A 2-Year-Old With 4 Weeks of Daily Fever

Abstract

A 2-year-old female presents for evaluation of 4 weeks of daily fevers. When the fevers began, she had mild upper respiratory tract symptoms, which quickly resolved. The fevers persisted, however, with a maximum of 40°C. The child's review of symptoms was significant for a 1-kg weight loss over the past month. Ten months before presentation, she had moved from Saudi Arabia with her family. One week before the onset of symptoms, she had visited a petting zoo. During episodes of fever, the patient was ill-appearing and had an elevated heart rate and respiratory rate. On examination, she was found to be thin, febrile, tachycardic, and with scattered lymphadenopathy. Results of laboratory tests were remarkable for an elevated white blood cell count of 16 100 cells per uL with a neutrophilic predominance. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 99 mm/h and 27 mg/dL, respectively. A chest radiograph indicated a small amount of fluid in the interlobar fissures. Our expert panel examines her case, offers a definition of fever of unknown origin, and makes diagnostic considerations. CASE HISTORY WITH SUBSPECIALTY INPUTJohn Darby, MD, Moderator, Pediatric Hospital Medicine:A 2-year-old girl was transferred for evaluation and management of fevers. She was well until 4 weeks before admission, when she developed symptoms of an upper respiratory tract infection (URTI) and intermittent fevers up to 40°C. Although the URTI symptoms resolved over 3 days, the patient continued to have daily fever spikes for the next 4 weeks. When febrile, she was ill-appearing, tachypneic, and tachycardic, but between fever spikes, she was a normal 2-year-old playing with her siblings. She had been evaluated in outpatient settings several times over the past month, with no definitive diagnosis, and had received ceftriaxone and clindamycin for unclear reasons, with no improvement in symptoms. Her parents initially attributed the fevers to a viral illness she acquired from day care.Review of systems was remarkable for weight loss of 1 kg (according to parental report) and poor appetite. Her medical history was unremarkable, and her immunizations were up to date through 1 year.The child was born in Toronto but lived in Saudi Arabia until 10 months before the onset of symptoms, when the family moved to Toronto. She then moved to Texas with her parents and younger siblings 1 month before presentation. The child attends day care and had visited a petting zoo ∼1 week before the symptoms began. Although she had a negative reaction to purified protein derivative (PPD) after her time in Saudi Arabia, her parents have never been tested for tuberculosis (TB). Dr Darby contributed to the design and execution of the case conference, drafted and edited the original manuscript, and made revisions to the manuscript; and Ms Liddell and Drs DeGuzman, McClain, Rubenstein, Chase, and Marquez contributed to the design and execution of the case conference, and reviewed and made revisions to the manuscript. All authors ...

The Mechanism of Fever and its Clinical Management

“…At this phase, thermogenesis activators are controlled and EP might be cleared away; meanwhile, the ascended set point of body temperature is back to the normal level, patients would present as exhausted with dehydration and circulation failure once seriously [5].…”