Diagnostic Dilemma

Fever without focus

A 10-month-old girl presented with recurrent fever for 6 months. She was investigated for the same and hemoglobin was 11.6 mg/dl with a WBC count of 13,500/cumm [42% polymorphs, 58% lymphocytes], Chest X-Ray was normal, there were no malarial parasites on peripheral smear and the Widal test was negative. HIV ELISA and Mantoux test were also negative. On examination, there was no abnormality detected.

What further test is required?
Expert Opinion :
This child has a recurrent fever without any focus. The respiratory tract system seems to be normal. Also, there is no organomegaly ruling out infections such as typhoid, malaria. Workup for TB and HIV is also negative. Since fever is recurrent and not continuous, autoimmune disorders and malignancy also seem unlikely and even the age group (fever starting at 4 months of age) does not seem to fit into these diagnoses. In an infant with recurrent fever without focus, one should always rule out a urinary tract infection (UTI). In this child, urine showed 30-35 pus cells/hpf and urine culture grew E.coli with a colony count of 100,000/hpf confirming the presence of UTI. Her DMSA Scan showed bilateral cortical defects suggestive of chronic pyelonephritis with MCU suggestive of bilateral Grade III vesicoureteral reflux (VUR).
It is very imperative that a child with fever without a focus should be investigated for UTI. UTI in children always needs to be investigated in detail to rule out VUR and urinary malformations. Such children may need to be on prophylactic antibiotics to prevent further UTI and further kidney damage. Also, parents should be advised about doing a urine examination and culture whenever there is fever without a focus prior to giving antibiotics.
Giving antibiotics to a child with fever without documenting the source of fever may hide urine infections and such a child may present later on in life with chronic kidney disease for a condition that was highly preventable.
Answer Discussion :
Rana Tohme
EBV test, UA, Urine culture,
1 year ago
Victor Hugo Hernndez Pozos
1 year ago

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