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Indian Pediatr 2018;55: 69 -70 |
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Etiology of Fever of
Unknown Origin in Children from Mumbai, India
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Amruta Avinash Landge and *Tanu
Singhal
Department of Pediatrics, Kokilaben Dhirubhai Ambani
Hospital and Medical Research Institute, Mumbai, India.
Email: [email protected]
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This descriptive study evaluated 49 children with
fever lasting for more than 7 days at a tertiary hospital in urban
Mumbai. Etiologic diagnosis could be established in 88% of the cases.
Infections were the causein 34 (79%)patients, 6 (14%) were diagnosed as
collagen vascular diseases, and 3 (7%) had other cause.
Keywords: Enteric fever, Pyrexia of unknown origin,
Tuberculosis.
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T here is paucity of recent data
on the etiology of fever of unknown origin (FUO) in Indian children.
This descriptive study prospectively enrolledconsecutive children aged 3
months to 18 years with FUO presenting to the outpatient department of a
tertiary care private hospital in Mumbai November 2014 and April 2015.
FUO was defined as fever ³38.3ºC
lasting for more than 7 days where history, examination and preliminary
investigations, including complete blood count (CBC), malarial parasite
(MP), urine routine examination, Chest X-Ray, ultrasound abdomen
were normal [1]. Children with nosocomial FUO, primary immuno-deficiency
disorders and human immuno-deficiency virus infection were excluded.
Further investigations were performed in accordance with the usual
clinical care pathway. The diagnosis was considered confirmed if it met
the gold standard for the illness (culture, molecular diagnosis,
specific IgM serology or standard diagnostic criteria for non infectious
diseases). The diagnosis was considered probable if clinical, radiologic
or laboratory criteria were satisfied but the gold standard was negative
or was unavailable. The study was cleared by the hospital Research and
Ethics Committee which granted waiver of informed consent from the study
participants.
Forty-nine children (23 males) were included in the
study with a mean age of 8 years (range 11 mo - 17 y). The median
(range) duration of fever prior to presentation 14 (8-60)day. A
diagnosis could be established in 43 patients; in 27 the diagnosis was
‘confirmed’ and in 16 it was ‘probable’. Infections were diagnosedin 34
(79%) patients, while 6 (14%) had collagen vascular diseases and 3 had
other causes.
The commonest infection was tuberculosis (TB)
accounting for 12 cases (Pulmonary TB 6; lymph node TB 4; one each of
disseminated and bone TB) Contrast enhanced computed tomography (CECT)
emerged as an important diagnostic investigation, picking up findings
suggestive of TB in 6 patients who had normal X -rays and
ultrasoundscans. The diagnosis was bacteriologically confirmed in six
out of 12 TB cases (cultures in 5 and Xpert MTB/Rif in 6). Three cases
were rifampicin susceptible while two isolates were multi-drug
resistant, and one isolate was extensively drug-resistant. The other
infectious causes were viral infections in 8 (18%) (Epstein Barr Virus
infection in 2, probable viral infections 6), enteric fever in 7 (16%),
bacterial sinusitis in 4 (9%), and rickettsial fever, S. aureus
osteomyelitis and atypical pneumonia in oneeach. The collagen vascular
disease included systemic onset juvenile rheumatoid arthritis in 2,
Kawasaki disease in 2, and reactive arthritis and dermatomyositis in one
each. The miscellaneous group included erythema nodosum in one and
drug-related hypersensitivity syndrome in two patients. In six cases
where the diagnosis could not be established, fever resolved in 3 cases,
continued in 2, and 1 patient was lost to follow up. At the end of the
study 43 patients were free of fever; there was no mortality.
Tuberculosis emerged as the commonest cause of FUO in
our study; in patients presenting with fever lasting for more than 2
weeks half the etiology was TB. This is in agreement with adult studies
on FUO from India [2,3]. An interesting finding of our study was
bacterial sinusitis as an etiology of FUO in the absence of prominent
upper respiratory signs; diagnosis was established by a CT of paranasal
sinus in children with FUO and high leukocyte count with no other septic
focus.
The study results may not be generalizable as
regional infections influence etiology [4]. Asthe study was conducted at
a tertiary care center, infections such as malaria, urinary tract
infections did not figure in the etiology as they were diagnosed and
treated prior to referral. The high prevalence of drug resistance in TB
is again possibly due to referral bias. The absence of malignancy as
cause of FUO is probably due to the small study size.
The study suggestsCECT as an important diagnostic
investigation in patients with FUO. The high prevalence of
drug-resistant TB in the study emphasizes the need for establishing a
bacteriologic diagnosis of TB and avoiding empirical therapy.
Funding: None; Competing interest: None
References
1. Palazzi DL. Fever without source and fever of
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WJ, Hotez PJ, editors. Textbook of Pediatric Infectious Diseases, 7th
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2. Kejariwal D, Sarkar N, Chakraborti SK, Agarwal V,
Roy S. Pyrexia of unknown origin: a prospective study of 100 cases. J
Postgrad Med. 2001;47:104.-7.
3. Bandyopadhyay D, Bandyopadhyay R, Paul R, Roy D.
Etiological study of fever of unknown origin in patients admitted to
medicine ward of a teaching hospital of eastern India. J Glob Infect
Dis. 2011;3:329-33.
4. Joshi N, Rajeshwari K, Dubey AP, Singh T, Kaur R. Clinical
spectrum of fever of unknown origin among Indian children. Ann Trop
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