Child with Fever — Unusual Exposure — Clinical Pathway: All Settings

Fever Clinical Pathway — All Settings

High Risk Unusual Exposures, Associated Infections, Diagnostic Testing

Exposures Infections Testing to Consider
Animal Exposures:
Reptiles and Amphibians
  • Salmonella
  • Stool culture
  • Blood culture
Animal Exposures:
Rodents
  • LCMV:
    • Wild and pet mice, hamsters, guinea pigs
  • CBC, CSF studies
  • Additional:
    • LCM IgM & IgG Ab (CSF & serum) LCM CSF PCR
Animal Exposures:
Petting Zoos/Farm Visits
  • Campylobacter
  • Salmonella
  • Brucellosis
  • Shiga toxin-producing E. coli:
    • (STEC)/O157:H7
  • Q fever:
    • Esp. livestock rearing facilities
  • Stool culture
  • Blood culture
  • Stool for Shiga/E.coli toxin assay
  • Additional:
    • BMP, UA, CBC if concern for hemolytic-uremic syndrome
    • Q fever IgG
Bird Exposure
  • Chlamydophila psittaci
  • H. capsulatum is found in bird roosts:
    • Grows in bird droppings
  • Chest X-ray
  • Additional:
    • Organism-specific serologies
Cat/Kitten Exposure
  • Bartonella (cat scratch disease)
    • 1-4 weeks after scratch/bite
  • Superinfected bite/scratch wound:
    • Consider Pasteurella, Capnocytophaga species
  • Cat scratch (Bartonella henselae) PCR
  • Antibodies
  • IgG & IgM
  • Wound culture
Camping
  • Campylobacter
  • Tick-borne relapsing fever:
    • Sleeping in rustic, rodent-infested cabins in western U.S.
  • Stool culture
  • Borrelia spirochetes in Giemsa stains of peripheral blood smears
Caving/Spelunking
  • Histoplasmosis:
    • Ohio and Mississippi River valleys, Texas/North Mexico
  • Hantavirus:
    • Central/western U.S. with possible rodent exposure
  • Rabies
  • CXR
  • Additional:
    • Histoplasma antigen (urine/serum).
    • Hantavirus Ab (to CDC)
Dog Exposure
  • Superinfected bite/scratch wound:
    • Consider Pasteurella, Capnocytophaga species
  • Wound culture
Ingestion of Undercooked Beef
  • Shiga toxin-producing E. coli (STEC)/O157:H7
  • Stool culture
  • Stool for Shiga/E.coli toxin assay
  • Additional:
    • BMP, UA, CBC if concern for hemolytic-uremic syndrome (HUS)
Ingestion of Undercooked Chicken
  • Salmonella
  • Stool culture
  • Blood culture
Ingestion of Raw/Unpasteurized Dairy
  • Listeria
  • Shiga toxin-producing E. coli:
    • (STEC)/O157:H7
  • Brucella
  • Yersinia
  • Large volume (3 mL) blood culture
  • Stool culture
  • Stool for Shiga/E.coli toxin assay
  • Additional:
    • Acute Brucella antibodies
    • BMP, UA, CBC if concern for hemolytic-uremic syndrome (HUS)
Ingestion of Undercooked Pork
  • Yersinia
  • Stool culture
Ingestion of Raw Seafood
  • Vibrio vulnificus
  • Vibrio parahaemolyticus
  • Specific stool studies
Exposure to Untreated Surface Water
  • Yersinia
  • Stool culture
Mosquito Bites:
In the Patient without Travel
  • Arboviruses:
    • West Nile virus
    • Eastern Equine virus
    • St. Louis encephalitis
    • La Crosse encephalitis virus
  • CSF evaluation
  • Additional:
    • Arbovirus-specific IgM antibody in serum or CSF
Tick Bites
  • Anaplasmosis:
    • Within 1-2 weeks of bite
  • Babesiosis:
    • Weeks to months after bite
  • Ehrlichiosis:
    • Within 1-2 weeks of bite
  • Lyme disease:
    • 3-30 days post-bite/early localized stage may have associated fever. Other stages rarely have fever.
  • Powassan virus:
    • 1-4 weeks after bite
  • Rocky Mountain spotted fever (RMSF):
    • Within 2-14 days of bite
  • Tularemia:
    • Antibodies to F. tularensis
  • Tickborne Diseases of the U.S.  
  • Peripheral blood smear for specified parasite
  • RMSF (R. rickettsii) antibodies
  • Antibodies to F. tularensis
  • Additional:
    • Consider CBC, CMP for hemolytic anemia in parasitic disease
Travel within the U.S.
  • CXR
  • Consider histoplasma and coccidioides antigens (urine/serum)
Tuberculosis Exposure
  • Tuberculosis
  • Tuberculin skin test
  • Chest X-ray
  • Focal testing for possible extra-pulmonary TB
  • DPH notification
  • Appropriate precautions