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Fever of Unknown Origin, Pediatric

Basics

Description

- Common infectious causes - Respiratory infections (otitis media, mastoiditis, sinusitis, pneumonia, pharyngitis, peritonsillar/retropharyngeal abscess) - Systemic viral syndrome - Infectious mononucleosis (Epstein-Barr virus [EBV], cytomegalovirus [CMV]) - Urinary tract infection (UTI) - Bone or joint infection - Enteric infection (Salmonella, Yersinia enterocolitica, Yersinia pseudotuberculosis, Campylobacter jejuni) - Cat-scratch disease

- Less common infectious causes - Tuberculosis (TB) - Lyme disease - Rickettsial disease (Rocky Mountain spotted fever, ehrlichiosis, anaplasmosis) - Malaria - CNS infection (bacterial or viral meningoencephalitis, intracranial abscess) - Dental or periodontal abscess - Subacute bacterial endocarditis (SBE) - HIV infection - Acute rheumatic fever

- Possible noninfectious causes - Collagen vascular disease (systemic juvenile idiopathic arthritis [JIA], systemic lupus erythematosus, dermatomyositis, sarcoidosis, vasculitis syndrome) - Malignancy - Kawasaki syndrome - Inflammatory bowel disease (IBD) - Drug fever - Hyperthyroidism - Factitious fever or Munchausen syndrome by proxy - Centrally mediated fever - Periodic fever syndrome - Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis)

- Phase 1 - Document fever. - Thorough history and physical exam - Determine whether constitutional symptoms (e.g., growth failure, developmental arrest) suggest a serious underlying disease. - Create broad differential diagnosis. - Begin initial laboratory evaluation while tailoring the cadence of evaluation to patient's severity of illness.

- Question: Ethnicity? - Significance: Some hereditary periodic fever syndromes have ethnic predilection. Consider familial Mediterranean fever (Armenian, Arab, Turkish, Sephardic Jew), hyper-IgD syndrome (Dutch, French), and tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS) (Irish, Scottish) - Question: Exposure to animals? - Significance - Household exposures including pets and rodents - Recreational activities (e.g., hunting) - Household contacts with occupational exposure to animals - Consider cat-scratch disease, brucellosis, tularemia, leptospirosis, and lymphocytic choriomeningitis virus (from mice)

Fever of unknown origin (FUO) implies пїЅ

  • A febrile illness (38.3 пїЅC on multiple occasions)
  • Present for >14 days
  • No apparent source despite careful history taking, physical exam, and preliminary lab studies

Diagnosis

Differential Diagnosis

FUO is more often an unusual presentation of a common disease than a common presentation of an unusual disease. Possible causes include the following: пїЅ

  • Common infectious causesRespiratory infections (otitis media, mastoiditis, sinusitis, pneumonia, pharyngitis, peritonsillar/retropharyngeal abscess)Systemic viral syndromeInfectious mononucleosis (Epstein-Barr virus [EBV], cytomegalovirus [CMV])Urinary tract infection (UTI)Bone or joint infectionEnteric infection (Salmonella, Yersinia enterocolitica, Yersinia pseudotuberculosis, Campylobacter jejuni)Cat-scratch disease
  • Less common infectious causesTuberculosis (TB)Lyme diseaseRickettsial disease (Rocky Mountain spotted fever, ehrlichiosis, anaplasmosis)MalariaCNS infection (bacterial or viral meningoencephalitis, intracranial abscess)Dental or periodontal abscessSubacute bacterial endocarditis (SBE)HIV infectionAcute rheumatic fever
  • Other infectious causesQ feverBrucellosisToxoplasmosisSyphilisParvovirus B19Endemic fungi (histoplasmosis, blastomycosis, coccidioidomycosis)PsittacosisTyphoid (Salmonella spp.)Chronic meningococcemia
  • Possible noninfectious causesCollagen vascular disease (systemic juvenile idiopathic arthritis [JIA], systemic lupus erythematosus, dermatomyositis, sarcoidosis, vasculitis syndrome)MalignancyKawasaki syndromeInflammatory bowel disease (IBD)Drug feverHyperthyroidismFactitious fever or Munchausen syndrome by proxyCentrally mediated feverPeriodic fever syndromeKikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis)

Etiology

Etiology has changed as the use of more sensitive tests (e.g., MRI, polymerase chain reaction [PCR] tests) permits earlier detection of many conditions that caused FUO in the past. Fever resolves in 40-60% of children without identification of a specific cause. пїЅ

Approach to the Patient

Find the cause of the fever and begin treatment of the underlying illness. пїЅ

  • Phase 1Document fever.Thorough history and physical examDetermine whether constitutional symptoms (e.g., growth failure, developmental arrest) suggest a serious underlying disease.Create broad differential diagnosis.Begin initial laboratory evaluation while tailoring the cadence of evaluation to patient's severity of illness.
  • Phase 2Begin invasive studies to seek rarer forms of fever, such as lymphoma, brucellosis, and SBE, only if clinically indicated.
  • Phase 3Reexamine patient, consider additional testing, and reconsider causes such as systemic JIA, sarcoidosis, and factitious fever.

Repeat history and physical exam combined with the results of previous testing should guide the subsequent evaluation. пїЅ

History

Initial studies should include a CBC, liver function tests, blood culture, urinalysis, urine culture, stool culture, and stool ova and parasite testing. пїЅ

  • Question: Temperatures and how they were measured (tympanic, oral, axillary, rectal)?
  • Significance:As many as 50% of children referred for evaluation of FUO have multiple unrelated infections, parental misinterpretation of normal temperature variation, or complete absence of fever at time of evaluation.Parents are sometimes told to add a 1-2 пїЅF "correction"пїЅ onto a temperature measured in the axilla to better approximate the core temperature. Such practices may further cloud the evaluation of the febrile child.
  • Question: Ethnicity?
  • Significance: Some hereditary periodic fever syndromes have ethnic predilection. Consider familial Mediterranean fever (Armenian, Arab, Turkish, Sephardic Jew), hyper-IgD syndrome (Dutch, French), and tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS) (Irish, Scottish)
  • Question: Exposure to animals?
  • SignificanceHousehold exposures including pets and rodentsRecreational activities (e.g., hunting)Household contacts with occupational exposure to animalsConsider cat-scratch disease, brucellosis, tularemia, leptospirosis, and lymphocytic choriomeningitis virus (from mice)
  • Question: Ingestion of raw meat, fish, or unpasteurized milk?
  • Significance: Trichinosis, brucellosis
  • Question: Travel history, including past residence?
  • Significance: Malaria, endemic fungi (e.g., coccidioidomycosis in Southwest, blastomycosis in Southeast, histoplasmosis in Midwest), typhoid (Indian subcontinent), TB
  • Question: Pica or dirt ingestion?
  • Significance: Toxocara canis or Toxoplasma gondii infection
  • Question: Change in behavior or activity?
  • Significance: Brain tumor, TB, EBV, Rocky Mountain spotted fever
  • Question: Pattern of fever?
  • Significance: May correlate with underlying cause. A fever diary kept by the parent or caretaker may provide more objective documentation of the fever pattern than simple recall.
  • Question: Medications (including OTC medications and eyedrops)?
  • Significance: Drug fever, atropine-induced fever, methylphenidate, and antibiotics (especially penicillin, cephalosporins, and sulfonamides)
  • Question: Well-water ingestion?
  • Significance: Giardiasis

Physical Exam

  • Finding: Impaired weight gain or linear growth?
  • Significance: Collagen vascular disease, malignancy, IBD
  • Finding: Toxic appearance?
  • Significance: Kawasaki syndrome
  • Finding: Conjunctivitis?
  • Significance: Kawasaki syndrome (limbic sparing), adenovirus, measles
  • Finding: Ophthalmologic exam?
  • Significance: Papilledema-consider CNS mass lesion; uveitis-consider TB, systemic lupus erythematosus, Kawasaki syndrome, and sarcoidosis
  • Finding: Sinus tenderness, nasal discharge, or halitosis?
  • Significance: Sinusitis
  • Finding: Pharyngitis?
  • Significance: Kawasaki syndrome, EBV, CMV
  • Finding: Tachypnea?
  • Significance: SBE, pneumonia
  • Finding: Rales?
  • Significance: Histoplasmosis, sarcoidosis, coccidioidomycosis
  • Finding: Cardiac murmur, gallop, or friction rub?
  • Significance: SBE, acute rheumatic fever, pericarditis
  • Finding: Hepatosplenomegaly?
  • Significance: Hepatitis, EBV, CMV, ehrlichiosis, anaplasmosis
  • Finding: Rectal abnormalities?
  • Significance: Pelvic abscess, IBD
  • Finding: Arthritis?
  • Significance: JIA, IBD, acute rheumatic fever
  • Finding: Bony tenderness?
  • Significance: JIA, leukemia, osteomyelitis

Diagnostic Tests & Interpretation

The laboratory evaluation for a child with FUO should be directed toward the most likely diagnostic possibilities. Consider the following initial studies: пїЅ

  • Test: CBC with differential and careful examination of WBC morphology
  • Significance: Kawasaki syndrome, cyclic neutropenia, malignancy, ehrlichiosis, anaplasmosis (morulae in WBC cytoplasm), and babesiosis
  • Test: ESR, C-reactive protein, or procalcitonin
  • Significance: Collagen vascular disease, IBD, occult infection. ESR is generally normal in drug fever and central fever.
  • Test: Blood cultures
  • Significance: Endocarditis, salmonellosis, other bloodstream infections
  • Test: Urinalysis and urine culture
  • Significance: UTI, Kawasaki syndrome (sterile pyuria)
  • Test: Tuberculin skin test (by purified protein derivative)
  • Significance: TB
  • Test: Stool bacterial culture and examination for ova and parasites
  • Significance: Salmonella, Giardia
  • Test: Specific antibody testing
  • Significance: Depending on clinical suspicion, consider the following:First line: Streptococcal enzyme titers (antistreptolysin O, anti-DNase B); EBV; CMV; cat-scratch disease; Lyme disease; hepatitis A, B, or C; or HIV (by PCR)Second line: Rocky Mountain spotted fever; ehrlichiosis/anaplasmosis, toxoplasmosis, brucellosis, Q fever, leptospirosis, tularemia, dengue fever
  • Test: Viral testing of nasopharyngeal aspirates
  • Significance: systemic viral syndrome (adenovirus)
  • Test: Evaluation for immune deficiency
  • Significance: underlying predisposition
  • Test: Bone marrow examination and culture
  • Significance: Salmonella infection, Mycobacterium avium complex, histoplasmosis, brucellosis, malignancy
  • Test: Lumbar puncture
  • Significance: CNS infection

Imaging

  • Guided by history, physical examination, and epidemiologic factors; indiscriminate use of imaging not likely to be helpful.
  • Sinus CT: sinusitis
  • Chest radiograph: TB, endemic fungi, pneumonia
  • Chest and/or abdominal CT scan: TB, liver abscess, hepatosplenic cat-scratch disease
  • Pelvic or extremity MRI: osteomyelitis, pyomyositis
  • Gallium or bone scan: osteomyelitis, malignancy

Additional Reading

  • Chow пїЅA, Robinson пїЅJL. Fever of unknown origin in children: a systematic review. World J Pediatr. 2011;7(1):5-10. пїЅ[View Abstract]
  • Drenth пїЅJPH, van der Meer пїЅJWM. Hereditary periodic fever. N Engl J Med. 2001;345(24):1748-1757. пїЅ[View Abstract]
  • Gattorno пїЅM, Caorsi пїЅR, Meini пїЅA, et al. Differentiating PFAPA syndrome from monogenic periodic fevers. Pediatrics. 2009;124(4):e721-e728. пїЅ[View Abstract]
  • Jacobs пїЅRF, Schutze пїЅGE. Bartonella henselae as a cause of prolonged fever and fever of unknown origin in children. Clin Infect Dis. 1998;26(1):80-84. пїЅ[View Abstract]
  • Talano пїЅJM, Katz пїЅBZ. Long-term follow-up of children with fever of unknown origin. Clin Pediatr. 2000;39(12):715-717. пїЅ[View Abstract]

Codes

ICD09

ICD10

SNOMED

  • 7520000 Pyrexia of unknown origin (finding)

FAQ

  • Q: Do all of the mentioned tests need to be performed?
  • A: A "shotgun"пїЅ approach to testing is rarely useful in making the diagnosis, and unanticipated abnormalities (e.g., false-positives) may lead to additional invasive tests with potential for harm.
  • Q: Is hospitalization required for the diagnosis of FUO?
  • A: Many tests, including MRI, can now be performed in the outpatient setting. Hospitalization is not routinely required for diagnosis but should be considered in patients who appear ill, have progression of symptoms, or when fever needs to be documented.
  • Q: How is cat-scratch disease acquired?
  • A: Cat-scratch disease, caused by Bartonella henselae, can be acquired through cat (usually kittens or young cats) scratches or licks. Rarely, dogs may transmit the organism. If the family does not own a kitten or young cat, remember to ask about other sources of exposure (e.g., friends, family, school trips).