Case 10: Fever

Front 1

When do the majority of adverse reactions to vaccines occur?

Back 1

first 24 to 48 hours after the firstdose of the particular innoculation.

Front 2

Examples of vaccines that can cause fever?

Back 2

The immunization against rotavirus is a live-virus vaccine that can cause fever in someinfants, usually within the first several days.

Front 3

What is fever without source?

Back 3

when a complete history has been obtained and a detailedphysical examination performed, and there is no identified source of the child's fever.

Front 4

Etiologies of serious bacterial illness?

Back 4

• Urinary tract infection (UTI)-the most common
  
• Meningitis
  
• Sepsis
  
• Pneumonia
  
• Bacterial gastroenteritis
  
• Osteomyelitis
  
• Septic arthritis
• Occult bacteremia

Front 5

What is occult bacteremia?

Back 5

Generally applied to a child with bacteremia who looks fairly well (or is a little fussy). A child withbacteremia who appears ill or "toxic" is more likely to be septic. The distinction is made becausemost children with occult bacteremia will NOT develop a serious bacterial illness (SBI), whereasa child with sepsis represents a medical emergency.

Front 6

Signs of meningitis in infants?

Back 6

• fever
  
• hypothermia
  
• bulging fontanelles
  
• lethargy, irritability, restlessness
  
• paroxysmal crying
  
• poor feeding
  
• vomiting/diarrhea
  

Front 7

What happens if an infant has kernig's or brudzinski's sign?

Back 7

must assume that he2/13or she may have meningitis and perform a lumbar puncture.

Front 8

Another finding meningitis?

Back 8

neck stiffness or nuchal rigidity

Front 9

Value of the WBC and diff?

Back 9

In a low-risk child (immunized and looked well), given the low prevalence of bacteremia inthat setting the positive predictive value of the WBC count would be very low. Almost allpatients with a positive WBC would be false positives.

It is a piece of the puzzle, however, and in the setting of a child with an increased likelihoodof SBI, the elevated WBC and bands increase the likelihood of a SBI.

Front 10

Oral vs parenteral antibiotics?

Back 10

Criteria for parenteral therapy include patients judged to be "toxic" or unable to retain oralmedications or situations in which compliance with oral medications is a concern.

Front 11

What is the role of prophylactic antibiotics?

Back 11

benefit in reducing UTI recurrence in childrenwith VUR in a high quality, placebo-controlled, randomized controlled trial.

Renal scarring, however, was unchanged when prophylactic antibiotics were compared toplacebo.

Front 12

Kernig's sign

Back 12

resistance to extension of the knee

Front 13

Brudzinski sign

Back 13

flexion of the hip and knee in response to flexion of theneck by the examiner.

Front 14

DDx for infant with fever?

Back 14

• UTI
  
• Pneumonia
  
• Sepsis/bacteremia
  
• bacterial meningitis
  
• viral meningitis
  
• roseola
  
• occult bacteremia
  
• HSV
  
• otitis media
  
• vaccine reaction
  
• viral URI
  

Front 15

UTI

Back 15

fever

no focus on exam

unremarkable ROS

fussiness

lack of appetite

Front 16

Pneumonia

Back 16

cough

tachypnea

fever

rales

low SaO2

Front 17

Sepsis/bacteremia

Back 17

fever

young infants -> hypothermia

don't look well

early sign -> high heart rate

late sign:

• delayed cap refill
  
• low bp
  
• altered mental status
• evidence of organ failure

Front 18

Bacterial meningitis

Back 18

• fever
  
• do B and K sign
  

Front 19

Viral meningitis

Back 19

• less severe than bacterial meningitis
  
• fever
  
• loose stools, rash, URI
  
• 
  

Front 20

Roseola

Back 20

• caused by HHV-6
  
• high fever
  
• rash as fever resolves
  

Front 21

Occult bacteremia

Back 21

high fever without no other symptoms

Front 22

Primary HSV gingiviostomatitis

Back 22

• can be asymptomatic
  
• fever and irritability
  
• oral lesions start as vesicles
  
• evolve into ulcerations
  

Front 23

otitis media

Back 23

poor mobility and at least mild bulging of TM

red tympanic membrane (no PPV)

Front 24

vaccine reaction

Back 24

fever, 1-2 days after receiving vaccine

Front 25

Viral URI

Back 25

• congestion
  
• cough
  
• rhinorrhea
  
• coryza
  

Front 26

How to test for fever without source?

Back 26

• urinalysis
  
• urine culture
  
• CBC and diff
  
• Blood culture
  
• LP
  

Front 27

interpretation of urinalysis?

Back 27

nitrite test

leukocyte esterase test

Front 28

nitrite test

Back 28

A positive nitrite on urinalysis is extremely helpful: It is highly specific for the presence ofbacteria in the urine (few false positives).7/13A negative nitrite, however, has a very poor sensitivity (lots of false negatives) for bacteruria,especially in young infants who urinate frequently.

Front 29

leukocyte esterase test

Back 29

A positive leukocyte esterase usually indicates the presence of white blood cells WBCs inthe urine, but pyuria can be seen in a variety of conditions in addition to urinary tractinfection. Thus, a positive leukocyte esterase test alone is insufficient to make the diagnosisof a urinary tract infection.

Front 30

What if nitrites and leukocyte esterase are positive?

Back 30

If both nitrites and leukocyte esterase are positive, it is strongly suggestive of a urinary tractinfection.

Front 31

Follow up for first episode of pyelonephritis?

Back 31

• US for kidneys and bladder
  
• Renal technetium scan
  
• voiding cysturethrogram
  

Front 32

US for kidneys and bladder

Back 32

Unless the illness is of unusual severity, or the child is not improving on antibiotics, theultrasound may be obtained at completion of the antibiotic course.

Front 33

Renal technetium scan

Back 33

Provides evidence of pyelonephritisNot required in a patient who has responded well to treatment

Front 34

VCUG

Back 34

Should not be performed routinely in children after a first febrile UTI unless there are findingson the renal and bladder ultrasound that suggest high-grade vesicoureteral reflux

Front 35

Management of occult bacteremia?

Back 35

A young febrile child who appears ill, however, should be evaluated carefully, because sepsisfrom non-vaccine pneumococcal serotypes and other bacteria still occurs-though rarely. It isimportant always to:Discuss your concerns with the parent(s)Provide close and careful follow-up, andDocument your findings in the medical recordIn this way, any patients who develop more serious complications will receive prompt treatmentand will likely have a good outcome

Front 36

Treatment of pyelonephritis, parenteral?

Back 36

• amp and gent
  
• ceftriaxone
  
• pip tazo
  
• cipro
  

Front 37

Oral treatment of pyelonephritis?

Back 37

Cephalexin - best choice