Original article
Clinical practice management
ACR Appropriateness Criteria Fever Without Source or Unknown Origin—Child

https://doi.org/10.1016/j.jacr.2016.04.028Get rights and content

Abstract

The cause of fever in a child can often be determined from history, physical examination, and laboratory tests; infections account for the majority of cases. Yet in 20%, no apparent cause can be found, designated as fever without source (FWS). The yield of chest radiography in children with FWS is low, and it is usually not appropriate. However, in children with respiratory signs, high fever (>39°C), or marked leukocytosis (≥20,000/mm3), chest radiography is usually appropriate, as it has a higher yield in detecting clinically occult pneumonia. In newborns with FWS, there is higher risk for serious bacterial infection, and the routine use of chest radiography is controversial. In children with neutropenia, fever is a major concern. In some clinical circumstances, such as after hematopoietic stem cell transplantation, chest CT scan may be appropriate even if the results of chest radiography are negative or nonspecific, as it has higher sensitivity and can demonstrate specific findings (such as lung nodule and “halo sign”) that can guide management. In a child with prolonged fever of unknown origin despite extensive medical workup (fever of unknown origin), diagnosis is usually dependent on clinical and laboratory studies, and imaging tests have low yield.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Section snippets

Introduction/Background

A febrile pediatric patient, especially an infant, represents a dilemma for a primary care physician. The definition of fever is generally regarded as a rectal temperature of ≥38°C 1, 2, 3. Oral temperatures are less reliable in infants and young children, although they are the usual method of measuring temperature in older children and adults. The cause of fever in a pediatric patient can often be determined from history, physical examination, and laboratory tests 4, 5, 6, 7, 8, 9. Prior

Summary of Evidence

Of the 79 references cited in the ACR Appropriateness Criteria Fever Without Source—Child document, 73 are categorized as diagnostic references, including 1 well-designed study, 3 good-quality studies, and 16 quality studies that may have design limitations. Additionally, 2 references are categorized as therapeutic references, including 1 well-designed study. There are 54 references that may not be useful as primary evidence. There are 4 references that are meta-analyses.

The 79 references cited

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an

Supporting Documents

For additional information on the ACR Appropriateness Criteria methodology and other supporting documents, go to www.acr.org/ac.

Take-Home Points

  • Neonates younger than one month with FWS are a high-risk group; however, the yield of routine chest radiography is low in the absence of respiratory symptoms.

  • In a child with FWS, chest radiography should be performed when there is clinical evidence of a respiratory illness and for those with fever ≥39°C or WBC count ≥20,000/mm3.

  • In children with neutropenia and FWS, especially those after bone marrow transplantation with persistent fever despite the administration of antibiotics, CT of the chest

References (80)

  • R.W. Steele et al.

    Usefulness of scanning procedures for diagnosis of fever of unknown origin in children

    J Pediatr

    (1991)
  • J.F. Sheng et al.

    Diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in patients with fever of unknown origin

    Eur J Intern Med

    (2011)
  • M.J. Dong et al.

    A meta-analysis of the value of fluorodeoxyglucose-PET/PET-CT in the evaluation of fever of unknown origin

    Eur J Radiol

    (2011)
  • K. Darge et al.

    Whole-body MRI in children: current status and future applications

    Eur J Radiol

    (2008)
  • S. Ley et al.

    Whole-body MRI in the pediatric patient

    Eur J Radiol

    (2009)
  • R. Chinnock et al.

    Hot tots: current approach to the young febrile infant

    Compr Ther

    (1995)
  • L.J. Baraff

    Management of infants and young children with fever without source

    Pediatr Ann

    (2008)
  • A.P. Kourtis et al.

    Practice guidelines for the management of febrile infants less than 90 days of age at the ambulatory network of a large pediatric health care system in the United States: summary of new evidence

    Clin Pediatr (Phila)

    (2004)
  • M.M. Massin et al.

    Management of fever without source in young children presenting to an emergency room

    Acta Paediatr

    (2006)
  • R.W. Tolan

    Fever of unknown origin: a diagnostic approach to this vexing problem

    Clin Pediatr (Phila)

    (2010)
  • M.E. Gabriel et al.

    Management of febrile children in the conjugate pneumococcal vaccine era

    Clin Pediatr (Phila)

    (2004)
  • J.A. Lohr et al.

    Prolonged fever of unknown origin: a record of experiences with 54 childhood patients

    Clin Pediatr (Phila)

    (1977)
  • H.J. McClung

    Prolonged fever of unknown origin in children

    Am J Dis Child

    (1972)
  • S. Mintegi et al.

    Predictors of occult bacteremia in young febrile children in the era of heptavalent pneumococcal conjugated vaccine

    Eur J Emerg Med

    (2009)
  • M.S. Rutman et al.

    Radiographic pneumonia in young, highly febrile children with leukocytosis before and after universal conjugate pneumococcal vaccination

    Pediatr Emerg Care

    (2009)
  • J.C. Gartner

    Fever of unknown origin

    Adv Pediatr Infect Dis

    (1992)
  • I. Brook

    Unexplained fever in young children: how to manage severe bacterial infection

    BMJ

    (2003)
  • P.L. Aronson

    Evaluation of the febrile young infant: an update

    Pediatric emergency medicine practice

    (2013)
  • A.G. Lacour et al.

    A score identifying serious bacterial infections in children with fever without source

    Pediatr Infect Dis J

    (2008)
  • M. Semeraro et al.

    A predictor of unfavourable outcome in neutropenic paediatric patients presenting with fever of unknown origin

    Pediatr Blood Cancer

    (2010)
  • O. Cogulu et al.

    Evaluation of 80 children with prolonged fever

    Pediatr Int

    (2003)
  • R.D. Goldman et al.

    Practice variations in the treatment of febrile infants among pediatric emergency physicians

    Pediatrics

    (2009)
  • B.M. Machado et al.

    Fever without source: evaluation of a guideline

    J Pediatr (Rio J)

    (2009)
  • S. Pasic et al.

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

    Acta Paediatr

    (2006)
  • P. McCarthy

    Fever without apparent source on clinical examination

    Curr Opin Pediatr

    (2005)
  • Palazzi DL. Fever of unknown origin in children: evaluation. Available at:...
  • Moher D, Hui C, Neto G, et al. Diagnosis and management of febrile infants (0-3 months). Evidence Report/Technology...
  • F.A. Bettenay et al.

    Differentiating bacterial from viral pneumonias in children

    Pediatr Radiol

    (1988)
  • J. Johnson et al.

    Intraobserver and interobserver agreement of the interpretation of pediatric chest radiographs

    Emerg Radiol

    (2010)
  • M. Korppi et al.

    The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children

    Acta Paediatr

    (2008)
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    The ACR seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

    Dr Safdar has received research funding from GE and has financial interest in Yottalook. The other authors have no conflicts of interest related to the material discussed in this article.

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