Children with fever of unknown origin in Argentina: an analysis of 113 cases

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.

Factitious disorder-experience at a neuropsychiatric center in southern India

OBJECTIVE

Factitious disorder is amongst the more intriguing but less-studied psychological disorders. Studies from different parts of the world have reported of varying prevalence rates. Here, we try to study the prevalence of factitious disorder in a specific sample of patients attending a neuropsychiatric center in India.

MATERIALS AND METHODS

We did a retrospective review of our institute's database for cases with a diagnosis of factitious disorder in the 10-year duration from 2001 to 2010. We reviewed the available clinical and socio-demographic data.

RESULTS

Of the 81,176 patients seen in the 10-year duration, only 8 patients had been assigned the diagnosis of factitious disorder, leading to a prevalence rate of 0.985 per 10,000 patients in this sample. Most of the patients were lost to follow-up; hence.

CONCLUSION

Factitious disorder remains highly underdiagnosed in developing countries like India. Mental health professionals need to be more aware and inquisitive about this particular disorder, so that they do not miss the diagnosis.

National survey of childhood febrile illness cases with fever of unknown origin in Japan

BACKGROUND

In Japan, an actual condition survey on childhood febrile diseases with fever of unknown origin has never been performed. We carried out a national survey on childhood febrile illnesses in order to collect useful information for the differential diagnosis.

METHODS

A nationwide survey using questionnaires was performed on febrile illness cases with fever of unknown origin (FUO) experienced by 2843 pediatrics institutions with sick beds during a 5-year period before 2007. FUO was defined as a febrile illness of at least 2 weeks' duration with a temperature ≥ 38°C, and failure to establish a diagnosis in spite of intensive evaluation during seven days' hospitalization.

RESULTS

Two hundred fifty-five of 2843 questionnaire-surveyed institutions had 960 FUO cases, of which 132 could not be diagnosed, and 828 could be diagnosed after detailed medical examinations. The diagnoses they clarified included infectious diseases in 190 cases (23%), rheumatic diseases in 448 cases (54%), neoplasms in 67 cases (8%), and others in 123 cases (15%).

CONCLUSION

Clarification of illnesses that ought to be differentiated in the diagnostic approach to an FUO case is essential for arriving at its definitive diagnosis by exclusion.

Obscure manifestations of Salmonella subdural empyema in children: case report and literature review

PURPOSE

Salmonella intracranial infections, including subdural empyema and brain abscess, are rare clinical manifestations in children. The aim of this study is to investigate the clinical course of Salmonella subdural empyema in infants and children.

METHODS

We report a 9-month-old female infant diagnosed as Salmonella subdural empyema with clinical features of prolonged fever for more than 2 months and episodic focal seizures. Literature published between 1986 and 2010 relevant to Salmonella subdural empyema in children were reviewed. The clinical presentations and laboratory findings were analyzed.

RESULTS

Seventeen cases with Salmonella subdural empyema, including our index case, has been reported with detailed clinical presentation. Fever (17/17; 100%), symptoms and signs of increased intracranial pressure (8/17; 47%), seizures (8/17; 47%), and limb paralysis (8/17; 47%) were the most frequent clinical features. Among these cases, unknown causative organism prior to surgery (11/17; 65%) and prolonged fever for more than 3 weeks (5/17; 29%) were also noticed. Sixteen out of 17 patients (94%) required surgical intervention for treatment. The morbidity rate and mortality rate were 29% (5/17) and 6% (1/17), respectively.

CONCLUSION

Subdural empyema is considered to be a disease with rapid progression. However, the cases caused by Salmonella species may present a slow disease course. Surgical intervention is sometimes the only way to detect the pathogen.

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.

Brucellosis as a cause of fever of unknown origin in children admitted to a tertiary hospital in the Aegean region of Turkey

The aim of the study was to determine the role of brucellosis in children with fever of unknown origin (FUO) in the Aegean region of Turkey. For this purpose, the records of all children referred or admitted with diagnosis of FUO to the Department of Pediatric Infectious Diseases, Ege University Medical School, between 2003 and 2008 were scanned and 92 cases were identified retrospectively. Fifty-eight of these 92 children (63%) were diagnosed with infectious diseases, brucellosis being the most frequent cause (15.2%). Although several other infectious diseases do appear as a cause of FUO, brucellosis should be particularly considered as a differential diagnosis.

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.

Fever of unknown origin in 185 paediatric patients: a single-centre experience

AIM

We conducted a prospective study to evaluate the causes and outcome in children with fever of unknown origin (FUO).

METHODS

From 1990 to 1999, 185 children with FUO were evaluated. Initial evaluation included routine haematological analysis, Epstein-Barr virus (EBV) serology, urine, stool or blood cultures, chest X-ray and tuberculin probe.

RESULTS

In 131 (70%) patients diagnosis was established, and 70 (37.8%) had infectious disease. EBV infection was the most common infection followed by visceral leishmaniasis (VL), urinary tract infection (UTI) and tuberculosis. Autoimmune disorders were diagnosed in 24 (12.9%), Kawasaki disease in 12 (6.4%), malignant diseases in 12 (6.4%) and miscellaneous conditions in 15 (8.1%) patients. In the remaining 54 (30%) patients, diagnosis was not established and most of them had self-limited disease. During the investigation, 26 (14%) patients developed serious organ dysfunction and five patients (two with virus-associated haemophagocytic syndrome, one with VL and two unknown) died.

CONCLUSION

The most important infectious causes of FUO in our study were EBV infection and VL. Kawasaki disease represented a significant cause of FUO at the beginning of our study because it was not recognized by primary-care physicians. We report myelodysplastic syndrome as another emerging cause of paediatric FUO. Repeated clinical examination and careful use of specific laboratory examinations, invasive diagnostic procedures or imaging are crucial in approaching paediatric FUO.

Pyrexia of unknown origin in children: a review of 102 patients from Turkey

Pyrexia of unknown origin (PUO) has not been appropriately investigated in Turkish children and therefore a study was undertaken to determine the causes of PUO and to evaluate which clinical procedures are useful in establishing a diagnosis. A total of 102 children fitting the classical PUO criteria seen in our clinic between 1995 and 2002 were investigated retrospectively. Infections, collagen vascular disorders, malignancy and miscellaneous conditions constituted 44.2%, 6.8%, 11.7% and 24.5% of cases, respectively, while 12.8% of the cases remained undiagnosed. Enteric fever, brucellosis and respiratory tract infections were the most commonly encountered infections, whereas familial Mediterranean fever was the commonest non-infectious disorder. Biopsy, aspiration, serology, bacteriology, radiology and observation of the clinical course were the most useful diagnostic procedures.

Fever of unknown origin in Israel

INTRODUCTION

Fever of unknown origin (FUO) is still a diagnostic challenge for the family physician and the internist. In the last decades a few reports have emphasized a changing pattern in the prevalence of the 3 main categories of FUO: infections, malignancies and collagen diseases.

AIMS

a. to find out if the changing pattern among the main diagnoses in patients with FUO is comparable to previous reports.

MATERIAL AND METHODS

Medical files of patients that were admitted in two 450 beds rural Israeli hospitals were checked by two physicians. All files of patients with either the diagnosis of FUO, or files of patients with fever that were hospitalized for a week or longer in internal medicine departments were reviewed.

RESULTS

101 files of patients fulfilling the criteria of FUO were found. Surprisingly 54.5% of them had infectious diseases, 7.9% had malignant disease and only 2% had collagen disease.

CONCLUSIONS

a. Infectious diseases are still the leading cause of FUO among Israeli patients. b. The prevalence of infectious and malignant diseases is comparable to other studies, however the low rate of connective tissue diseases in our study is unusual. c. The rate of undiagnosed FUO was remarkably high (32.7%), although all these patients recovered during hospitalization and probably had self limited infectious (viral) disease.

[Noninfectious febrile inflammatory syndromes in children: diagnosis and usefulness of diagnostic procedures]

OBJECTIVE

To determine the causes and to quantify the benefits obtained from further diagnostic investigations in children presenting with a non infectious inflammatory fever.

METHODS

The records of 62 children aged from two-months to 15 years (median: four years) admitted to a paediatric department between 1990 and 2000 for the evaluation of a fever associated to an inflammatory syndrome, defined as temperature over 38 degrees C with an increase of the erythrocyte sedimentation rate (ESR) more than 20 mm/h and/or a serum C-reactive protein level (CRP) > 20 mg/L, and excluding overt infectious diseases, were retrospectively reviewed.

RESULTS

Of these patients, 79% children (49 cases) had inflammatory systemic disease, 3.2% (two cases) had malignancy, and 17.8% (11 cases) had undiagnosed disorders. The most frequent disease was Kawasaki disease (22 children), especially in young children. Increase of ESR above 100 mm/h and of CRP above 100 mg/L was present in 59% of Kawasaki disease, 71% of idiopathic juvenile arthritis, 100% of malignancies and 7% of unknown diagnoses. Increase of ESR below 50 mm/h and of CRP below 50 mg/L was present in 75% of hemophagocytic syndromes and 46% of unknown diagnosis. The polymorphonuclear count, hepatic function evaluation, triglycerides levels, abdominal ultrasound, abdominal computed tomography, echocardiography, biopsies were useful diagnosis tools. Technetium scintigraphy was helpful only when abnormalities were found on physical examination.

CONCLUSION

The diagnosis of Kawasaki disease must be quickly suspected in febrile young children with inflammatory syndrome without infection. ESR and CRP values, abdominal ultrasound and echocardiography are helpful tools for the diagnostic procedure.

Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge

Factitious disorder, Munchausen's Syndrome, and deliberate self-harm have recently been conceptualized as different facets of self-destructive behavior. A descriptive typological classification has been presented by Willenberg et al., but has not yet been tested with a clinical sample. The instrument distinguishes between direct self-harm (e.g., self-inflicted wounds), self-induced disease (e.g., factitious fever), and indirect self-harm delegated to medical staff (e.g., repeated operations occasioned by feigned symptoms). All patients referred to the psychosomatic-psychotherapeutic liaison-consultation service or to the outpatients' department within 14 months (n = 995) and all patients discharged from in-patient psychosomatic-psychotherapeutic treatment within 2 months (n = 62) were assessed. Expert instruction and supervision were provided for the diagnosticians. The assessment was continued for a subsequent year, without special supervision (n = 1,058). Self-destructive behaviors were diagnosed in 7.5% of the cases in the first sample, with certainty (59.5%) or on suspicion (40.5%). In the subsequent sample without supervision, the rate reduced to 3.6%. Referrals had come from almost all clinical departments, including the emergency unit (26%), surgery, internal intensive care, endocrinology (9.5% each), neurology, infectiology, nephrology (7.1% each), dermatology, gastro-enterology, cardiology (4.8% each) and surgical intensive care (2.4%). The occurrence of pathological self-destructive phenomena is underrated when using only the ICD-criteria. The rate is influenced by diagnostic attention.

Munchausen by Proxy in an international context

OBJECTIVE

The professional literature on Munchausen by Proxy (MBP) abuse consists of more than 400 articles, chapters, and books. Most have come from a handful of English-speaking industrialized countries. Our aims were to establish the extent to which published work about MBP has emerged from outside these countries, and to determine the characteristics of any reported cases.

METHOD

Numerous health care computer databases were queried, and the results supplemented by materials accumulated less formally.

RESULTS

We identified 59 articles from 24 countries describing at least 122 cases in 9 different languages. Among cases in which the information was available, the mother was the sole perpetrator in 86%, the victim was aged between 3 years and 13 years in 52%, and the victim was male in 54%. The presentations of MBP appear to be similar across the world with the exception of induced apnea, which emerged as notably uncommon in this review. An extensive table presents the characteristics of each case.

CONCLUSIONS

MBP clearly is not a phenomenon unique to Western or highly medicalized societies. This form of abuse is being increasingly recognized and reported throughout the world. The literature from the US, Canada, UK, Australia, and New Zealand often presupposes access to resources, such as subspecialists and social service agencies, that may be seriously constrained in other countries. The contributions of professionals elsewhere will be vital in ensuring that the efforts in English-speaking industrialized settings to develop standards of care encompass an international perspective.

[Management of prolonged fever in infants]

Prolonged fever is defined as an unexplained fever of more than 5 days duration. In infancy and early childhood, it is most often of infectious origin, viral infections being the most frequent. Mycoplasma pneumoniae infections, urinary tract infection and otitis media are also commonly involved. Kawasaki disease is the main inflammatory etiology, juvenile rhumatoïd arthritis in its systemic form (Still's disease) being much rarer. In most cases the etiological diagnosis can be made with a limited number of laboratory and/or imaging investigations based upon a careful clinical evaluation and an oriented chronological strategy.

Fever of unknown origin

The causes of fever in a child can vary from minor brief illnesses to life-threatening infectious, malignant, or autoimmune diseases. The physician often has to evaluate children with fevers of as yet undiagnosed cause lasting fewer than 2 weeks, in whom it is important to determine whether localizing findings are present. Fever without localizing signs and fevers complicating chronic disease and resulting from specific localized infection are considered in the sections concerning infectious causes, immunodeficiency diseases, and rheumatic diseases. The diagnostic and therapeutic approaches to the child with both prolonged fever and fever of unknown origin are then discussed, with emphasis on rheumatic diseases.