Fever Without a Source in the 1- to 3-Month-Old Infant Case File
https://medical-phd.blogspot.com/2021/05/fever-without-source-in-1-to-3-month.html
Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J.
Rosh, MD, MS
Case 28
A 10-week-old infant is brought to the emergency department (ED) by his mother for 1 day of fever. The
mother tells you that her son was delivered vaginally at full term and was the product of an uncomplicated
pregnancy. He has had regular well-baby checks and has been gaining weight appropriately. He has met his
normal developmental milestones and vaccinations are up-to-date. He has had no prior illnesses. This morning
his mother noticed he felt warm to the touch and discovered an axillary temperature of 101°F. No other signs or
symptoms of infection including runny nose, cough, difficulty breathing, rash, nuchal rigidity, seizure activity,
abdominal distension, vomiting, or diarrhea. She states her son has been breast-feeding less than normal, but
overall has had a normal number of wet diapers. She is very concerned because this is her first child and he has
never had a fever before.
On examination, the child is found to have a heart rate of 180 beats per minute, a blood pressure of 90/50 mm
Hg, a respiratory rate of 40 breaths per minute, an oxygen saturation of 99% on room air, and a rectal
temperature of 102.7°F. He is overall well appearing and has an unremarkable physical examination. Although
he cries when you perform the examination, his mother is able to console him easily.
⯈ What is the most likely diagnosis?
⯈ What is the next step in management?
⯈ What is the best therapy?
ANSWER TO CASE: 28
Fever Without a Source in the 1- to 3-Month-Old Infant
Summary: A previously healthy 10-week-old infant is brought in by his mother for fever The cause of the fever
is not clearly identified by the history or physical examination. His vital signs in the emergency department are
significant for fever and tachycardia. His examination is unremarkable.
Most likely diagnosis: Fever without a source (FWS).
Next step: Order CBC, blood cultures, urinalysis, urine culture. You may also order stool studies, a
chest x-ray, and perform a lumbar puncture depending on the clinical presentation.
Best therapy: It is up to physician discretion to decide which well-appearing infants with fever without
a source should receive antibiotics. If antibiotics are given, the best drug is ceftriaxone, either IV or IM.
ANALYSIS
Objectives
1. Understand the appropriate workup for fever without a source in the well-appearing 1- to 3-month-old
infant.
2. Appreciate the controversy regarding the management of fever without a source in this age group.
3. Learn the treatment options for fever without a source in a 1- to 3-month-old infant.
Considerations
This 10-week-old infant presented with fever without any other signs or symptoms of infection including runny
nose, cough, difficulty breathing, rash, nuchal rigidity, seizure activity, abdominal distension, vomiting, or
diarrhea. Importantly, the emergency physician must be aware that the 1- to 3-month-old infant will not
manifest the same signs of infection as an older child. For this reason, the workup of fever in this age group
must remain broad and one must have a low threshold for both further testing and treatment with antibiotics.
Approach To:
Fever Without a Source in the 1- to 3-Month-Old Infant
DEFINITIONS
FEVER WITHOUT A SOURCE: Fever without a source is an acute febrile illness in which the etiology of
the fever is not apparent after a careful history and physical examination. A rectal temperature greater than 38°C
(100.4°F) is defined as a fever.
SERIOUS BACTERIAL ILLNESS (SBI): Illnesses including bacteremia, pneumonia, urinary tract infection,
skin and soft tissue infections, bone and joint infections, enteritis, or meningitis due to a bacterial pathogen.
CLINICAL APPROACH
Diagnosis of Potential Fever in the 1- to 3-Month-Old Infant
While many parents will bring in their infants for a chief complaint of fever, not all parents will have actually
taken their child’s temperature with a thermometer. If an infant has had a rectal temperature more than 38°C at
home but is afebrile and well appearing in the emergency department, this infant still requires full workup for
fever. If the parent only reports a tactile fever and the infant is afebrile and well appearing in the emergency
department, no laboratory testing for fever workup is required. Temperature must be measured with a rectal
thermometer in order to rule out a fever. Axillary and tympanic membrane thermometers are not adequate to
evaluate for fever in an infant. If an infant is brought in bundled and has a mildly elevated temperature, it is
worthwhile to recheck a rectal temperature 15 minutes after unbundling the infant. However, a temperature
more than 38.5°C should never be attributed to bundling.
Evaluation of Fever Without a Source in the 1- to 3-Month-Old Infant
The evaluation of fever in this age group has changed dramatically in the last 30 years in the wake of vaccines
targeting haemophilus influenzae type b and Streptococcus pneumoniae. These vaccines have dramatically
decreased the burden of SBI in this age group. Prior to the development of these vaccines, the majority of
febrile infants in this age group were hospitalized and often started on empiric antibiotic therapy. Morbidity and
mortality for SBI was high and early clinical identification was very difficult.
Given the controversy and difficulties identifying infants with SBI several decision rules have been developed.
These are the Rochester, Boston, and Philadelphia criteria, each using a combination of factors including
history, physical examination, and laboratory parameters to identify low-risk infants. Although all these criteria
use slightly different testing strategies, all of the criteria support the use of CBC, blood cultures, urinalysis, and
urine culture to identify infants at low risk for SBI. Test results suggestive of high risk for SBI include WBC
greater than or equal to 15,000/mm or less than or equal to 5000/mm , a band-to-neutrophil ratio of greater than
3 3
or equal to 0.2, a urine dipstick test positive for nitrite or leukocyte esterase, or a finding of greater than or equal
to 5 WBCs/hpf or organisms seen on
Gram stain.
