Fever
Fever: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
Samir S. Shah
Approach to the Patient with Fever
I. Definition of the Complaint
The complaint of fever accounts for a large portion of ambulatory pediatric
visits. Although fever is classically defined as a temperature greater than
38.0
°C for neonates or 38.5°C for older children, the term is subject to significant interpretation. An
isolated temperature measurement of 38.0
°C in a toddler may not be meaningful, but repeated daily temperatures of 38.0°C over a period of several weeks may indicate underlying pathology.
Practitioners must also recognize that body temperature normally fluctuates
throughout the day, tending to be lower in the early morning and peaking in the
evening. Certain conditions or activities (e.g., exercise, warm baths, hot
drinks) also affect the measured temperature. Additionally, axillary
measurements of temperature may be 0.5 to 1.0
°C lower than oral, rectal, or tympanic measurements. To compensate for such
discrepancies, parents are sometimes instructed to add 0.5
° or 1.0°C to axillary measurements to approximate the “real” temperature. Such “corrections” may further cloud evaluation of the febrile child.
II. Complaint by Cause and Frequency
Fever may develop in response to injury, infection, autoimmune disease, or
malignancy. The release of endogenous pyrogens triggers a cascade of reactions
that ultimately raise the hypothalamic set-point. Fever may also be caused when
the body
's heat production or environmental heat overwhelms heat loss mechanisms or when
heat loss mechanisms are deficient. Viruses are the most common cause of fever
in children. Specific common causes of fever are too numerous to list here, but
less common causes are listed in Table 11-1.
III. Clarifying Questions
Certain clarifying questions may help provide clues to the diagnosis.
• What temperature value is the parent using to define a fever?
— Although 37°C (98.6°F) is commonly considered to be the normal body temperature, normal temperature
exhibits significant daily variation, with a nadir in the early morning and a
peak in the early evening.
• Are there symptoms of specific illness?
— The presence of certain complaints, such as bloody diarrhea, cough, and stiff
neck, suggests specific diagnostic categories.
• Has there been exposure to animals?
— In addition to pets in the home, inquiry should be made about contact with
rodents or farm animals and consumption of unpasteurized dairy products. For
example, exposure to house mice may suggest lymphocytic choriomeningitis virus,
and exposure to farm animals suggests brucellosis as a potential cause.
Household contacts with occupational exposure to potentially infectious animals
should also be sought.
• Have there been recent tick or flea bites?
— Tularemia, ehrlichiosis, Rocky Mountain spotted fever, and Lyme disease may be
acquired in this manner.
• Has there been any recent travel?
— Travel to regions where certain diseases are endemic may shift the differential
diagnosis. For example, travel to the Indian subcontinent raises the suspicion
for typhoid fever and malaria. Coccidioidomycosis would be included in the
differential diagnosis of a child with atypical pneumonia who has traveled to
the southwestern United States.
• What medications is the child receiving?
— Medications, including penicillins, cephalosporins, acetaminophen,
anticonvulsants, and methylphenidate, can cause fever.
• What is the pattern of fever?
— The evaluation of acute, prolonged, and recurrent fevers differs dramatically.
If differentiating between prolonged and recurrent fevers is difficult,
documenting the fevers in a
“fever diary” may help clarify the pattern.
• Are there family members with recurrent episodes of fever?
— Familial dysautonomia, familial Mediterranean fever, and cyclic neutropenia are
some of the hereditary disorders that cause recurrent fever.
IV. References
1. Calello DP, Shah SS. The child with fever of unknown origin. Pediatr Case Rev 2002;2:226–239.
2. Nizet V, Vinci RJ, Lovejoy FH Jr. Fever in children. Pediatr Rev 1994;15:127–135.
3. Saper BC, Breder CD. The neurologic basis of fever. N Engl J Med 1994;330:1880–1886.
4. Tunnessen WW Jr. Fever. In: Tunnessen WW Jr, ed. Signs and symptoms in pediatrics, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 1999:3–7.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Fever - Case 11-1: 18-Month-Old Girl (Pediatric Complaints and Diagnostic Dilemmas)
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