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7/31/2019 most common causes of fever thailand
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Warunee Punpanich, MD
Pediatric Infectious Division
Queen Sirikit National Institute of
Child Health
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The kids in our classroom are infinitely
more significant than the subject matterwere teaching them!
Meladee McCarty
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Normal core temperature : 37C (98.6F) + 0.8
diurnal variation = 0.6 - 1.1C
maximum temperature ~4 - 6 pm.
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Oral - axilla temp < 1C
Rectal - oral temp < 1C (generally 0.4C (0.7F) higher
than oral readings)1
Tympanic membrane ~oral temperature (not reliable for< 3 year old children): underestimate core temp by 0.5 C
Axillary temp underestimate core temp 1 C
Lower esophageal temp > core temp
The standard definition of fever is a rectal temperature of >
100.4F (38.0
C).
A life-threatening event occurs in approximately 1%
of children presenting to an acute care setting with fever.21. Harrisons Internal Medicine
2. http://www.emedicine.com/EMERG/topic377.htm
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Raising of the hypothalamic set point in CNS Infection, CNT disease, Malignancy
Reduced by antipyretic & physical removal of heat
Heat production exceeding heat loss ASA overdose,
hyperthyroidism
excessive environmental temperature
malignant hyperthermia
Defective heat loss ectodermal dysplasia, heat stroke
anticholinergic drug poisoning
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Exgenous Pyrogens
Viruses Endotoxin
Bacteria Ag-Ab complexesFungi Drugs
Antigen+
Sensitized Phagocytic LeukocytesT-Cells
Monocytes
MacrophagesNeutrophils
Interleukin-1 Interleukin-1
lymphocyte-activating endogenous pyrogen
Interleukin-2 T-Cell Preoptic Anterior
Hypothalmic NucleiProliferation ofHelper T-Cells Prostaglandins
Fever
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Interleukin-1
Phospholipids
phospholipase A2
Arachidonic acid Leukotrienes
lipogenase
Cyclo-oxygenaseEndoperoxides
Prostacyclins Prostaglandins Thromboxanes(PGE-2)
Fever
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1. HR increase~
15 BPM/1C
2. Metabolic Rate 10-12%/1C
3. Insensible water loss : 300-500 ml/m2/day
4. Electrolyte & nutritional consequence
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Endogenous Cause
- Infection & Inflammation
- Malignancy
- CNT Disease Tissue injury
- Hereditary : FMF, Ectodermic dysplasia
- Metabolic Dz
- Kawasaki- Endocrine
- CNS (thermoregulatory center)
- granulomatous Dz
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Exogenous cause
- Drug : cocaine, amphotericin, ATB
- Vaccine
- Biologic agent : GM-CSF, IL, IFN
- Factitious fever
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1. Fever with localizing sign
2. Fever without localizing sign (FWLS)
self-limited
fever with localizing sign
fever of unknown origin
3. Fever with nonspecific sign
4. Fever of unknown origin
uncommon presentation of common diseaseInfections (30-50%)CNT disease (10-20%)Neoplasm (5-10%)Miscellaneous (10-20%)
Unknown (10-25%)
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Fever w/o localizing sign
Occult bacteremia occurs 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 therates to as low as 0.5-1%.
This change is most likely due to the increasing ratesof pneumococcal vaccinations.
http://www.emedicine.com/EMERG/topic377.htm
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History taking :
-Characteristic of fever : onset, duration, pattern
-Associated symptoms
-Assessment of risk factors:- Host, Agent, Environment
(animal-contact, recent travel, raw meat
consumption (tularemia), vaccination etc.)
- Hx of pica: Toxocara (visceral larva
migrans) or Toxoplasma gondii
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PE : -general assessment
-level of fever
Risk of bacteremia
BT < 39C : 1.2%
39.5C : 6.2% then
( 0.5C : Risk 2%
> 41C : 26%
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PE : -Sweating: The continuing absence of sweat suggests
dehydration, anhidrotic ectodermal dysplasia, familial
dysautonomia, or exposure to atropine.
source of infection: eye & eye ground, TM, sinuses, skinsign, CNS, PR, corneal reflex, DTR, Iodine test
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Nailfold capillary pattern in rheumatic diseases. A, Normal nailfold capillary
pattern in a healthy child, with a homogeneous distribution and uniform
appearance of capillary loops. B, The nailfold capillary pattern in a child with
juvenile dermatomyositis that shows dropout of capillary end-loops, resulting
in a wide band of avascularity. Dilated, tortuous capillaries are also seen,
some with terminal bush formation that is found in patients with juvenile
dermatomyositis, with scleroderma, and with Raynaud phenomenon that
may progress to scleroderma
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1. Quality of cry
2. Reaction to parent stimulation
3. State variation
4. Color
5. Hydration
6. Response to social overtures
Mccarthy et al : Pediatrics 1982;74:802
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Incidences of serious illness are 2.7% for a score of 10or less, 26% for a score of 11-15, and 92.3% for a scoreof 16 or more (McCarthy, 1982).
For quality of cry, 1 = strong or no cry; 3 = whimper or sob; and 5= weak cry, moan, or high-pitched cry.
For reaction to parents, 1 = brief cry or content, 3 = cries on andoff, and 5 = persistent cry.
For state variation, 1 = awakens quickly, 3 = difficult to awaken,and 5 = no arousal or falls asleep.
For color, 1 = pink; 3 = acrocyanosis (cyanosis of theextremities); and 5 = pale, cyanotic, or mottled.
For hydration, 1 = eyes, skin, and mucus membranes moist; 3 =mouth slightly dry; and 5 = mucus membranes dry and eyessunken.
For social response, 1 = alert or smiles; 3 = alert or brief smile;
and 5 = no smile, anxious or dull.
Although high scores correlate well with ill appearanceand higher rates of SBI, low scores cannot be used toexclude SBI.
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1. CBC
Risk of bacteremia5 times if total leukocyte
> 15,000
2. ESR, CRP
increase in bacterial infection, CNT Dz, neoplasm
ESR > 100 : suggestive of Kawasaki
Tuberculosis
CNT D2
Malignancy
Newborn : normal CRP have high NPV (99%)
3. Specific laboratory investigation : culture, X-ray, TT, serology
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Age < 3 months : 10-15% serious bacterial infection
5% bacteremia
Clinical :Toxic ---> Admit + septic W/U + empiric ATBNontoxic ---> assessment : CBC, ESR, CRP
Lab assessment - Low Risk : Culture ---> ceftriaxone+F/U- High Risk : Admit + empiric ATB
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Clinical : Toxic Admit + septic W/U + empiric ATB
Nontoxic level of body temperature
BT < 39C observe & F/U within 48 hr.
BT > 39C Laboratory assessment : CBC, ESR, CRP Admit + culture + empiric ATB Culture & F/U 48 hr.
Lab assessment : Low Risk F/UHigh Risk Admit + C/S +empiricATB
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Clinical criteria Laboratory criteria
Previous healthy WBC 5,000 15,000,Nontoxic clinical appearance Band < 1500, Normal ESR
No focal bacterial infection Normal UA (WBC < 5/HPF)When diarrhea present :< 5 WBC/HPF in stool
*LP : certainly is not required in all febrile children, but shouldbe reserved for those in whom there is any clinical suspicion ofCNS involvement (esp. in children < 12 month)
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Harper MB. Update on the management of the febrile infant. Clin Ped Emerg Med 5:5-12.
2004
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Prolong fever : BT > 38.5C > 2 wk
FUO : prolong fever of indiscernible
cause despite careful initial
evaluation
Classic FUO (Adult) : Fever lasting for 3 wk after
1 wk of hospitalization
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Scrub typhus (7.5%) Typhoid fever (1.9%)
Influenza (6.0%) Chikungunya (1.1%)
Dengue fever (5.7%) Leptospirosis (1.1%)
Murine typhus (5.3%) Melioidisis (0.9%)
Bacteremia (3.0%) JE infection (0.6%)
A. Lelarasmi 1992
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History taking :
1. Duration of fever
usually < 3 week in infections etiology
2. Age groupDF, DHF rarely seen in > 40 yr
Rickettsial disease and leptospirosis : beyond infancy
Typhoid : late childhood/young adolescent
3. Place
scrub typhus & malaria : rural
dengue, murine typhus, leptopirosis : urban
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4. SeasonInfluenza, DHF, Leptospirosis: common in rainy-
season & winter
rare in summer
GI - transmitted disease : common in summer
5. Family history
Dengue & Lepto : outbreak or epidemic prone
6. Myalgia
If markedly tender suggesting Leptospirosis,
staphylococcal septicemia, Trichinosis &
Gnathostomiasis
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1. Eschar : Scrub typhus
Thai tick typhus
2. Rash : generalized rash Evidence against
leptospirosis, malaria & enteric fever
3. Subconjunctival hemorrhage (& uveitis) : highly
suggestive of leptospirosis & Rickettsia
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1. CBC
- WBC if < 3,000 suggesting Dengue infection
> 15,000 suggesting Leptospirosis (severe form)
- platelet if decrease suggestive DHF, leptospirosis
(severe form of leptospirosis with thrombocytopenia
usually have WBC elevation)
- Malarial pigment
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2. Serum creatinine > 2 mg/dl20% of leptospirosis elevate Cr.
3. Evidence of aseptic meningitis
leptospirosis / Rickettsia
4. Weil-felix test, IFA or IIP for Rickettsia
leptospira titer
5. Stool C/S, BM C/S for typhoid
6. Sterile pyuria : TB kidney & Kawasaki
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1. Repeat PBS for malaria
2. Empiric treatment with cotrimoxazole for typhoid
fever
3. If not improve Doxycycline which effective
for : Lepto, Scrub, murine typhus, Mycoplasma
defervescence within 48 hr.
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