Fever

Question 1

What defines fever in children

Answer 1

> 38 OR reported parental perception of fever

Question 2

What are the causes of fever

Answer 2

Acute fever: URTI, tonsilitis, otitis media, viral infections, pneumonia, meningitis, septic arthritis, UTI
Fever + rash: measles, rubella, roseola, scarlet fever, hand/foot/mouth disease, varicella, meningococcus
Fever + neck swelling: cervical adenitis, infectious mononucleosis, mumps, thyroiditis, mastoiditis
Recurrent: immunodeficiency, HIV, hyposplenism/splenectomy
Pyrexia of unknown origin

Question 3

What are the common causes of pyrexia of unknown origin

Answer 3

Infective endocarditis
Osteomyelitis
Inflammatory bowel disease
Neoplastic disease
Factitious fever

Question 4

At what age is a fever worrying and what should be done for them

Answer 4

<8 weeks
All should be admitted

Question 5

Describe how temperature-taking methods differ from eachother (age and use)

Answer 5

< 4 weeks: electronic thermometer in the axilla
>4 weeks-5 years: electronic thermometer OR chemical dot thermometer in the axilla OR infra-red tympanic thermometer

Axillary temperatures are 0.5oc lower than oral or rectal temperatures. Rectal temperatures can be used if the child is unconscious
Forehead thermometers/oral/rectal routes are not recommended

Question 6

What investigations should be done for a fever in children

Answer 6

Bedside: throat swab for culture, urine dip + MC&S, stool culture
Bloods: Blood cultures, FBC, CRP
Other: LP, CXR

Question 7

What supportive management can be done for a fever

Answer 7

Antipyretics: paracetamol/calpol or ibuprofen
Undress the child, discourage wrapping in blankets
Sponging/tepid baths (lukewarm water)

Question 8

What are the most common causes of fever <1 month

Answer 8

GBS
E. Coli
Listeria
HSV

Question 9

What is the management for fever <1 month

Answer 9

Always admit
Full septic screen (blood cultures, urine culture, LP, CXR ± NPA, stool)
Commence Abx without waiting - cefotaxime + amoxicillin IV

Question 10

What are the most common causes of fever 1-3 months

Answer 10

GBS, E. coli, listeria
Meningococcal/strep/staph/Hib
RSV, enterovirus, adenovirus, HSV

Question 11

What are the most common causes of fever >3 months

Answer 11

Meningococcal/sepsis
Viruses e.g. RSV

Question 12

What is the aetiology of scarlet fever

Answer 12

Bacterium Streptococcus pyogenes - a group A streptococcus (GAS)
Highly contagious, transmitted through saliva/mucous or aerosol transmission → colonises the throat and skin
Incubation 2-3 days
Rash and fever due to exotoxin or superantigen release

Question 13

What are the risk factors for scarlet fever

Answer 13

At extremes of the age range, such as the very young and old, or postpartum women.
Immunocompromised or immunosuppressed.
Comorbidities such as skin breakdown, diabetes mellitus, or underlying malignancy.
Concurrent chickenpox or influenza.
IVDU or alcohol dependent

Question 14

What defines an outbreak of scarlet fever

Answer 14

a credible report of two or more probable or confirmed scarlet fever cases attending the same school or nursery or other childcare setting, notified within 10 days of each other (two maximum incubation periods), with an epidemiological link between cases, for example they are in the same class or year group

Question 15

What are the symptoms and signs of scarlet fever

Answer 15

Prodrome: sore throat, fever (>38.3), headache, fatigue, N&V
Blanching rash
- starts on trunk, spreads to limbs
- Red, generalised, pinpoint (punctate)
- Rough ‘sandpaper’ texture
- Accentuated in the skin folds of the neck, axillae, groin etc. (Pastia’s lines)
- Palm and sole sparing
- Skin peeling after rash resolvement
Strawberry tongue (covered with a white coat through which red papillae may be seen → White coat disappears to leave a beefy red appearance
Cervical lymphadenopathy
Flushed face, circumoral pallor
Pharyngitis and petechiae on the hard and soft palate (‘Forchheimer spots’).

Question 16

What investigations should be done for scarlet fever

Answer 16

Mainly clinical diagnosis

Bedside: throat swab for culture for GAS
Bloods: Serum anti-streptolysin O (ASO) antibody titres

Question 17

What is the management for scarlet fever

Answer 17

1. Notify the local health protection team within 3 days
2. Phenoxymethylpenicillin (penicillin V) for 10 days (Second line: clarithromycin (<6 months), azithromycin (>6 months))
3. Advice:
   a. Sources: PHA patient leaflet, NHS patient leaflet
   b. Paracetamol or ibuprofen for symptom relief
   c. Rest and drink adequate fluids
   d. Clean and cover any skin breaks e.g. bites, cuts, wounds
   e. EXCLUSION: at least 24 hours after starting Abx
   f. Avoid sharing eating utensils and towels, and dispose of tissues promptly.
   + follow up if symptoms worsen or do not improve

Question 18

What are the complications of scarlet fever

Answer 18

Suppurative complications due to local spread: otitis media, peritonsillar cellulitis, peritonsillar abscess, retropharyngeal abscess, acute sinusitis, mastoiditis
Non-suppurative (immune-mediated) complications: acute rheumatic fever, acute-post-streptococcal glomerulonephritis
Invasive GAS infection: Streptococcal pneumonia, meningitis, cerebral abscess, endocarditis, cellulitis, sepsis, death

Question 19

What is the prognosis for scarlet fever

Answer 19

In most cases, the clinical features of infection including rash resolve over about 1 week.
Once a person has had scarlet fever, a recurrence of infection is unlikely, but they are still susceptible to other forms of streptococcal infection.

Question 20

What are the causes of fever and swelling in the neck

Answer 20

Cervical lymph nodes: URTI, cervical adenitis, infectious mononucleosis, neoplastic process
Parotid gland: mumps
Thyroid gland: thryoiditis
Mastoid: mastoiditis
Generalised: CMV, toxoplasmosis, rubella, leukaemia, lymphoma

Question 21

What investigations should be done for cervical adenitis

Answer 21

Bedside: throat swab for culture (GAS), urine amylase (mumps)
Bloods: FBC, EBV serology, serum amylase (mumps), TFTs, thyroid antibodies

Question 22

What are the causes of pyrexia of unknown origin

Answer 22

Bacterial: UTI, pneumonia, endocarditis, occult abscesses, TB, osteomyelitis
Viral: infectious mononucleosis, hepatitis, HIV
other: collagen vascular disease, IBD, neoplastic, Juvenile arthritis, leukaemia

Question 23

What investigations should be done for pyrexia of unknown origin

Answer 23

Bedside: urine MC&S,
Bloods: FBC, blood film and smear, CRP/ESR, blood cultures, LFTs, serology
Other: tuberculin skin testing, X-rays, bone marrow aspirate, radioactive scans, echo, US, total body CT/MRI