to the number of wet diapers
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Physical

While performing a complete physical examination, pay particular attention to assessing hydration status and identifying the source of infection. [6, 7] Physical examination of every febrile child should include the following:

Record vital signs.

  • Temperature: Rectal temperature is the standard. Temperature obtained via tympanic, axillary, or oral methods may not truly reflect the patient's temperature.
  • Pulse rate
  • Respiratory rate
  • Blood pressure

Measure pulse oximetry levels.

  • Pulse oximetry may be a more sensitive predictor of pulmonary infection than respiratory rate in patients of all ages, but especially in infants and young children.
  • Pulse oximetry is mandatory for any child with abnormal lung examination findings, respiratory symptoms, or abnormal respiratory rate, although keep in mind that the respiratory rate increases when children are febrile.

Record an accurate weight on every chart.

  • All pharmacologic and procedural treatments are based on the weight in kilograms.
  • In urgent situations, estimating methods (eg, Broselow tape, weight based on age) may be used.

During the examination, concentrate on identifying any of the following:

  • Toxic appearance, which suggests possible signs of lethargy, poor perfusion, hypoventilation or hyperventilation, or cyanosis (ie, shock)
  • A focus of infection that is the apparent cause of the fever
  • Minor foci (eg, otitis media [OM], pharyngitis, sinusitis, skin or soft tissue infection)
  • Identifiable viral infection (eg, bronchiolitis, croup, gingivostomatitis, viral gastroenteritis, varicella, hand-foot-and-mouth disease)
  • Petechial or purpuric rashes, often associated with bacteremia
  • Purpura, which is associated more often with meningococcemia than is the presence of petechiae alone

For all patients aged 2-36 months, management decisions are based on the degree of toxicity and the identification of serious bacterial infection.

The Yale Observation Scale is a reliable method for determining degree of illness. [8, 9] It consists of 6 variables: quality of cry, reaction to parent stimulation, state variation, color, hydration, and response. A score of 10 or less has a 2.7% risk of serious bacterial infection. A score of 16 or greater has a 92% risk of serious bacterial infection. It is important to remember that this scale was validated in the occult bacteremia era, prior to widespread pneumococcal conjugate vaccination.

Regarding the height of temperature, Hoberman et al found that 6.5% of patients with a temperature of 39.0°C (102.2°F) or more had a urinary tract infection (UTI) and that white females with that temperature had a 17% incidence of UTI. [10]

Table. Summary of the Yale Observation Scale (Open Table in a new window)

Observation Items 1 (Normal) 3 (Moderate Impairment) 5 (Severe Impairment)
Quality of cry Strong with normal tone or contentment without crying Whimpering or sobbing Weak cry, moaning, or high-pitched cry
Reaction to parent stimulation Brief crying that stops or contentment without crying Intermittent crying Continual crying or limited response
Color Pink Acrocyanotic or pale extremities Pale or cyanotic or mottled or ashen
State variation If awake, stays awake; if asleep, wakes up quickly upon stimulation Eyes closed briefly while awake or awake with prolonged stimulation Falls asleep or will not arouse
Hydration Skin normal, eyes normal, and mucous membranes moist Skin and eyes normal and mouth slightly dry Skin doughy or tented, dry mucous membranes, and/or sunken eyes
Response (eg, talk, smile) to social overtures Smiling or alert (< 2 mo) Briefly smiling or alert briefly (< 2 mo) Unsmiling anxious face or dull, expressionless, or not alert (< 2 mo)
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Causes

Several common bacteria cause serious bacterial infections, including the following:

  • S pneumoniae: S pneumoniae is still the leading cause of nearly all common bacterial upper respiratory tract infections (eg, pneumonia, sinusitis, OM). This organism is also still the most common cause of meningitis in the United States, despite use of the conjugate pneumococcal vaccine. [11]
  • N meningitidis
  • H influenzae type b
  • L monocytogenes
  • E coli: E coli is the most common cause of UTIs. Among febrile children with UTIs, 75% have pyelonephritis, with consequences that, if missed, include renal scarring in 27-64% of patients, a 23% risk of hypertension, a 10% risk of renal failure, and a 13% risk of preeclampsia as adults. Approximately 13-15% of end-stage renal disease is believed to be related to undertreated childhood UTIs.
  • Salmonella
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