Fever Without a Focus

Question 1

What is the significance of a particularly high fever?

Answer 1

In infants <3 months, a fever >38 indicates a greater likelihood of bacterial sepsis

Question 2

What is vesico-ureteric reflux?

Answer 2

Retrograde travel of urine from bladder into ureter and sometimes into the kidney

Question 3

Investigations if a UTI is suspected

Answer 3

Urine microscopy and culture
FBC
CRP
Blood culture

Question 4

High risk for serious illness symptoms, associated with a fever

Answer 4

Pale/mottled/ashen/blue skin, lips or tongue
No response to social cues[1]
Appearing ill to a healthcare professional
Does not wake or if roused does not stay awake
Weak, high-pitched or continuous cry
Grunting
Respiratory rate greater than 60 breaths per minute
Moderate or severe chest indrawing
Reduced skin turgor
Bulging fontanelle

Question 5

Intermediate risk for serious illness symptoms, associated with a fever

Answer 5

Pallor of skin, lips or tongue reported by parent or carer
Not responding normally to social cues[1]
No smile
Wakes only with prolonged stimulation
Decreased activity
Nasal flaring
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Rigors

Question 6

Low risk for serious illness symptoms, associated with a fever

Answer 6

Normal colour of skin, lips and tongue
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry or not crying
Normal skin and eyes

Question 7

In renal disease what are significant levels of proteinuria?

Answer 7

> 20 mmol/ml may indicate tubular disease

> 200 mmol/mg - nephrotic range

Question 8

Nephrotic triad

Answer 8

Low serum albumin - <25mmol/l

Proteinuria - >200 mmol/mg

Swelling

Question 9

What are the complications of minimal change disease in children?

Answer 9

Recurrent disease
Infection with streptococci
Spontaneous peritonitis

Question 10

When in gestation to kidneys form?

Answer 10

From 5 weeks

Glomeruli still forming until 34 weeks

Question 11

Commonest congenital renal anomaly

Answer 11

Renal hypoplasia

Question 12

Management of upper UTI in children

Answer 12

Oral cefalexin (dose dependent on age)

Or co-amoxiclav if susceptible

Question 13

Management of lower UTI in children

Answer 13

Oral abx

Trimethoprim (if low risk of resistance) or Nitrofurantoin (if eGFR is >45ml/min)

Question 14

Risk factors for serious underlying pathology in UTI

Answer 14

Poor urine flow
History suggesting previous UTI or confirmed previous UTI
Recurrent fever of uncertain origin
Antenatally-diagnosed renal abnormality
Family history of vesicoureteric reflux (VUR) or renal disease
Constipation
Dysfunctional voiding
Enlarged bladder
Abdominal mass
Spinal lesion
Poor growth
High blood pressure

Question 15

Features of an atypical UTI

Answer 15

Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Septicaemia
Failure to respond within 48 hours
Non E coli

Question 16

Definition of recurrent UTIs

Answer 16

2 or more upper UTI
1 upper and 1 or more lower UTI
3 or more lower UTI

Requires investigations for underlying cause

Question 17

Features that make upper UTI more likely

Answer 17

Bacteriuria and fever of 38 or higher ±loin tenderness
Bacteruria, loin pain/tenderness and fever less than 38
Age - < 3 months

Question 18

Features that make lower UTI more likely

Answer 18

Bacteriuria but no systemic features

Age - > 3 months, no systemic features

Question 19

What is the reason for carrying out investigations on children with proven UTI?

Answer 19

Up to 50% of infants with UTI my have structural abnormalities

Adults with ESRD have associated anatomical renal tract abnormalities and history of infection

Question 20

When is renal USS indicated?

Answer 20

Looks at shape, size and location
Identifies hydronephrosis

Infants <6 months with confirmed UTI
Children > 6 months old only if atypical

Question 21

When is a micturating cystogram (MCUG) indicated?

Answer 21

Used to identify VUR, bladder abnormalities and posterior urethral valves

Catheterise child in order to fill bladder with a radio-contrast agent, x-ray as child voids

Infants < 6months with atypical or recurrent UTI
Consider in children > 6 months if dilation on USS, poor urine flow, non-E coli infection or FH VUR

Question 22

When is a DMSA indicated?

Answer 22

Radionucleotide scan
Assesses renal function and identifies any scarring of kidneys due to UTI
Healthy tissue takes up isotope, unhealthy tissue does not

All children with recurrent UTI
Children <3 with atypical UTI

Question 23

How can UTI present in children?

Answer 23

Fever
Haematuria
Dysuria
Febrile Convulsions
Abdo pain
Bedwetting/enuresis
Constipation

Question 24

What is the most common cause of AKI in childhood?
Pre-renal
Renal
Obstructive

Answer 24

Pre-renal