fever without source 1 36mo n.
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Fever Without Source 1-36mo. Case 1. 5mo girl, fever, well-appearing, no underlying medical problems VS nml except T 39.8 R; exam normal Anything else you want to know? What’s your approach? What next?. Case 1 (cont.). She is incompletely immunized.

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case 1
Case 1
  • 5mo girl, fever, well-appearing, no underlying medical problems
  • VS nml except T 39.8 R; exam normal
  • Anything else you want to know?
  • What’s your approach? What next?
case 1 cont
Case 1 (cont.)
  • She is incompletely immunized.
    • Any infant <6mo by definition since they hasven’thad 3 sets of Hib +Prevnar. Risk of bacteremia approx 5%. So…
  • What next?
  • Tests
    • CBC + diff
    • Blood culture
    • UA + culture
    • CXR
case 1 cont1
Case 1 (cont)
  • WBC = 15,500 /microL
  • Bands = 1600 / microL
  • UA neg
  • Blood culture recommended if WBC < 15,000/microL; often ordered simultaneously; can be held until WBC is back
  • CXR not indicated
case 1 cont2
Case 1 (cont)
  • Antibiotics?
  • YES!
    • Recommendation: ceftriaxone
  • Admit or home?
    • Home only if 24 hour follow up
case 1 cont3
Case 1 (cont.)
  • Take home points:
    • Any child under 6mo old is by definition incompletely immunized. They haven’t received 3 doses of Hib and Prevnar.
    • The risk of bacteremia in incompletely immunized infants is 5% (data use from pre-Hib/Prevnar studies
    • All temps should be rectal, all urines cathedif not potty trained
    • Fever in 3-36mo is temp >39C (102.2F)
    • WBC >15,000/microL warrants Bcx and removes infant from low risk group
    • Must have follow up within 24 hrs to discharge
case 2
Case 2
  • 7mo girl, fever, well-appearing, no underlying medical problems
  • VS nml except T 39.8 R; exam normal
  • Anything else you want to know?
    • Immunizations complete
  • What’s your approach? What next?
case 2 cont
Case 2 (cont.)
  • Completely immunized, risk of bacteremia <1%
  • What next?
  • Test:
    • UA + culture
case 2 cont1
Case 2 (cont.)
  • UA neg
  • Antibiotics?
    • No.
  • Dispo?
    • Home with 24-48 hr follow up
case 2 cont2
Case 2 (cont.)
  • Take home points
    • In completely immunized children, risk of bacteremia is <1%
    • UA + culture in all girls 3-24mo with fever >39C
case 3
Case 3
  • 9mo boy, well appearing, no underlying medical conditions, immunizations complete, home temp 39.5C oral
  • VS nml except T 38.2C
  • Anything else you want to know?
    • Circumcised? No.
    • Is temp rectal? No, oral. Repeat rectal T = 39.0C
  • Tests?
case 3 cont
Case 3 (cont.)
  • UA + culture
  • UA shows WBC & bacteria
  • Treat and home with follow up
case 3 cont1
Case 3 (cont.)
  • Take home points
    • Always check immunization status
    • Make sure the temps are rectal
    • Home temps are as good as ED temps
    • In boys, always check for circumcision
      • UTI in uncircumcised boys with FUS = 10-25%
      • UTI in circumcised boys with FUS = 2-4%
    • All completely immunized children with =>39C and FUS should have UA + cxIF; 1. Uncircumcised <12mo; 2. Circumcised <6mo; 3. Girl <24 mo.
case 4
Case 4
  • 2 ½ yo boy, fever for 3 days, well appearing, no med problems; immunizations complete, intake down a little
  • PE: VS BP 80/35, HR 143, RR 43, T 40.2C SaO2 96%; mild diffuse abd tenderness
  • Anything else you want to know?
    • Cap refill 3 sec
  • What’s your approach?
case 4 cont
Case 4 (cont.)
  • Know age appropriate VS
  • T and RR are abnormal
    • RR > 40 = tachypnea
    • T > 39C = fever
  • What next?
  • Tests?
    • CBC + diff
    • Blood cultures
    • CXR
    • CRP
    • UA + cx
case 4 cont1
Case 4 (cont.)
  • WBC 23,000/microL
  • CXR neg
  • CRP 85mg/L / 8.5mg/dL
  • Blood culture not needed since fully immunized; bacteremia <1%
  • UA + culture possible but not really needed
case 4 cont2
Case 4 (cont.)
  • Treatment?
    • Yes
      • Amoxicillin
  • f/u in 24-48 hrs
case 4 cont3
Case 4 (cont.)
  • Take home points
    • 1-5yo tachypnea >40bpm
    • WBC > 15,000/microL suggests pyogenic infection; >20,000/microL with tachypnea, think PNA
    • Here CXR: 1. radiographic PNA may lag behind symptoms; 2. hypovolemic patients with PNA may have neg CXR; evident after volume repletion
    • Radiographic PNA found in 20-30% of febrile young children without clinical evidence of PNA, but with WBC =>20,000/microL
    • Studies support the use of CRP levels when considering PNA. Elevated levels suggest bacterial etiology
    • No blood cultures needed since fully immunized
case 5
Case 5
  • 1.5mo girl, well appearing, no med probs, VS normal for age
  • PE: T 39.4 R, otherwise nml
  • Anything else you want to know?
  • What’s your approach?
case 5 cont
Case 5 (cont.)
  • Tests
    • CBC + diff
    • Blood culture
    • UA + culture
    • CXR
case 5 cont1
Case 5 (cont.)
  • CBC 13,000/microL
  • UA neg
  • CXR not needed
  • Anything else you want to know?
  • Bands 4176/microL
    • Nml <1500/microL
case 5 cont2
Case 5 (cont)
  • Plan?
    • LP or not?
      • Yes
    • Antibiotics or not?
      • Yes, IM rocephin
    • Home vs admit?
      • Home OK
    • Since fever + high bands in 1.5mo, suggested to treat with IM rocephin and f/u in 24 hrs
    • Also since patient is 1-3mo and plan involves treating with antibiotic, recommendation is to do LP prior to antibiotics
  • 24hr f/u showed Bcx no grow, Ucx +growth
case 5 cont3
Case 5 (cont)
  • Take home points
    • Check bands… order diff’s
    • CXR in 1-3 mo recommended only with 1+ pulm symptom
        • RR >50, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, cough
    • LP before antibiotics in this age group
    • LP not always necessary if caregivers knowledgeable, have transportation, well-established f/u. not recommended to give abx
    • UTI possible with nml UA
    • Recommendation for most: CBC +diff, Bcx, UA +Cx, CSF cell count +Cx; come clinicians elect to perform fewer labs.
    • There are no guidelines for minimal evaluation of fever in well-appearing infants age 29-60d.
case 6
Case 6
  • 3mo boy, well appearing, no med probs,
  • PE 38.2R, otherwise VS nml
  • Anything else you want to know?
  • What is your approach?
case 6 cont
Case 6 (cont)
  • Tests:
    • CBC + diff
    • UA
    • Blood cx
  • What next?
    • LP
      • In 1-3mo, <5K or >15k/microL suggests need for LP
case 6 cont1
Case 6 (cont)
  • WBC 15,600/microL
  • UA neg
  • Cultures pending
  • CSF neg
  • What next?
case 6 cont2
Case 6 (cont)
  • Treatment?
    • Antibiotics?
      • Yes, Ceftriaxone
  • Dispo
    • Admit?
      • Yes
    • WBC >15000/micoL, suggests admission with parental Abx until all cultures neg
  • During admission, patient became agitated, tachypneic, O2 sat dropped; CXRLobar infiltrate; patient required intubation.
case 6 cont3
Case 6 (cont)
  • Take home points
    • In 1-3mo, WBC <5K or >15k/microL suggests need for LP
    • WBC <5K or >15k/microL, suggests need for admission with parental Abx until all cultures neg
    • Fever may be the only sign of occult PNA in young children.