Author: Kevin Ren
So, a young child presents to the ED with a fever of 41 degrees! But on a quick review of systems – nothing. No cough, vomiting, diarrhea, earache, or dysuria. The parents say that other than the fever, they’re totally fine. On a quick inspection, the child does not look sick at all, sitting calmy in their parent’s lap. What do you do?
Epidemiology
- Up to 45% of children with fever have no source on clinical exam
History and Physical
- Head to toe approach to confirm there’s no focus
- Eyes – pain, redness
- Ears – discharge, pain
- Sore throat
- Cough
- Dyspnea
- Nausea/vomiting
- Diarrhea
- Painful urination/CVA tenderness
- Skin infections
- Joint pain
- Ask about child’s
- Oral intake, change in activity/behavior, wet diapers
- If no sxs, or no change in behavior, we have a case of fever with no focus
- Ask about immunization status – completely or incompletely immunized
- PMHx – ask about immunocompromise, sickle cell, etc.
Etiologies
- Self-limiting viral infection (majority of cases)
- Occult UTI (asxs bacteruria)
- Occult pneumonia
- Occult bacteremia = most serious etiology we must rule out
Approach
- Goal = rule out occult bacteremia
- Key hx question = is the child completely immunized?
- Yes = <1% chance of occult bacteremia
- No = 3-11% chance of occult bacteremia
- If child is completely immunized
- Just do UA, maybe CXR if suspicion is high
- No bloodwork needed
- If child is incompletely immunized
- CBC-D
- WBC > 15 or ANC > 10 → blood culture
- WBC > 20 → CXR
- Procalcitonin (limited evidence on utility)
- UA with culture
- CBC-D
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