Evaluation of 80 children with prolonged fever

Update on Fever of Unknown Origin in Children: Focus on Etiologies and Clinical Approach

Fever of unknown origin (FUO) can be caused by four etiological categories of diseases. The most common cause of FUO in children is represented by infections, followed by inflammatory conditions and neoplastic causes; a decreasing quote remains still without diagnosis. Despite the fact that several diagnostic and therapeutic approaches have been proposed since the first definition of FUO, none of them has been fully validated in pediatric populations. A focused review of the patient's history and a thorough physical examination may offer helpful hints in suggesting a likely diagnosis. The diagnostic algorithm should proceed sequentially, and invasive testing should be performed only in select cases, possibly targeted by a diagnostic suspect. Pioneering serum biomarkers have been developed and validated; however, they are still far from becoming part of routine clinical practice. Novel noninvasive imaging techniques have shown promising diagnostic accuracy; however, their positioning in the diagnostic algorithm of pediatric FUO is still not clear. This narrative review aims to provide a synopsis of the existent literature on FUO in children, with its major causes and possible diagnostic workup, to help the clinician tackle the complex spectrum of pediatric FUO in everyday clinical practice.

Fever of unknown origin: a retrospective review of pediatric patients from an urban, tertiary care center in Washington, DC

BACKGROUND

Fever of unknown origin (FUO) continues to challenge clinicians to determine an etiology and the need for treatment. This study explored the most common etiologies, characteristics, and average cost of hospitalization for FUO in a pediatric population at an urban, tertiary care hospital in Washington, DC.

METHODS

Records from patients admitted to Children's National Health System between September 2008 and April 2014 with an admission ICD-9 code for fever (780.6) were reviewed. The charts of patients 2-18 years of age with no underlying diagnosis and a temperature greater than 38.3 ºC for 7 days or more at time of hospitalization were included. Final diagnoses, features of admission, and total hospital charges were abstracted.

RESULTS

110 patients qualified for this study. The majority of patients (n = 42, 38.2%) were discharged without a diagnosis. This was followed closely by infection, accounting for 37.2% (n = 41) of patients. Rheumatologic disease was next (n = 16, 14.5%), followed by miscellaneous (n = 6, 5.4%) and oncologic diagnoses (n = 5, 4.5%). The average cost of hospitalization was 40,295 US dollars.

CONCLUSIONS

This study aligns with some of the most recent publications which report undiagnosed cases as the most common outcome in patients hospitalized with FUO. Understanding that, often no diagnosis is found may reassure patients, families, and clinicians. The cost associated with hospitalization for FUO may cause clinicians to reconsider inpatient admission for diagnostic work-up of fever, particularly given the evidence demonstrating that many patients are discharged without a diagnosis.

Clinical approach to fever of unknown origin in children

BACKGROUND/PURPOSE

Fever of unknown origin (FUO) can be caused by many clinical conditions and remains a diagnostic challenge in clinical practice. The etiology of FUO varies markedly among different age groups, geographic areas, and seasons. A four-stage investigative protocol for FUO is widely applied in clinical practice. The aim of this study was to evaluate the usefulness of this four-stage protocol for identifying the etiology of FUO in children.

METHODS

We enrolled children younger than 18 years of age who were admitted to the Taichung Veterans General Hospital during the period from January 2006 to December 2014 with FUO persisting for more than 3 weeks. The four-stage FUO investigative guideline was used to evaluate the etiology of fever in all patients enrolled in the study.

RESULTS

The etiology of FUO was identified in 79 (84.9%) of the 93 patients enrolled in the study. The most common cause of FUO was infectious disease (37.6%), followed by malignancy (17.2%), miscellaneous disease (16.1%), and collagen vascular disease (14.0%). With respect to the four-stage survey of FUO, 36 of the 79 patients (45.6%) were identified in Stage 3, 28 patients (35.4%) in Stage 2, 13 patients (16.5%) in Stage 4, and only two patients (2.5%) in Stage 1.

CONCLUSION

A well-designed systemic review of the epidemiological information, medical history, physical examination, laboratory analysis, and adequate invasive procedures provide adequate data to identify the most common causes of FUO in children.

Clinical analysis of fever of unknown origin in children: A 10-year experience in a northern Taiwan medical center

BACKGROUND

Fever of unknown origin (FUO) was first described in 1961 as fever >38.3°C for at least 3 weeks with no apparent source after 1 week of investigations in the hospital. Infectious disease comprises the majority of cases (40-60%). There is no related research on FUO in children in Taiwan. The aim of this study is to determine the etiologies of FUO in children in Taiwan and to evaluate the relationship between the diagnosis and patient's demography and laboratory data.

METHODS

Children under 18 years old with fever >38.3°C for >2 weeks without apparent source after preliminary investigations at Taipei Veterans General Hospital during 2002-2012 were included. Fever duration, symptoms and signs, laboratory examinations, and final diagnosis were recorded. The distribution of etiologies and age, fever duration, laboratory examinations, and associated symptoms and signs were analyzed.

RESULTS

A total of 126 children were enrolled; 60 were girls and 66 were boys. The mean age was 6.7 years old. Infection accounted for 27.0% of cases, followed by undiagnosed cases (23.8%), miscellaneous etiologies (19.8%), malignancies (16.6%), and autoimmune disorders (12.7%). Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were the most commonly found pathogens for infectious disease, and Kawasaki disease (KD) was the top cause of miscellaneous diagnosis.

CONCLUSIONS

Infectious disease remains the most common etiology. Careful history taking and physical examination are most crucial for making the diagnosis. Conservative treatment may be enough for most children with FUO, except for those suffering from malignancies.

Fever of unknown origin in children: a systematic review

BACKGROUND

there are no previous systematic reviews of published pediatric case series describing the etiology of fever of unknown origin (FUO). The purpose of collecting these data is to determine the etiologies for children with FUO in both developing and developed countries.

METHODS

the database Ovid Medline R (1950 to August 2009 week 4) and Ovid Embase (1980 to 2010 week 2) were used to conduct the search. Studies in any language were included if they provided the diagnosis in a series of 10 or more children with FUO. The diagnosis of each child at the time of publication of the study was recorded.

RESULTS

there were 18 studies that met the inclusion criteria, describing 1638 children. The diagnosis at the time of publication was malignancy for 93 children (6%), collagen vascular disease for 150 (9%), miscellaneous non-infectious conditions for 179 (11%), infection for 832 (51%), and no diagnosis for 384 (23%). There were 491 bacterial infections (59% of all infections) with common diagnoses being brucellosis, tuberculosis, and typhoid fever in developing countries, osteomyelitis, tuberculosis, and Bartonellosis in developed countries, and urinary tract infections in both. For children with no diagnosis after investigations, most had fever that ultimately resolved with no sequelae.

CONCLUSIONS

about half of FUOs in published case series are ultimately shown to be due to infections with collagen vascular disease and malignancy also being common diagnoses. However, there is such a wide variety of possibilities that investigations should primarily be driven by the clinical story.

Clinical spectrum of fever of unknown origin among Indian children

BACKGROUND

Fever of unknown origin (FUO) is an important cause of morbidity and mortality in children, especially in tropical and developing countries.

AIM

To determine the aetiology and outcome of FUO in Indian children.

METHODS

A hospital-based, prospective, observational study was conducted over a 1-year period (2006-2007). Children aged > or =3 months to 12 years who qualified for the definition of FUO were recruited. Initial evaluation included complete blood count, peripheral smear for malarial parasites, erythrocyte sedimentation rate (ESR), urine analysis and culture, blood culture, tuberculin test and chest X-ray.

RESULTS

Of 49 patients evaluated, a diagnosis was reached in 43 (88%). Infections were the predominant cause of FUO in 34 patients (69%). Enteric fever was the most common infection (14), followed by visceral leishmaniasis (10) and tuberculosis (5). The next most common cause was malignancy (6, 12%). Among the six undiagnosed patients, spontaneous resolution occurred in five whereas one child continued to be febrile without an established cause at the end of the study.

CONCLUSION

Repeated, thorough clinical examination and carefully selected laboratory examinations proved useful in the diagnosis of FUO. Serology (e.g. enteric fever) and bone marrow examination (e.g. leishmaniasis, malignancy) were the most useful diagnostic tests.