Child with Fever — Fever of Unknown Origin — Clinical Pathway: All Settings

Fever Clinical Pathway — All Settings

Fever of Unknown Origin

Consider Infectious Disease and/or Rheumatology consultation.

Definition Fever > 101°F (38.3°C) of ≥ 8 days duration
History/Physical Exam
  • Fever duration
  • Height
  • Pattern (sustained, relapsing, recurrent)
  • Method of temperature taking
  
Constitutional symptoms (weight loss, sweating) or associated symptoms  
Sweating Thyroid/dysautonomia
Red eyes Kawasaki
Nasal discharge Sinusitis
Recurrent pharyngitis with aphthous ulcers PFAPA
GI symptoms
  • Salmonellosis
  • Intra-abdominal abscess
  • Bartonella
  • Inflammatory bowel disease
Limb or bone pain
  • Leukemia/oncologic process
  • Osteomyelitis
Lymphadenopathy
  • Oncologic process
  • Mycobacterium
Arthritis/arthralgia Rheumatologic
Rashes/skin lesions or eschars  
Travel or unusual exposures
Ethnic or genetic background Familial fever disorders
Exposure to medications Drug fever
Laboratory and Diagnostic Testing of FUO
  • All patients:
    • CBC w/differential and peripheral smear
    • ESR, CRP
    • CMP
    • Large volume aerobic and anaerobic blood cultures
    • UA, urine culture
    • CXR
  • Consider the following based on distinct physical examination or historical findings:
    • EBV, CMV, parvovirus, and Bartonella, HIV serology
    • Tuberculin skin testing
    • ECHO if concern for infectious endocarditis
    • Uric acid, LDH, ferritin if concern for oncologic process/hemophagocytic lymphohistiocytosis
    • ANA, rheumatoid factor, C3/C4/CH50 if concern for autoimmune process
    • Immunoglobulins, antibody titers to known vaccines if concern for immunodeficiency
    • Tagged WBC scans or bone scans/MRI
    • Abdominal U/S, CT or MRI to evaluate for abscesses, tumors, and lymphadenopathy:
      • e.g., psoas abscess, liver abscess
Consultations and Considerations for Empiric Treatment
  • Consider consultation with subspecialists:
    • Infectious Diseases
    • GI
    • Rheumatology
    • Oncology
    • Cardiology
    • Other
  • Consider Incomplete Kawasaki disease
  • Treatment while diagnosis is pending:
    • Clinically stable → empiric antibiotic therapy or other treatments (e.g., steroids) generally NOT recommended as they may mask or delay the diagnosis
    • Stop all nonessential medications including antipyretics (drug fever)
  • NOT clinically stable → broad spectrum antibiotics are indicated