most common causes of fever thailand

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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accomplish something truly worthwhile.Walt Disney

most common causes of fever thailand

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