Kiddo with Fever

Question 1

When is a fever in an infant serious?

Answer 1

Under 3 months full septic work-up!!!!

Question 2

What are complications from a fever?

Answer 2

Seizure, direct cellular effect (damage to DNA), inflammation, systemic effects (gut bacteria translocation), liver failure, AKI, sepsis, organ failure, loss of function of BBB, death

Question 3

Most common causes of fever in neonates

Answer 3

Listeria
Group B streptococci
HSV

Viral infection is the most common cause of fever without obvious source

Question 4

High risk neonates for serious bacterial illness (and maternal risk factors)

Answer 4

Maternal risk factors: Group B strep, HIV, active herpes simplex

Prematurity, Autoimmune , factitious fever (overbundling)

Question 5

Workup for child < 3 weeks

Answer 5

0-28 days:
Admit to hospital
Blood, urine, CSF culture
Emperric Abx treatment

Question 6

Workup for child 1 month- 3 months

Answer 6

If appear well w/ no complications in PMH:
- CBC, blood culture, urinalysis and culture +/- CXR, lumbar puncture, stool studies depending on CC

Based on test results: can decide on empiric abx +/-hospital admission; must FU in 24 hours

If sick appearing – ADMIT

Question 7

Workup for child >3 year

Answer 7

If sick appearing - workup

Fever < 39 and well appearing - Nothing

> 39 and well appearing consider: urine analysis and culture, ensure up to date w/ immunizations

Consider treating empirically – if elevated WBC, not up to date w/ immunization

Question 8

Where is the thermoregulation centre?

Answer 8

Hypothalamus (35.6-37.8)

Question 9

Why are infants less able to maintain body temperature?

Answer 9

High surface area/ mass ratio

Do not shiver or sweat

Question 10

How do we sense changes in temp

Answer 10

Thermoreceptors on skin: free never endings
2 types:
- Warm receptors (increase firing 32-45)
- Cold receptors (increase firing 40-26)

Question 11

Body Reaction to Cold:

Answer 11

Shivering, piloerection, vasoconstriction (sympathetic activation), increase heat production

Question 12

Body reaction to Heat

Answer 12

Vasodilation (heat loss), sweating, decreased metabolic rate

Question 13

Pathophysiology in fever

Answer 13

Pathogens release pyrogens –> inc production of IL in phagocytic cells –> IL signals anterior hypothalamus to increase PG production –> PGE2 inc the set point temperature

Question 14

What is the role of PGE2

Answer 14

Set point of temperature

- peripheral vasoconstriction, increased metabolic heat production, shivering, behavioural changes

Question 15

Benefits of a fever

Answer 15

Inhibit bacterial growth
Inc efficiency of immune cells
Inc chemotaxis

Question 16

Mediators of inflammation response

Answer 16

Histamine - increased permeability of blood vessels

Prostaglandin - intensify the effects of histamine and kinins

Leukotrienes - increased permeability and attract phagocytes

Complement - stimulate histamine release, attack neutrophils by chemotaxis, promotes phagocytosis

Question 17

Common cause of fever in infants (1-3 months)

Answer 17

E.coli
H. influenza
Varicella
Enterococci
Streptococcus pneumoniae
N. meningitis

Question 18

3 months- 36 months

Answer 18

Streptococcus pneumoniae
N. meningitis
E.coli
Viruses

Question 19

> 3 mo

Answer 19

Streptococcus pneumoniae
N. meningitis
Viral
Leukemia,Lymphoma

Question 20

Initial resuscitation measures for an infant with sepsis.

Answer 20

First hour of resuscitation:
Obtain rapid peripheral IV access, push isotonic crystalloids (normal saline or lactated ringers)
Begin maintenance 10% dextrose if necessary
Begin antibiotics as soon as possible

Question 21

Indications for lumbar puncture

Answer 21

Indications:

• Infants younger than 1 month
• All infants 1-3 months who appear unwell
• Infants 1-3 months with a WBC less than 5 x10^9 or greater than 15x10^9

Question 22

Contraindications for lumbar puncture

Answer 22

Increased ICP
Respiratory insufficiency
Local infection at LP site 
Shock (unusual skin colour, tachycardia/ hypotension, cold hands/ feet, alerted mental state, poor urine output) 
Extensive or spreading purpura 
Coagulation abnormalities

Question 23

Reye’s syndrome

Answer 23

Disease affects mitochondrial function, causing disturbance in fatty acid 
- Rare form of acute encephalopathy and fatty infiltration of the liver 
Using salicylates (generally aspirin) during such illness increases the risk by much as 35 fold

Question 24

Simple Febrile Seizures

Answer 24

last < 15 minutes, have no focal features, and do not recur within a 24 hour period

Most, > 90%, febrile seizures are simple

Question 25

Complex Febrile Seizures

Answer 25

last > 15 minutes continuously or with pauses, or have focal features (i.e. affects specific body parts the corresponds with specific area of the brain), or recur within 24 hours

Question 26

Kawasaki Disease

Answer 26

Fever > 5 days
Changes in lips and oral cavity (erythema, dryness, fissuring, bleeding) STRAWBERRY TONGUE
Bilateral conjunctival infection
Erythematous polymorphous rash
Changes in extremities (erythema and/or induration of palms and soles)
Cervical lymphadenopathy, often unilateral