Lecture note Week:

CLINICAL APPROACH IN
CHILDREN WITH FEVER

Infectious Diseases &

Tropical Medicine
Department of Child Health
Lecture Description
(from Content in Block Book)
-Definition of fever
-Measurement of body temperature
-Fever pattern
-How to differentiate fever
-Fever with rash
-Fever lasting > 7 days
Key-term
Fever
Pattern of fever
Fever with/ without localizing signs
Rash
What is fever
A rise in the temperature set point at
hypothalamus by a variety of physiological
mechanism

Fever usually occurs as a result of the bodys

exposure to infecting micro organism, immune
complexes or other sources of inflammation
How to define fever
Need to know what is normal body
temperature
How we can assess fever ( by history?
Touch? Use termometer?)
Temperature tips
You can take a
reading:
from your child's
mouth
under the arm
in the ear
using a forehead
strip.
Child presenting with fever
When fever is present, assess the child
further for signs related to it
Classify fever according to the signs which
are present or absent
Definition of fever
Pathophysiologically : is an IL-1 mediated
elevation of the thermoregulatory set point
of the hypothalamic center
Clinically: fever is body temperature of 1
C (1.8F) or greater above the mean at the
site of temperature recording.

El Radhi et al 2009
 The following degrees of temperature are accepted as
fever :
Rectal : > = 38.0 C
Oral : > = 37.6 C
Axillary : > = 37.4 C
Tympanic membrane : > 37.6 C

The importance of at least 1C higher than the mean

temperature lies in the diurnal variation of normal body
temp, reaches its highest level in early evening (5-7 pm).
Arch Dis Child Educ Pract Ed 2008;93:2629.
PATTERN OF FEVER
Continuous (sustained ) fever :
persistent elevation of body temperature with a max
fluctuation of 0.4 C during a 24-h period
Remitten : a fall in temp each day but not to a normal level
Intermitten : temp returns to normal each day, usually in
the morning and peaks in the afternoon
Hectic (septic) : when remitten or intermittent fever shows
a very large difference between the peak and the nadir
Recurrent : describes a single illness involving the same
organ or multiple organ system in which fever recurs at
regular
Keterangan:

A.Continuous
B.Continuous with abrupt onzet

C. Remittent
D.Intermittent
E.Hectic

F. Recurrent
Fever in childhood
among the most likely reason to seek
for medical help
may be infectious / non-infectious; viral
origin is the majority; serious bacterial
infection may ensue
Differentiation between viral and
bacterial disease may be difficult,
especially in neonates and young
infants
Special attention should be paid to the
following in children presenting with fever
HISTORY
Duration of fever
Residence in or recent travel to an area with malaria
transmission
Skin rash
Stiff neck
Headache
Pain on passing urine
Ear pain
Examination
Stiff neck
Skin rash : haemorrhagic (petechiae),
maculopapular
Skin sepsis
Discharge from ear
Severe palmar pallor
Local tenderness
Fast breathing
Local tenderness
Severe malnutrition
Clinical appearance and risk

Well-appearing
Smiles, playfull, not irritable, alerts quickly, feeds well, cries
strongly but easiky consoled by the caregiver
No signs of dehydration
Good peripheral perfusion: pink, warm
No signs of respiratory distress
 Clinical appearance and risk

Ill-appearing

Brief smile, irritable with crying and sobbing, still responsive to

a caregiver, less playful or active than usual, poor feeding
Signs of mild or moderate dehydration
Good peripheral perfusion: extremities pink and warm
 Clinical appearance and risk

Toxic (Baraff 1993)

Irritable and not easily consolable, poor/absent eye contact,

failure to interact with parents or objects in environment,
lethargic/unresponsive, too weak to feed, seizures/signs of
meningeal irritation
Ptechiae, purpura
signs of severe dehydration
Poor perfusion, mottled, cool extremities
Pale, thready pulse
Resp rate >60, retractions, grunting to apnea, cyanosis,
respiratory failure
Possible cause of
disease .....
Laboratory examination
Blood smear
Lumbar puncture if signs suggest
meningitis
Urine microscopy
What localizing sign in
the baby .
What local sign?
What is the local sign?
What is the possible diagnosis of this child?
What problem of this baby?
Differential diagnosis of fever with
localized signs
Meningitis ( neck stiffness, bulging fontanelle)
Otitis media ( pus draining from ear)
Mastoiditis ( tender swelling above or behind ear)
Osteomyelitis ( local tenderness)
Septic arthritis ( tender, hot, swelling of joint)
Pneumonia ( fast breathing, lower chest indrawing)
Throat abscess ( sore throat, tender cervical nodes)
Dengue (joint and muscle pains, liver tenderness)
Sinusitis ( facial tenderness, nasal discharge)
Differential diagnosis of fever without
localizing signs
Malaria ( anemia, blood smear +, enlarged spleen)
Septicemia (seriously ill with no apparent cause,
shock)
Typhoid (seriously ill with no apparent cause,
abdominal tenderness, confusion, shock)
Urinary tract infection (crying on passing urine,
incontinence, frequent on passing urine)
Fever associated with HIV infection (severe
malnutrition)
What possible
diseases the
child suffered
from
What specific
signs
Classification morphology
of rash
Krugman: makulopapular and papulovesikular
others:
Macular
Maculopapular
Vesicular, Bullosa, dan Pustular
Petechiae dan Purpural
Urticarial
Papular, Nodular, Ulcerative
Eritema Multiforms
Eritema Nodosum
Diffuse Eritrodermal
Distinctive Rashes
Anulare
 Rash definition
SKIN LESION DESCRIPTION

Macule Flat discoloration <1 cm in diameter

Patch Flat discoloration >1 cm in diameter
Papule Solid elevated lesion <1 cm in diameter
Plaque Flat-topped elevated lesion >1.5 cm in diameter
Nodule Rounded elevated lesion >1 cm in diameter
Vesicle Fluid-filled elevated lesion up to 1 cm in diameter
Bulla Vesicle >1 cm in diameter
Pustule Elevated lesion filled with pus
Wheal Well-demarcated raised lesion lasting <24 hours
Petechiae Pinpoint hemorrhage
Ecchymosis Large areas of bleeding into the skin
Diffuse erythema Large area of redness that blanches with pressure
MORPHOLOGY

Macula Nodules
Papule Urtica
Vesicel Pustules
 Krugman classification
Diseases are classified based on :
History of illness and vaccination
prodromal stage
morphology of rash
Specific signs
Laboratory test
 Krugman
MACULOPAPULAR PAPULOVESICULAR
Measles Varicella zoster infection
Atypical measles Smallpox
Rubella Eczema herpeticum
Scarlet fever Eczema vaccinatum
Staphylococcal scalded skin syndrome Coxsackievirus infection
Staphylococcal toxic shock syndrome Other enterovirus infections
Meningococcemia Atypical measles
Typhus and tick fever Rickettsialpox
Toxoplasmosis Impetigo
Cytomegalovirus infection Insect bites
Erythema infectiosum (parvovirus) Papular urticaria
Roseola infantum (HHV-6) Drug eruptions
Enteroviral infections Molluscum contagiosum
Infectious mononucleosis Dermatitis herpetiformis
Toxic erythema
Drug eruptions
Sunburns
Miliaria
Kawasaki disease
Differential diagnosis of fever with rash

Measles ( typical rash, runny nose, red

eyes)
Viral infection ( transient non specific rash)
Meningococcal infection (purpuric rash)
Dengue hemorrhagic fever ( bleeding,
petechiae, liver enlargement)
Fever lasting longer than 7 days
There are many causes of prolonged fever
It is important to know the most common causes in a
given area
Investigation for the most likely cause can then be
started and treatment decided
There could be a trial of treatment
Take a history for any possible chronic illness or
malignancy which may cause persistent fever
Some persistent fever may presenting with or without
localizing signs
 Some causes of fever are only found in
certain regions
Other fever are mainly seasonal
Or can occur in epidemics
Differential diagnosis of fever
lasting than 7 days
Infective endocarditis
Rheumatic fever
Miliary Tuberculosis
Malaria
Abscess
Salmonella infection
HIV
Meningitis
Laboratory examinations to confirm
diagnosis
Blood film for malaria parasite
Complete blood count
Urinalysis
Mantoux test
Chest X-ray
Blood culture
HIV testing
Lumbar puncture
Key points on making diagnosis in
child presenting with fever
History taking
Physical examinations
Considered the signs which are present or
absent ( localizing signs, rash etc)
Considered the local setting
( epidemiological data)
Laboratory investigations
Refferences