Fever – Recurrent

Recurrent or relapsing fever is a cluster of febrile episodes that occur over a period of time, with documented fever-free intervals and without an apparent medical cause for each episode. It should be differentiated from cyclic fever, which refers to febrile episodes with periodicity, and from fever of unknown origin, which refers to prolonged daily fever with no fever-free intervals.

Differential Diagnosis

• Repeated viral infections
  –Most common cause of recurrent febrile episodes in childhood
  –Start of day care or change of geographic location may be related
• Urinary tract infection (UTI)
  –May be self-limited but recur especially if underlying anomaly exists
• Epstein-Barr virus (EBV)
  –May present with recurrent febrile episodes due to one initial infection
• Other specific viral syndromes
  –Parvovirus B19
  –CMV
• Immunodeficiency
  –Repeated bacterial infections should lead to investigation of immune status
• Dental abscess (non-dental abscesses typically present with prolonged daily fever)
• Chronic meningococcemia
• Acute rheumatic fever
• Inflammatory bowel disease (IBD)
• Juvenile rheumatoid arthritis (JRA)
• Behçet disease
• Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) or Hibernian Fever
  –Autosomal dominant disease with fever, myalgias with migratory pattern, conjunctivitis and rash
• Familial cold autoinflammatory syndrome or familial cold urticaria
  –Rash, fever, arthralgia, and conjunctivitis
  –Precipitated by exposure to cold
• Muckle-Wells syndrome
  –Similar presentation to familial cold urticaria
  –Symptoms not triggered by cold
• Brucellosis
  –Most prevalent around the Mediterranean and Arabic countries, also present in South America and India
• Yersiniosis
• Typhoid fever
• Rat-bite fever
• Malaria
• Factitious fever

Workup and Diagnosis

• History
  –Documentation of fever
  –Duration of episodes and fever-free intervals
  –Symptoms associated with the fever
  –Symptoms during the fever-free intervals
  –Weight loss
  –Recent documented infections, medications
  –Travel, animal and insect exposure
  –Specific conditions related to episodes (e.g., cold)

• Physical exam
  –Vitals, growth parameters (failure to thrive can be a presentation of UTI and immunodeficiency)
  –Rash (transient pink rash in JRA)
  –Ophthalmologic exam: Uveitis (IBD and Behçet), conjunctivitis (TRAPS)
  –Hepatosplenomegaly, lymphadenopathy
  –Genital ulcers (Behçet)
  –Perianal skin tags (IBD)
  –Mouth ulcers, pharyngitis
  –Arthritis

• CBC with differential
• ESR or CRP
• Urine culture
• Blood culture
• Serology for EBV, CMV, or Parvovirus B19
• Low levels of serum type 1 TNF receptor in TRAPS
• Documentation of fever in the office should exclude the possibility of factitious fever

Treatment

• Repeated viral illnesses
  –Reassurance of the parents
  –Advice on antipyretics
  –Encourage fluid intake
  –Limit of sick exposure if possible
• UTI
  –Antibiotics based on bacteria and sensitivity
  –Prophylactic antibiotics if underlying cause is present
• Bacterial infections: Bacteria-specific antibiotic
• JRA, Behçet, or IBD
  –Prednisone or immunosuppressive medications
• TRAPS
  –Prednisone and etanercept
• Familial cold urticaria and Muckle-Wells syndrome
  –Prednisone may be used
  –If amyloidosis is present, colchicine may be required

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Infection

• Back to symptom: Infection: Introduction (review 311 causes)
• Next Book Extract About Infection: Bibliography: Human Immunodeficiency Virus Infection (A Pocket Manual of Differential Diagnosis)
• All Book Extracts: All Online Book Extracts for Infection

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Bibliography: Human Immunodeficiency Virus Infection (A Pocket Manual of Differential Diagnosis)

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