Case Series of Prolonged Febrile Illness in Pediatric Age Group: A Diagnostic Challenge

Abstract

Background: Fever is defined as a rectal temperature of 100.4oF or more. It is a physiologic response characterized by an elevation of body temperature above normal variation. Fever is one of the common causes of medical consultation in children, responsible for 15%–25% of consultations in Pediatrics practice. Children with prolonged fever worry their parents and are a diagnostic challenge to pediatricians. Persistence of fever raises clinical queries towards diagnosis, especially in patients without identifiable focus. Children with a temperature of more than 38°C (100.4°F) recorded by a healthcare professional without any determined reason after at least 8 days of evaluation should be classified as having a “fever of unknown origin”. Most fevers with unknown causes usually have atypical presentations of common illnesses. Case Presentation: We reviewed the case records of 9 children admitted to our pediatric ward with prolonged fever episodes from December 2021 to October 2022. They were diagnostic challenges for clinicians. In our cases, 2 children had scrub typhus, 1 was diagnosed with acute lymphoblastic leukemia, and 1 had multidrug-resistant typhoid fever. However, 2 patients remained with a fever of unknown origin. Three children were found to have coinfections and diagnosed with enteric fever with other coinfections like dengue, leptospirosis, and urinary tract infection. Cases 1, 2, and 9 had persistent fever despite appropriate antibiotics therapy based on sensitivity patterns, hence a significant diagnosis challenge. Cases 3 and 6 had initial diagnostic deviations due to their atypical presentations, and both cases were diagnosed as scrub typhus. After extensive evaluation, case 4 was diagnosed as malignancy (acute lymphoblastic leukemia). Cases 5 and 7 posed a diagnostic challenge: The causes were not found after extensive evaluation, and there was persistent fever after 10 days of admission. Hence, they were diagnosed as “fever of unknown origin”. Conclusions: A complete history and detailed examination are essential in evaluating pediatric illnesses. We have found that there might be deviators during disease evolution. We should not settle with a single diagnosis until a good clinical response is achieved and also consider alternative diagnoses or coinfections. Common causes of prolonged fever should be ruled out first. Coinfections should also be considered if there is no clinical response to treatment in a patient. A practical, systematic, and stepwise approach can be helpful with the assessment and management of prolonged fever in the pediatric age group.