Aetiology and management of children with acute fever of unknown origin

Prevalence of Lassa Virus Disease (LVD) in Nigerian children with fever or fever and convulsions in an endemic area

Background

Convulsions with fever in children are a common neurologic emergency in the tropics, and determining the contribution of endemic viral infections can be challenging. In particular, there is a dearth of data on the prevalence and clinical differentiation of Lassa virus disease (LVD) in febrile children in endemic areas of Nigeria, which has multiple lineages of the virus. The aim of this study was to determine the prevalence and presentation of LVD in febrile children with and without convulsions.

Methodology/Principal findings

This was a prospective study of consecutive febrile children aged ≥1 month– 15 years admitted to the Children’s Emergency Room of Irrua Specialist Teaching Hospital over a period of 1 year. Febrile children with convulsions (Cases) were compared with those without convulsions (Controls). LVD was defined by the presence of a positive Lassa virus RT-PCR test. Rates were compared between groups using χ2 or Fisher’s exact tests and p <0.05 taken as significant. 373 (40.9%) of 913 admissions had fever. Of these, 108/373 (29%) presented with convulsions. The overall prevalence of LVD was 13/373 (3.5%; 95% CI = 1.9%, 5.7%) in febrile admissions, 3/108 (2.8%) in Cases and 10/265 (3.8%) in Controls [(Odds Ratio (95% Confidence Interval) (OR (95% CI)) of LVD in Cases versus Controls = 0.73 (0.2, 2.7)]. Only vomiting (OR (95% CI) = 0.09 (0.01, 0.70)) and bleeding (OR (95% CI) = 39.56 (8.52, 183.7)) were significantly associated with an increased prevalence of LVD.

Conclusions/Significance

LVD is an important cause of fever, including undifferentiated fever in children in endemic areas, but it is not significantly associated with convulsions associated with fever. Its prevalence, and lack of clinical differentiation on presentation, underscores the importance of a high index of suspicion in diagnosis. Screening of febrile children with undifferentiated fever in endemic areas for LVD could be an important medical and public health control measure.

There has, perhaps, been undue focus on malaria as a cause of childhood fever and convulsions, often with delayed/missed diagnosis of other serious prevalent infections, and correspondingly very little published data on the contribution of Lassa virus disease (LVD) in endemic areas. There is also very little published data on the contribution of LVD to childhood morbidity and mortality in Nigeria, a large LVD-endemic country that has in circulation 3 of the 4 currently known lineages of the Lassa virus. This study was carried out to address these gaps. The results should also be of relevance in the formulation of policies for the treatment and control of viral haemorrhagic fevers. The prevalence of LVD was 5.4% among children with clinically undifferentiated fever (n = 243); 3.9% among those with convulsions associated with fever (n = 77) and 6.0% among those with fever but no convulsions (n = 166). The results underscore the importance of LVD as a cause of acute undifferentiated fever. The results also underscore the need of diagnostic testing for LVD in children with acute undifferentiated fever in endemic areas in order to facilitate control, including the prevention of nosocomial transmission.

Human herpes viruses are associated with classic fever of unknown origin (FUO) in Beijing patients

BACKGROUND

Few reports have examined the viral aetiology of fever of unknown origin (FUO).

OBJECTIVE

This study determined the prevalence of human herpes virus (HHV) DNA in blood of Chinese patients with classic FUO using the polymerase chain reaction (PCR) and explored the possible role of HHV.

STUDY DESIGN

Blood samples were collected from 186 patients (151 children, 35 adults) with classic FUO and 143 normal individuals in Beijing during the years 2009-2012. The HHV DNA, including Herpes simplex virus (HSV)-1/2, Varicella zoster virus (VZV), Cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Human herpes virus (HHV)-6 and -7, was detected by multiplex PCR. The epidemiological and clinical features were also analysed.

RESULTS

HHV DNA was detected in 63 (33.9%) of the FUO patients, and the prevalence of EBV and HHV-6 was significantly higher than in the normal cohort. HHV co-infection was also frequent (10.2%) in the patients with FUO. The majority of patients with HHV infection present with a fever only. Our data also revealed that EBV infection was associated with hepatitis and abnormal blood indices, HHV-6 was associated with a cough, and HHV-7 was associated with hepatitis.

CONCLUSIONS

HHVs are associated with Chinese patients (especially for children) with classic FUO. Our study adds perspective to the aetiological and clinical characteristics of classic FUO in beijing patients.

Fever of unknown origin: a diagnostic approach to this vexing problem

Fever is a common complaint leading families to seek medical attention. Its routine management is the bread and butter of pediatric practice. When fever is seen as prolonged beyond the expected time course (eg, 10 days for a presumed viral respiratory tract infection or 3 weeks for mononucleosis), concern for fever of unknown origin (FUO) may ensue. This diagnosis is among the most challenging for health care providers to approach and often involves referral to subspecialists. Generally, the pace of the evaluation should be guided by the severity of the disease, rather than the anxiety of the family or of the health care providers. It is useful to recognize that uncommon manifestations of common diseases are more likely than are rare diseases. Furthermore, clues to the diagnosis are frequently present in the history and physical examination but are not elicited or unappreciated (perhaps due to time constraints). Therefore, thoroughness and repetition are vitally important. Although the differential diagnosis of FUO is vast, a thoughtful, focused approach based on information gleaned from a thorough history and physical examination (together with any laboratory or other study results) is preferable to a "shotgun" or "running the list" one. Finally, FUO in special populations, including children in the hospital, those with HIV infection or other immunocompromise, and those in the developing world, require special consideration. Most children do well, compared to adults with FUO, but true FUO is not always a benign condition, necessitating the best care a health care provider can offer.

Referral and previous care of children with meningitis in Nigeria: implications for the presentation and outcome of meningitis in developing countries

There is a paucity of data on the referral of children with meningitis in developing countries, and on the relationship of presentation and outcome to previous care. Referral and previous care were investigated in 281 post-neonatal children treated in two tertiary centres. Data were obtained through the review of referral notes from orthodox health facilities, interview of parents/guardians and review of admission notes. Forty-four (16%) children were facility-referred and 81 (29%) self-referred from orthodox facilities while 156 (55%) were self-referred without previous care in these facilities. The facility-referrals (n=44) included 19 (43%) with meningitis on treatment, 13 (30%) with suspected meningitis and 12 (27%) with unsuspected meningitis. Twenty-two (50%) were referred because of deterioration, partial response or non-response to treatment, 5 (11%) on request by the parents, 9 (21%) on the suspicion of meningitis or other neurological disorder and 7 (16%) for mixed reasons. No reason was given in 1 case of meningitis on treatment. Among the 19 children referred with meningitis on treatment, only 1 was referred within 24 h of diagnosis, a confirmatory lumbar puncture was done only in 7, and only 10 of 18 (no data in 1 case) were on reasonably appropriate antibiotic regimens. Previous care in orthodox facilities was significantly associated with delayed presentation (>3 days of illness, p<0.001), partial treatment (p<0.001), lack of typical signs (p<0.05), severe illness (p<0.01), and adverse outcome (death or recovery with neurological sequelae, p<0.05). Limited recognition of the possibility of meningitis in acutely ill children and an inadequate referral practice may account for these effects. A clear delineation of referral needs might reduce the magnitude of these problems.

Management of children with prolonged fever of unknown origin and difficulties in the management of fever of unknown origin in children in developing countries

This is Part II of a 2-part paper on fever of unknown origin (FUO) in children. It examines the aetiology and management of prolonged FUO in children and the difficulties in the management of FUO in children in developing countries. Part I of this paper discussed acute FUO in children and was published in the March 2001 issue of Paediatric Drugs. Prolonged FUO is documented fever of more than 7 to 10 days which has no apparent source and no apparent diagnosis after 1 week of clinical investigations. About 34% of cases of prolonged FUO are caused by infections, with bacterial meningitis and urinary tract infection accounting for about 6.5 and 11.4%, respectively, of cases attributable to infections. Chronic infections, particularly tuberculosis and 'old' disorders such as Kawasaki disease, cat-scratch disease and Epstein-Barr virus infection presenting with 'new' manifestations, collagen-vascular diseases and neoplastic disorders are the other issues of major concern in prolonged FUO. Overall, however, there is a trend towards an increased number of undiagnosed cases. This is due to advancements in diagnostic techniques, such that illnesses which were previously common among the causes of prolonged FUO are now diagnosed earlier, before the presentation becomes that of prolonged FUO. Clinical examination supplemented with laboratory tests to screen for serious bacterial infections should be the mainstay of initial evaluation of children with prolonged FUO. Use of scanning techniques (such as computerised tomography and ultrasound) as additional supplements to this clinical examination may allow for the earlier diagnosis of causes of prolonged FUO in children such as 'occult' abdominal tumours. A common error in management of children with prolonged FUO is the failure to perform a complete history and physical examination; repeated clinical examination and continued observation are of paramount importance in the diagnosis of difficult cases. Major difficulties in the management of FUO in children in developing countries include constraints in the availability and reliability of laboratory tests, cost, misuse of antibiotics and difficulties encountered in the diagnosis of malaria and typhoid fever. Malaria and typhoid fever are major aetiological considerations in both acute and prolonged FUO in children in developing countries. The newer quinolones may hold great promise for the treatment of serious bacterial infections, including meningitis, which are associated with prolonged FUO in developing countries.