A 15-month-old with a temperature of 39° C is seen    in your office for the fourth time this month with unexplained intermittent episodes of fever. The mother has used children’s ibuprofen to treat the fever and has been able to bring the temperature down to 38° C. However, the mother is now frustrated because this is her fourth visit to the office and nobody knows why her child is continuing to have these fevers. The child is not in daycare and has no history of any serious illnesses, travel, or sick contacts. The child has had no symptoms of an upper respiratory infection.

On examination, the child is found actively playing with his toys. He does not look ill or toxic. His rectal temperature is 39° C. The findings on the head, neck, lung, cardiovascular, abdominal, neurologic, and musculoskeletal examination are all normal.

Your clinical judgment is that the child looks well and has no serious illness.

1. What is your diagnosis at this time? fever of unknown origin (FUO)
2. What is the most appropriate next step in the workup: order a complete blood count (CBC) and urinalysis
3. Strict definition of FUO? fever for more than 3 weeks with no diagnosis after three outpatient visits or 3 days in the hospital
4. Which of the following is the one preliminary diagnosis in this case that you should always consider? occult bacteremia
5. What is the most common organism causing occult bacteremia in children Streptococcus pneumoniae
6. The most common cause(s) of recurrent fever occurring at regular intervals in a child is? periodic fever, aphthous ulcers, pharyngitis, and adenopathy (PFAPA) syndrome
7. What is the most common condition seen in infants with occult bacteremia? otitis media
8. In a child between the ages of 3 and 36 months, the probability of occult bacteremia is decreased if: temperature is below 39° C; WBC range is between 5000 and 15,000 cells/mm3; there is a negative exposure history

A 3-year-old girl presents to the family health center  with a fever for the past 36 hours. Maximum temperature was 40° C at 2 am, which decreased to 38.7° C with children’s ibuprofen. Her appetite and fluid intake have decreased during the past 24 hours.

Physical examination shows an ill-looking child. Her temperature is 37.2° C. The skin has a macular-papular petechial rash on the chest and back. The remainder of the physical examination is normal.

1. Which of the following best describes your clinical impression at this time? meningitis
   • There are some red flags in this presentation that should alarm the physician. A prodromal respiratory illness or sore throat often precedes the fever, headache, stiff neck, and vomiting that characterize acute The rash is suspect because it could indicate meningococcemia. In infants between the ages of 3 and 24 months, symptoms and signs are less predictable. There are no localizing signs for an infection. Sepsis would require another criterion in addition to fever, such as tachycardia, hypotension, or leukocytosis.
2. Which laboratory testing would you order at this time? CBC; blood culture; urine culture; lumbar puncture
3. Which of the following is the most likely organism that you need to consider in this situation: pneumoniae influenzae meningitidis pneumoniae Listeria monocytogenes ? meningitidis
   • Although all of these organisms can cause meningitis, and S. pneumoniae is still the leading cause in this age group, petechiae are most commonly seen with N. meningitidis.
4. Which antibiotic would you consider in the treatment of this condition? ceftriaxone (Rocephin)
   • A third-generation cephalosporin is usually added because it is highly effective against common meningeal pathogens in patients of all ages. However, in areas of high pneumococcal resistance, vancomycin with or without rifampin should be added. In newborns, ampicillin is usually included to cover Listeria, and gentamicin may be added to expand the gram-negative coverage. These patterns of treatment are changing continually on the basis of resistance in the community and availability of newer antibiotics. For example, levofloxacin (Levaquin) is a newer antibiotic that has a broad range of coverage, including gram-positive and gram-negative anaerobic and atypical organisms. The dilemma faced is that inappropriate use, or overuse of these antibiotics, has also led to increased resistance within the community.
5. What would you do next concerning this patient? immediate hospitalization