The Febrile Baby

Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever is defined as a higher-than-normal body temperature. In modern medicine, fever is defined as a temperature > 38°C (100.4°F). It is a common symptom in the pediatric population as an isolated symptom or accompanied by other findings that can help narrow the differential diagnosis. Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever is most commonly the body’s response to infectious processes; however, it can also be seen in other pathologic processes. In neonates and very young infants, the clinical presentation lacks specificity, so more diagnostic aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS are deployed to rule out severe bacterial infection (SBI) and to begin treatment according to age and clinical evolution.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition of fever

  • ≤ 56 days of age, any temperature ≥ 38°C (100.4°F)
  • > 56 days of age, any temperature ≥ 38.5°C (101.3°F)
  • Babies with an underlying immunocompromised state:
    • ≥ 38.5°C once
    • ≥ 38.0°C 3 times in a 24-hour period, 1 hour apart

Etiology

  • Infectious:
    • Viral
    • Bacterial
  • Noninfectious:
    • Malignancy
    • Rheumatic disease
    • Drug reaction

Systematic approach in determining the cause of fever

  • History and a complete physical examination, looking for infectious foci
  • Workup: labs and diagnostic imaging, according to the presenting signs and symptoms

When to admit to inpatient care

  • Signs of clinical instability:
    • Decreased level of consciousness
    • Signs of hypovolemic/ shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Signs of respiratory distress
  • High-risk babies:
    • Immunosuppressed 
    • Babies with a chronic disease
  • Baby requiring inpatient-level care:
    • Multiple repeated physical examinations due to the condition’s instability
    • Choice of empiric treatment requires IV medication or hydration.
    • Need for supplemental oxygen

Young Infants

Overview

  • 29–60 days old
  • Severe bacterial infection (SBI) prevalence: 6%–10% (most often urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections (UTIs))

Diagnosis and management

  • Labs:
    • Urinalysis
    • Urine culture
    • CBC
    • Blood culture
    • +/– C-reactive protein (CRP)
    • +/– Procalcitonin
    • LP should be performed if:
      • Born preterm (< 37 weeks of gestation)
      • Prolonged NICU stay
      • History of chronic medical problems
      • Has received antibiotics within the past 72 hours
      • Appears ill or is depressed or inconsolable
      • Visible infections on inspection
      • WBC < 5000 or > 15,000
      • Band-to-neutrophil ratio (bands/bands + neutrophils) > 0.2 
      • Chest x-ray (if obtained) shows infiltrate
    • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) testing indicated for all with:
      • Pleocytosis or RBCs in CSF
      • Ill appearance
      • Abnormal neurologic status, including seizure
      • Vesicular, blistering, rash
      • Lab evidence of hepatitis
      • History of maternal primary HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 infection during delivery
  • If baby appears well and all labs are normal, discharge and follow-up in 12–24 hours.
  • Abnormal labs:
    • Admission
    • Lumbar puncture (LP) if meets criteria
    • Empiric antibiotic administration:
      • Ampicillin and gentamicin
    • If urinalysis is positive and CSF is clear, discharge with oral antibiotics.
Table: Criteria for the management of the febrile baby (28 days–56 days old)
Rochester, NY Philadelphia, PA Boston, MA
Ultrasonography, urine culture, CBC, blood culture Yes Yes Yes
Spinal tap If abnormal testing Yes Yes
Ceftriaxone If abnormal testing If abnormal testing Yes

Children 3 Months–3 Years of Age

Note: This approach is appropriate for children who are not immunocompromised. Specific pediatric fever guidelines exist for children with:

  • Oncologic processes
  • Sickle cell disease Sickle cell disease Sickle cell disease (SCD) is a group of genetic disorders in which an abnormal Hb molecule (HbS) transforms RBCs into sickle-shaped cells, resulting in chronic anemia, vasoocclusive episodes, pain, and organ damage. Sickle Cell Disease
  • Indwelling medical devices (e.g., central lines, ventriculoperitoneal shunts, urinary catheters)

Viral infections are the most common cause of fever in this age group.

Degree and focus of empiric testing in this age group depends on:

  • History of present illness 
  • Physical exam
  • Clinical appearance of the child

Well-appearing children with unremarkable exams can be discharged without lab testing or presumptive antibiotics. Routine testing is not needed in a previously healthy, immunized child.

  • Routine use of CBC and blood culture is not recommended.
  • For bronchiolitis and fever, routine use of urine and blood culturing is not indicated.

Testing of nasal secretions for a viral etiology such as respiratory syncytial viral ( RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus) or influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza A or B may be helpful in a child with respiratory symptoms.

For ill-appearing children a full sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock workup should be performed with hospitalization.

Infectious Pathogens of the Newborn Infant

Group B Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus (GBS)

  • Gram-positive diplococcus
  • Commonly colonizes GI and genitourinary tracts: provides route of transmission from colonized mother to neonate
  • Neonatal infection can be classified by age at onset:
    • Early onset: normally birth to 24 hours of life, but can be as late as 6 days of life
    • Late onset: 7–89 days of life
    • Late, late onset: > 3 months
  • Clinical presentation:
    • Early onset:
      • Sepsis (80% of cases): fever or hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia, hypotonia, increased fussiness
      • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia (10% of cases): fever or hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia, shortness of breath, increased work of breathing, uneven lung sounds, persistent desaturations
      • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis (10% of cases): fever or hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia, increased or decreased tone, increased fussiness, poor feeding
    • Late onset:
      • Bacteremia (60% of cases): fever, irritability, lethargy, tachypnea, and apnea
      • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis (30% of cases): temperature instability, irritability, lethargy, poor feeding or vomiting, bulging fontanel, nuchal rigidity, focal neurologic findings and seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
      • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and joint infection (5% of cases): fever may be absent; may be unable to to bear weight; or may be complete active or have passive full range of motion of affected joint
      • Soft tissue infection (5% of cases): fever, tenderness, erythema, purulent discharge
    • Late, late onset:
      • Bacteremia without focus: fever, malaise, low tone
      • Other focal infections seen, but rare
  • Diagnosis:
    • Based on clinical appearance and presence of risk factors 
    • Lab testing:
      • CBC
      • Blood culture
      • Lumbar puncture if signs of sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock or meningitis are present or if infant is < 28 days old
      • Chest x-ray if respiratory symptoms are present
      • Urine culture
  • Management: antimicrobial therapy
    • Empiric therapy in all babies in whom sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock is suspected, usually with ampicillin and gentamicin initially (+ cefotaxime if meningitis is suspected), then narrowed based on sensitivity of bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview
    • Supportive care
    • Respiratory support, if necessary

TORCH infections TORCH infections Congenital infections are acquired in utero or during passage through the birth canal at birth and can be associated with significant morbidity and mortality for the infant. The TORCH infections are a group of congenital infections grouped due to their similar presentation. The acronym TORCH arises from the names of the infectious agents that cause the diseases included in this group: toxoplasmosis, other agents (syphilis, varicella zoster virus (VZV), parvovirus B19, and HIV), rubella, CMV, and herpes simplex. Congenital TORCH Infections

TORCH is an acronym for the causative pathogens of a group of particularly devastating congenital infections:

  • Toxoplasmosis
  • Others
  • Rubella virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview
  • Cytomegalovirus
  • Herpes simplex virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview

Toxoplasmosis

  • Caused by the protozoan Toxoplasma Toxoplasma Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis gondii:
    • Ubiquitous parasite infecting animals and humans
    • Found in cats and transmitted through contact with feces or being scratched by cat
    • In immunocompetent individuals, the infection is asymptomatic.
  • Transmitted transplacentally from the infected mother to the developing fetus
  • Clinical presentation:
    • Chorioretinitis Chorioretinitis Chorioretinitis is the inflammation of the posterior segment of the eye, including the choroid and the retina. The condition is usually caused by infections, the most common of which is toxoplasmosis. Some of these infections can affect the fetus in utero and present as congenital abnormalities. Chorioretinitis
    • Hydrocephalus
    • Intracranial calcifications
    • Abnormal CSF findings
    • Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice 
    • Thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia 
    • Anemia  
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever  
    • Microcephaly
  • Diagnosis:
    • Who to test:
      • Children of mothers with evidence of primary T. gondii infection during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
      • Children of immunocompromised mothers who also have serologic evidence of T. gondii infection 
      • Infants with clinical presentation consistent with T. gondii infection
      • Infants with positive screening test for Toxoplasma Toxoplasma Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis IgM
    • Testing:
      • Lumbar puncture: CSF often has elevated protein and can be sent for PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) testing.
      • Neuroimaging (prenatal and postnatal) may reveal intracranial calcifications, ventriculomegaly, or hydrocephalus.
      • Serology for Toxoplasma Toxoplasma Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis IgG, Toxoplasma Toxoplasma Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis-specific IgM and  IgA
  • Management:
    • Who to treat:
      • Infants diagnosed prenatally
      • Symptomatic infants
    • Pharmacotherapy with antiparasitics:
      • Pyrimethamine
      • Sulfadiazine
      • Folinic acid

Other ( syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis, varicella-zoster, parvovirus B19 Parvovirus B19 Primate erythroparvovirus 1 (generally referred to as parvovirus B19, B19 virus, or sometimes erythrovirus B19) ranks among the smallest DNA viruses. Parvovirus B19 is of the family Parvoviridae and genus Erythrovirus. In immunocompetent humans, parvovirus B19 classically results in erythema infectiosum (5th disease) or "slapped cheek syndrome." Parvovirus B19)

Syphilis is caused by Treponema Treponema Treponema is a gram-negative, microaerophilic spirochete. Owing to its very thin structure, it is not easily seen on Gram stain, but can be visualized using dark-field microscopy. This spirochete contains endoflagella, which allow for a characteristic corkscrew movement. Treponema pallidum.

  • Transmitted by contact with infected mother during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care or childbirth
  • Clinical presentation:
    • Bloody nasal discharge (called “snuffles”) 
    • Hepatosplenomegaly/jaundice/↑ hepatic enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes
    • Hemolytic anemia Hemolytic Anemia Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia/thrombocytopenia 
    • Rash on palms and soles
    • Blindness due to chorioretinitis
  • Diagnosis:
    • Primary test: rapid plasma reagin and VDRL
    • Confirmatory test: T. pallidum immobilization (TPI), fluorescent treponemal antibody absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption (FTA-ABS), and T. pallidum particle agglutination (TPPA)
  • Management: penicillin G

Varicella is caused by the varicella-zoster virus Varicella-Zoster Virus Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Varicella-zoster infections are highly contagious and transmitted through aerosolized respiratory droplets or contact with infected skin lesions. Varicella-Zoster Virus/Chickenpox, also known as chickenpox Chickenpox Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Chickenpox is the primary infection and occurs most commonly in children. The typical clinical presentation includes prodromal symptoms and a generalized, intensely pruritic vesicular rash. Varicella-Zoster Virus/Chickenpox.

  • Clinical presentation:
    • Cutaneous scars
    • Atrophy of extremities
    • Neurogenic bladder/ hydronephrosis Hydronephrosis Hydronephrosis is dilation of the renal collecting system as a result of the obstruction of urine outflow. Hydronephrosis can be unilateral or bilateral. Nephrolithiasis is the most common cause of hydronephrosis in young adults, while prostatic hyperplasia and neoplasm are seen in older patients. Hydronephrosis
    • CNS manifestations: microcephaly/cortical atrophy/ seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures/mental retardation 
    • Eye disease: microphthalmia/cataracts/chorioretinitis
  • Diagnosis:
    • Clinical diagnosis is by appearance of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions
    • Direction fluorescent antibody (DFA) testing or PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) of fluid collected from blisters or CSF
    • Serology for immunoglobulins Immunoglobulins Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins
  • Management: acyclovir

Parvovirus B19 infection during the 2nd trimester can be associated with hydrops fetalis or fetal loss.

  • Clinical presentation:
    • Hydrops fetalis
    • Anemia
    • Most intrauterine infections do not result in fetal developmental defects.
  • Diagnosis: serologic assays for IgG and IgM against parvovirus B19 Parvovirus B19 Primate erythroparvovirus 1 (generally referred to as parvovirus B19, B19 virus, or sometimes erythrovirus B19) ranks among the smallest DNA viruses. Parvovirus B19 is of the family Parvoviridae and genus Erythrovirus. In immunocompetent humans, parvovirus B19 classically results in erythema infectiosum (5th disease) or "slapped cheek syndrome." Parvovirus B19
  • Management: supportive care

Rubella

  • Caused by the rubella virus Rubella Virus Rubella (also known as German measles or three-day measles) is caused by a single-stranded, positive-sense RNA virus of the Togaviridae family and the Rubivirus genus. Rubella only infects humans and spreads prenatally via vertical transmission or postnatally via droplet contact. Rubella Virus
  • Transmitted transplacentally
  • Clinical presentation:
    • Usually asymptomatic at birth.
    • Congenital rubella Rubella Rubella (also known as German measles or three-day measles) is caused by a single-stranded, positive-sense RNA virus of the Togaviridae family. Rubella only infects humans and spreads prenatally via vertical transmission or postnatally via droplet contact. Congenital rubella is associated with a classic triad of symptoms: cataracts, cardiac defects, and deafness. Infection in children and adults may be mild and present with constitutional symptoms along with a viral exanthem. Rubella Virus syndrome is associated with 4 common anomalies: 
      • Deafness (60%–70% of fetuses)
      • CNS abnormalities (10%–25%)
      • Eye defects such as cataracts (10%–30%)
      • Cardiac malformations (10%–20%)
    • Growth restriction
    • Hepatosplenomegaly
    • Extramedullary hematopoiesis results in a “blueberry muffin” appearance in many infected infants. 
  • Diagnosis:
    • PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) for rubella Rubella Rubella (also known as German measles or three-day measles) is caused by a single-stranded, positive-sense RNA virus of the Togaviridae family. Rubella only infects humans and spreads prenatally via vertical transmission or postnatally via droplet contact. Congenital rubella is associated with a classic triad of symptoms: cataracts, cardiac defects, and deafness. Infection in children and adults may be mild and present with constitutional symptoms along with a viral exanthem. Rubella Virus RNA RNA Ribonucleic acid (RNA), like deoxyribonucleic acid (DNA), is a polymer of nucleotides that is essential to cellular protein synthesis. Unlike DNA, RNA is a single-stranded structure containing the sugar moiety ribose (instead of deoxyribose) and the base uracil (instead of thymine). RNA generally carries out the instructions encoded in the DNA but also executes diverse non-coding functions. RNA Types and Structure (throat swab, CSF)
    • Serology (IgM/IgG antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins)
    • Viral culture (nasopharynx, blood)
  • Management: acyclovir in maternal varicella infections

Cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus (CMV)

  • Occurs early during the neonatal period or later during childhood
  • Early presentation usually includes: 
    • Intrauterine growth restriction
    • Microcephaly
    • Lethargy
    • Optic neuropathy
    • Intracranial calcifications
    • Motor delay
    • Hepatosplenomegaly
  • Mortality rate is high and can reach 12% within the 1st 6 months of life.
  • Mental retardation and hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss can occur during childhood and are usually progressive.
  • Management with ganciclovir

Herpes simplex virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview ( HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2)

  • Direct passage from the mother to the baby
  • Clinical presentation:
    • Occurs between 7 and 28 days of life
    • Irritable
    • Vesicular rash 
    • Seizure
    • Hypothermia
  • Workup and diagnosis:
    • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) of blood test
    • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 culture: eyes, nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose, mouth, rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal
    • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) of CSF
    • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests
  • Management:
    • Obtain blood cultures.
    • Skin–eye–mouth disease: acyclovir
    • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis or disseminated HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2: acyclovir

References

  1. Nield, L. S., Kamat, D. (2020). Fever. Chapter 201 of R. M. Kliegman R. M., et al. (Eds.), Nelson Textbook of Pediatrics, Elsevier, pp. 138–1388.e1. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501002017
  2. Brower, L., Shah, S. S. (2020). Fever without a focus in the neonate and young infant. Chapter 202 of R. M. Kliegman R. M., et al. (Eds.), Nelson Textbook of Pediatrics (pp. 138–1392.e1). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501002029
  3. Arora, R., Mahajan, P. (2013). Evaluation of a child with fever without source. Pediatric Clinics of North America. 60, 1049–1062. https://pubmed.ncbi.nlm.nih.gov/24093895/
  4. Ghory, H. (2019). Emergent Management of pediatric patients with fever. Emedicine. Retrieved March 27, 2021, from https://emedicine.medscape.com/article/801598-overview
  5. Allen, C. (2020). Fever without a source in children 3 to 36 months of age: evaluation and management. UpToDate. Retrieved from March 26, 2021, from https://www.uptodate.com/contents/fever-without-a-source-in-children-3-to-36-months-of-age-evaluation-and-management
  6. Gould, J. (2019). Fever in the infant and yoddler. Emedicine. Retrieved March 26, 2021, from https://emedicine.medscape.com/article/1834870-overview#a6
  7. Hymes, S. (2016). Fever without a focus. Emedicine. Retrieved March 26, 2021, from https://emedicine.medscape.com/article/970788-overview
  8. Ghory, H. (2019). Emergent management of pediatric patients with fever. Emedicine. Retrieved March 27, 2021, from https://emedicine.medscape.com/article/801598-overview
  9. Johnson, K. (2020). Overview of TORCH infections. UpToDate. Retrieved March 28, 2021, from https://www.uptodate.com/contents/overview-of-torch-infections
  10. Marino, T. (2017). Viral infections and pregnancy. Emedicine. Retrieved March 29, 2021, from https://emedicine.medscape.com/article/235213-overview#a4

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