1. Chest x-ray. Useful in patients who have fever without localizing signs, particularly if physical exam findings raise suspicion of pulmonary involvement (especially tachypnea).
2. Abdominal imaging. "Blind" abdominal imaging for clues to an abdominal source of fever seldom is useful. Abdominal imaging, as well as imaging in general, should be guided by clinical suspicion.
3. Ultrasound. By virtue of its rapid availability, often a useful study if clinical signs or symptoms direct an evaluation to a given area. May reveal abscesses or other fluid collections.
4. Bone scan or MRI. Particularly useful if bone infection is suspected.
5. Thoracentesis, arthrocentesis, bone aspirate. As a general rule, obtaining material for culture from locations of fluid collections has a high yield and is warranted whenever possible. Perform whenever possible prior to antimicrobial treatment, because it can direct treatment.
6. Echocardiogram. Can be useful to assess for myocardial dysfunction, as seen in viral myocarditis, acute rheumatic fever, and Kawasaki disease. May also implicate valvular disease of acute rheumatic fever, infective endocarditis, and coronary dilation or aneurysm of Kawasaki disease.
V. Plan. Age of the involved child is a critical ingredient in the clinical decision tree. Any ill-appearing child requires thorough evaluation.
A. Young Infants. Approach each febrile infant with the goal of first ruling out meningitis or overwhelming sepsis. Neonates must be considered functionally "immunocompromised" as they not only often fail to localize infection but also have a limited repertoire of clinical responses.
1. Infants, especially those who are younger than 1 month or who appear ill, require thorough evaluation with blood culture, urine evaluation and culture, and cerebrospinal fluid (CSF) evaluation with culture and appropriate CSF polymerase chain reaction (eg, herpes, enterovirus).
2. Admission and empiric treatment to cover group B Streptococcus, Listeria monocytogenes, and gram-negative enteric organisms is warranted, as well as consideration of empiric treatment of herpesvirus with acyclovir. A third-generation parenteral cephalosporin or an aminoglycoside (usually gentamicin) coupled with ampicillin is the current treatment of choice in most settings. Clinician must still rule out meningitis in this patient.
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