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Recurrent Fever in the Pediatric Patient

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Recurrent Fever in the Pediatric Patient Ping-Wei Chen Emergency Medicine Resident Much thanks to: Drs. Bryan Young, Graham Thompson, Susan Kuhn,Chris Waterhouse ... – PowerPoint PPT presentation

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Title: Recurrent Fever in the Pediatric Patient


1
Recurrent Fever in the Pediatric Patient
  • Ping-Wei Chen
  • Emergency Medicine Resident
  • Much thanks to
  • Drs. Bryan Young, Graham Thompson, Susan
    Kuhn,Chris Waterhouse, Paivi Miettunen, Ron
    Anderson

2
Concerned Parent
  • 4 year old boy
  • 5 weeks of intermittent fevers (Tmax 389C)
  • last a few days
  • fatigue, malaise
  • Unsure if ever completely gone
  • ?red rash the first few days
  • Walk-in clinic x 2
  • viral illness
  • the flu
  • Negative urine dip
  • PLC ER
  • Today is visit 2

3
PLC ER Visit 1
  • CBC
  • Hgb 96
  • WBC 9.7
  • Plt 530
  • Electrolytes, Creatinine, BUN normal
  • Urine dip, RM negative

4
PLC ER Visit 2
  • 5 weeks intermittent fevers
  • Tmax 389C
  • ? fatigue/malaise
  • Øvomiting, Ødiarrhea
  • Ørespiratory symptoms
  • Øgenitourinary symptoms
  • ?red rash first few days
  • Øsick contacts
  • From Turkey 6 months ago
  • Preschool student
  • Previously healthy
  • Immunizations UTD
  • On exam
  • 379C, 100/65, 102bpm, 100 RAO2
  • HNT normal
  • CV normal
  • Resp clear, equal BS
  • Abdo soft, nontender
  • MSK Ørash/joint pain

5
Objectives
  • Discuss definitions
  • Recurrent Fever/Periodic Fever
  • Fever of Unknown Origin (FUO)
  • Outline differential diagnoses
  • Regular VS Irregular fever intervals
  • Describe an approach
  • Expert opinion
  • ID, GI, Rheumatology, Oncology

6
Definitions
7
(No Transcript)
8
Working Definition
  • Recurrent/Periodic Fever
  • Repeating episodes of fever separated by periods
    of normal temperature that return at regular or
    irregular intervals
  • Fever of Unknown Origin
  • Fever of greater than 3 weeks duration and
    uncertain diagnosis after 1 week of intensive
    investigation

9
Recurrent Fever
  • John and Gilsdorf 2003
  • 3 episodes of fever in a 6 month period with no
    defined medical illness to explain the fever and
    with an interval of at least 7 days in between
    febrile episodes

10
Recurrent/Periodic Fever
  • Long 2005
  • Recurrent Fever
  • A single illness in which fever and other signs
    and symptoms wane and wax
  • Periodic Fever
  • Recurring episodes of illness for which fever is
    the cardinal featurewith intervening intervals
    of weeks to months of complete well-being.
    Episodes can have either clockwork or irregular
    periodicity

11
Fever of Unknown Origin
  • Petersdorf and Beeson 1961
  • fever persisting more than 3 weeks in duration,
    with documented temperatures of 38.3oC on several
    occasions, and uncertain diagnosis after
    intensive study of at least 1 weeks duration

12
Throw me a frickin bone here
13
(No Transcript)
14
Etiology
  • Common disorders with uncommon presentations
  • INFECTION
  • Inflammatory/Autoimmune
  • Undiagnosed (recurrent)/Neoplasms (FUO)

15
Etiology
Infectious Autoimmune/Inflammatory Malignant No diagnosis Misc
McClung 1972 (n99) 28 14 8 11 16
Pizzo et al. 1975 (n100) 52 20 6 12 10
Feigen and Shearer 1976 (n20) 35 20 5 30 10
Lohr and Hendley 1977 (n54) 33 21 13 19 15
16
Etiology
  • Ciftci et al. 2003
  • Pasic et al. 2006
  • Etiology FUO (n102)
  • Infection 44.2
  • Collagen Vascular 6.8
  • Malignancy 11.7
  • Misc. 24.5
  • Undiagnosed 12.8
  • Etiology FUO (n185)
  • Infection 37.8
  • Autoimmune 12.9
  • Kawasaki Disease 6.4
  • Malignancy 6.4
  • Misc. 8.1
  • Undiagnosed 30

17
Recurrent Fever
  • Differential Diagnosis
  • Fever Intervals

Regular?
Irregular?
18
Fevers at Regular Intervals
  • Fever occurring at regular intervals
  • PFAPA syndrome
  • Cyclic neutropenia
  • Relapsing fever (Borrelia spp. other than
    burgdorferri)
  • Undiagnosed cause
  • Fever occasionally at regular intervals
  • Familial Mediterranean Fever
  • Hyper-IgD syndrome
  • EBV infection

John and Gilsdorf 2002
19
Fever at Regular Intervals
  • Periodic Fever, Aphthous Stomatitis, Pharyngitis,
    and Cervical Adenopathy (PFAPA)
  • high fever q21-28 days
  • Leukocytosis, ?ESR
  • well/investigations normal between episodes
  • Tx prednisone, cimetidine
  • No long-term sequelae

20
Fever at Regular Intervals
  • Cyclic Neutropenia
  • Uncommon
  • May be clinically indistinguishable from PFAPA
  • Usually no bacterial infection during neutropenia
  • Diagnosis
  • CBC X2-3/week for 6 weeks (ANC lt500) and
    spontaneous recovery
  • Bone marrow
  • If symptomatic, G-CSF

21
Fever at Regular Intervals
  • Relapsing Fever
  • Spirochetes of Borrelia genus (not burgdorferi)
  • Fevers 1-6 days separated by 4-14 days
  • crisis (?BP,HR) followed by profuse
    diaphoresis, falling temperature, and ?BP.
  • Mortality for untreated fever during crisis and
    its aftermath
  • Treatment penicillin or tetracycline

22
Fevers at Irregular Intervals
John and Gilsdorf 2002
23
An Approach
  • Careful history physical exam
  • Establish pattern of fever (fever diary)
  • Constant VS Recurrent
  • Duration
  • Associated symptoms
  • Hematologic exam
  • Hepatosplenomegaly
  • Lymphadenopathy

24
When to refer?
  • Dr. Susan Kuhn (Pediatric Infectious Diseases)
  • 3 episodes of recurrent fever

25
What to order?
  • Infectious Disease
  • Order
  • CBC
  • Urine dip/RM/CS
  • Blood culture
  • ESR/CRP
  • EBV serology (IgM/IgG)
  • Quantitative immunoglobulins
  • Maybe
  • CXRay resp symptoms
  • Stool CS/OP diarrhea
  • Thin/Thick blood smear travel to endemic area
    1 year

26
What to Order?
  • Dr. Chris Waterhouse (Paediatric GI)
  • Add
  • Hepatobiliary studies (ALT, GGT, ALP, lipase)
  • Iron studies (ferritin, iron)
  • Albumin (losses/decreased production)
  • Stool studies (CS, OP, C. diff)

27
What to order?
  • Dr. Paivi Miettunen (Pediatric Rheumatology)
  • If referring directly to Rheumatology Clinic
  • Order
  • CBC
  • Creatinine, Urea
  • ESR/CRP on days 1, 5, 10 of fever
  • Ferritin
  • IgD
  • Urine RM
  • Urine Mevalonic Acid

28
What to Order?
  • Dr. Ron Anderson (Pediatric Oncology)
  • Order
  • CBC
  • CXRay
  • if lymphadenopathy, hepatomegaly, splenomegaly,
    abdominal mass

29
Prognosis
  • Generally excellent
  • If no diagnosis after investigations
  • Fevers resolve
  • Growth/Development unaffected
  • No further testing unless new signs/symptoms

30
Back to our Case
  • Referred to urgent paediatrics
  • Bloodwork/Urine investgations unremarkable
  • No diagnosis
  • Fevers resolved
  • Still being followed by paediatrics

31
Conclusions
  1. Recurrent Fever ? Fever of Unknown Origin
  2. Differential Diagnosis are not the same
  3. Urgent Paediatrics/Outpatient Paediatrics
  4. Workup guided by ID/GI suggestions
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