Fever Without a Focus Flashcards
What is the significance of a particularly high fever?
In infants <3 months, a fever >38 indicates a greater likelihood of bacterial sepsis
What is vesico-ureteric reflux?
Retrograde travel of urine from bladder into ureter and sometimes into the kidney
Investigations if a UTI is suspected
Urine microscopy and culture
FBC
CRP
Blood culture
High risk for serious illness symptoms, associated with a fever
Pale/mottled/ashen/blue skin, lips or tongue
No response to social cues[1]
Appearing ill to a healthcare professional
Does not wake or if roused does not stay awake
Weak, high-pitched or continuous cry
Grunting
Respiratory rate greater than 60 breaths per minute
Moderate or severe chest indrawing
Reduced skin turgor
Bulging fontanelle
Intermediate risk for serious illness symptoms, associated with a fever
Pallor of skin, lips or tongue reported by parent or carer Not responding normally to social cues[1] No smile Wakes only with prolonged stimulation Decreased activity Nasal flaring Dry mucous membranes Poor feeding in infants Reduced urine output Rigors
Low risk for serious illness symptoms, associated with a fever
Normal colour of skin, lips and tongue Responds normally to social cues Content/smiles Stays awake or awakens quickly Strong normal cry or not crying Normal skin and eyes
In renal disease what are significant levels of proteinuria?
> 20 mmol/ml may indicate tubular disease
> 200 mmol/mg - nephrotic range
Nephrotic triad
Low serum albumin - <25mmol/l
Proteinuria - >200 mmol/mg
Swelling
What are the complications of minimal change disease in children?
Recurrent disease
Infection with streptococci
Spontaneous peritonitis
When in gestation to kidneys form?
From 5 weeks
Glomeruli still forming until 34 weeks
Commonest congenital renal anomaly
Renal hypoplasia
Management of upper UTI in children
Oral cefalexin (dose dependent on age)
Or co-amoxiclav if susceptible
Management of lower UTI in children
Oral abx
Trimethoprim (if low risk of resistance) or Nitrofurantoin (if eGFR is >45ml/min)
Risk factors for serious underlying pathology in UTI
Poor urine flow History suggesting previous UTI or confirmed previous UTI Recurrent fever of uncertain origin Antenatally-diagnosed renal abnormality Family history of vesicoureteric reflux (VUR) or renal disease Constipation Dysfunctional voiding Enlarged bladder Abdominal mass Spinal lesion Poor growth High blood pressure
Features of an atypical UTI
Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond within 48 hours Non E coli
Definition of recurrent UTIs
2 or more upper UTI
1 upper and 1 or more lower UTI
3 or more lower UTI
Requires investigations for underlying cause
Features that make upper UTI more likely
Bacteriuria and fever of 38 or higher ±loin tenderness
Bacteruria, loin pain/tenderness and fever less than 38
Age - < 3 months
Features that make lower UTI more likely
Bacteriuria but no systemic features
Age - > 3 months, no systemic features
What is the reason for carrying out investigations on children with proven UTI?
Up to 50% of infants with UTI my have structural abnormalities
Adults with ESRD have associated anatomical renal tract abnormalities and history of infection
When is renal USS indicated?
Looks at shape, size and location
Identifies hydronephrosis
Infants <6 months with confirmed UTI
Children > 6 months old only if atypical
When is a micturating cystogram (MCUG) indicated?
Used to identify VUR, bladder abnormalities and posterior urethral valves
Catheterise child in order to fill bladder with a radio-contrast agent, x-ray as child voids
Infants < 6months with atypical or recurrent UTI
Consider in children > 6 months if dilation on USS, poor urine flow, non-E coli infection or FH VUR
When is a DMSA indicated?
Radionucleotide scan
Assesses renal function and identifies any scarring of kidneys due to UTI
Healthy tissue takes up isotope, unhealthy tissue does not
All children with recurrent UTI
Children <3 with atypical UTI
How can UTI present in children?
Fever Haematuria Dysuria Febrile Convulsions Abdo pain Bedwetting/enuresis Constipation
What is the most common cause of AKI in childhood?
Pre-renal
Renal
Obstructive
Pre-renal
