CLIPP case 10. Infant with fever

Question 1

Fever of unknown origin

Answer 1

Fever > 38.3 (101) for >2 weeks, without diagnosis after 1 week evaluation

Question 2

Fever without a source

Answer 2

No identified source after complete H & P

*Usual viral, but can be serious bacterial illness (UTI most common)

Question 3

UTI in infants

Answer 3

Must be on differential for any infant with fever and nonfocal H&P

• Only test to diagnose: urine cx from cath specimen (not bag). +nitrite, but - does not r/o. +LE means pyuria (≥5 per hpf or ≥10 per microL)
• Tx: Cover enteric GNs (E. coli, kleb, proteus). Admit, parenteral abx for severe symptoms.
• Renal and bladder US to assess for reflux
• 2nd UTI: Voiding cystourethrogram to assess for vesicoureteral reflux
• Radionucleotide cystogram periodically to follow course of VUR

Question 4

Meningitis in infants

Answer 4

Must be on differential for any infant with fever

*Only reliable way to r/o in infant <12months with fever: LP

Question 5

Occult bacteremia

Answer 5

Bacteremia in child with high fever

*Most often S. pneumoniae (PCV13 only protects against 13 serotypes)

Question 6

Kernig’s and Brudzinski’s sign

Answer 6

Kernig’s: + resists knee extension after flexing hip
Burdzinski’s: + retracts legs toward chest when you flex neck
*Most patients with bacterial meningitis <12 months will have (-) signs
*If (+) perform LP

Question 7

Symptoms of bacterial meningitis in children

Answer 7

Hypothermia, lethargy, fever, respiratory distress, poor feeding, vomiting, diarrhea, seizures, restlessness, irritability, bulging fontanelles

Question 8

Pneumonia

Answer 8

Most have cough or tachypnea, but fever may be only sign!

Question 9

Roseola

Answer 9

Caused by HHV-6. Can present as only fever. When fever resolves -> diffuse erythematous maculopapular rash

Question 10

Fever in infant

Answer 10

1. UTI
2. Meningitis
3. Pneumonia
4. Occult bacteremia
5. Roseola
6. Less likely: Herpes gingivostomatosis, otitis media, vaccine symptoms (1-2 days after vaccine, or 7-10 days with MMR, VZV), viral URI

Question 11

UTI abx

Answer 11

IV: Ampicillin+Gentamycin or Ceftriaxone (gap for pseudomonas and enterococcus)
PO: TMP-SMX or cephalexin. Amox-Clav expensive.