Fever of Unknown Origin: Clinical Case and Viva Q&A

Clinical Case of Fever of Unknown Origin in Children

A 6-year-old boy is brought to the pediatric clinic by his parents with complaints of persistent fever for the past 3 weeks. The fever has been intermittent, ranging from 38.5°C to 39.5°C, typically higher in the evenings. The child has experienced occasional chills but no rigors.

History

• No specific pattern to the fever
• No recent travel history
• No known exposure to infectious diseases
• Up-to-date on vaccinations
• No pets at home
• No history of recurrent infections

Associated Symptoms

• Mild fatigue and decreased appetite
• No weight loss
• No night sweats
• No rash or joint pain
• No abdominal pain or changes in bowel habits
• No respiratory or urinary symptoms

Physical Examination

• Temperature: 38.7°C
• Heart Rate: 110 bpm
• Respiratory Rate: 22/min
• Blood Pressure: 100/60 mmHg
• Weight: 20 kg (slight decrease from last visit 2 months ago)
• General: Alert, mildly pale, no apparent distress
• HEENT: No pharyngeal erythema, no lymphadenopathy
• Chest: Clear breath sounds bilaterally, no murmurs
• Abdomen: Soft, non-tender, no hepatosplenomegaly
• Skin: No rashes or lesions
• Musculoskeletal: No joint swelling or tenderness
• Neurological: Grossly intact

Initial Laboratory Results

• WBC: 7,500/μL (slightly elevated neutrophils)
• Hemoglobin: 11.2 g/dL
• Platelets: 280,000/μL
• ESR: 55 mm/hr
• CRP: 3.5 mg/dL
• Urinalysis: Normal
• Blood and urine cultures: Pending

Assessment

The patient presents with classic features of fever of unknown origin in the pediatric population: fever >38.3°C (101°F) of at least 8 days duration, with no apparent diagnosis despite initial outpatient or hospital evaluation. The normal physical examination and nonspecific laboratory findings necessitate further investigation.

Plan

1. Admit for further evaluation and management
2. Complete blood count with differential, comprehensive metabolic panel
3. Blood cultures (aerobic and anaerobic)
4. Chest X-ray
5. Abdominal ultrasound
6. Consider testing for EBV, CMV, and other viral etiologies
7. If fever persists, consider advanced imaging (CT or MRI) and rheumatologic workup
8. Consult infectious disease and rheumatology specialists as needed

This case highlights the challenge of diagnosing FUO in children and the need for a systematic approach to evaluation.

Clinical Presentations

Varieties of Clinical Presentations in Pediatric FUO

1. Classic FUO with Nonspecific Symptoms

   • Persistent fever (>38.3°C) for ≥8 days
   • Fatigue and decreased activity
   • Mild appetite loss
   • No localizing signs

2. FUO with Predominant Gastrointestinal Symptoms

   • Fever accompanied by abdominal pain
   • Changes in bowel habits (diarrhea or constipation)
   • Possible nausea or vomiting
   • May suggest inflammatory bowel disease or abdominal abscess

3. FUO with Musculoskeletal Manifestations

   • Fever with joint pain or swelling
   • Morning stiffness
   • Muscle aches
   • May indicate juvenile idiopathic arthritis or other rheumatologic conditions

4. FUO with Recurrent Episodes

   • Periodic fever syndromes
   • Episodes of high fever alternating with periods of normal temperature
   • May be accompanied by rash, joint pain, or abdominal pain
   • Examples include PFAPA syndrome, Familial Mediterranean Fever

5. FUO with Respiratory Focus

   • Fever with subtle respiratory symptoms
   • Mild cough or tachypnea
   • Normal or near-normal chest examination
   • May indicate occult pneumonia or tuberculosis

6. FUO with Hematologic Abnormalities

   • Fever with pallor or easy bruising
   • Lymphadenopathy or hepatosplenomegaly
   • Abnormal blood counts
   • May suggest leukemia or lymphoma

7. FUO with Neurological Symptoms

   • Fever with headache, neck stiffness, or altered mental status
   • Subtle neurological deficits
   • May indicate central nervous system infection or autoimmune encephalitis

8. FUO in Immunocompromised Children

   • Fever in a child with known immunodeficiency or on immunosuppressive therapy
   • May have subtle or atypical presentations of common infections
   • Higher risk of opportunistic infections

9. FUO with Dermatological Manifestations

   • Fever accompanied by rash or skin lesions
   • Rash may be subtle or transient
   • May suggest viral exanthems, Kawasaki disease, or systemic juvenile idiopathic arthritis

10. FUO with Occult Dental or ENT Focus

    • Fever without apparent source
    • Subtle signs of dental abscess or sinusitis
    • May require specialized ENT examination or imaging to diagnose

VSD Quiz for Medical Students & Professionals

This interactive quiz component covers essential concepts about Ventricular Septal Defects (VSD) in pediatric cardiology. It includes 25 high-yield viva questions with detailed answers

Question 1 of 30

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