Fever Caused By Occult Infections In The 3-To-36-Month- Old Child

It’s 3 am and the ED is winding down. You look up to find that the next patient to be seen is a 9-month-old with the chief complaint of “fever.” You swig down the last of your lukewarm coffee, grab the chart, and head off to room 5. On entering, you find a teary-eyed white female infant sitting in her mother’s lap, eyeing you suspiciously. Mom relates that she has been ill for the past three days with upper respiratory congestion and a nonproductive cough, which her mom has been treating with an over-the-counter decongestant. Today, however, the child was less active, drank less of her formula than usual, and felt hot to the touch, prompting Mom to check her temperature. Her initial fever of 101.2°F responded to a dose of acetaminophen, but when the mother rechecked the child’s temperature several hours later, it had climbed to 103.5°F, so she called her pediatrician’s answering service and was told to bring her immediately to the emergency department. The young girl has had two episodes of nonbloody, nonbilious emesis related to her cough, no diarrhea or rash, and has maintained her urinary output. She has been exposed to other children with upper respiratory illnesses in her day care class. To date, however, she has been in good health—no underlying medical conditions and no chronic medications or allergies, and her immunizations are current. When seen in triage 30 minutes ago, she was given another dose of acetaminophen by your nursing staff. Your examination reveals an alert but quiet patient who is nontoxic-appearing and apparently well hydrated. She reaches for your stethoscope while drinking from her bottle. With examination, she gets appropriately cranky but calms easily with her mother’s touch. No source for her fever is readily identifiable—her tympanic membranes are normal in appearance, her chest is clear, she has no rash, and her physical findings are reassuring. Mom is concerned about several issues: the height of the fever, the fact that it July 2007 Volume 4, Number 7