Pyrexia of Unknown Origin in Children

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Pyrexia of Unknown Origin in Children

29 Jun, 2:30 PM

[Music] hello everyone and good evening uh welcome to another enriching session by the uh dr baldwin is a renowned and experienced pediatrician graduated from bj medical college and he has more than three decades of cumulative experience in the uh the industry and he currently works at the amraps hospital and postgraduate institute and he has written a book on iap clinical methods which is one of the if not the best book for the clinical examination in children so i welcome sir and request him to begin with the session welcome sir thank you very much for kind words of the introduction so good evening friends it is my pleasure to share with you this very specific topic common topic in the reality practice and that is pyrexia and part of it i will address these parents of unknown origin friends all of us know that it's a most common symptom in the practice it is said that 30 percent of all of his visits and lots of the phone calls are due to the fever in our pediatric practice many times it happens so that measured the fever is get better even before we know the exact cause for this and among all these problems probably by pirates of hungarian po commonly what we say may not be that common in day to day practice but of course it is in the practice it's a major concern for the patients parents and even the physicians certainly it's a great challenge to the treating meditation the point which i would like to insist over here that before you say the fever please check that documentation if done and documentation by proper method of measuring the body temperature reason is you know why i insist this point many times what the parents complain bomb head or warm body in true sense may not be the exact figure so documentation of body temperature and defining fever is the first step go for the approach of you or any parents and children always i insist to my students and friends in the practice whenever you come across the fever patient always try to define the fever pattern because it will help you to desire the approach fever can be of short duration it can be of wrong fever it can be recurrent fever can be periodic fever fever without focus or source and fewer of furniture and this pattern designation of this particular group of this problem will give you the idea that how exactly we should approach species of prolonged fuel that means a single unless in which duration of your exists usually beyond our expectation commonly more than 10 days invariant or parasitic infection or even more than three weeks in a case of infectious monolith monitors and then prolong fear then you always think for some other reason once we say recurrent fear most of the times it is single less but there is a vaccine and bearing and that probably may be due to some incomplete course of these drugs especially the antimicrobial therapy sometimes it can be the for the multiple illnesses appearing at irregular intervals involving different organ systems and with the fever is variable component so try to define it exactly once you see periodic fever that means recurring episodes of illness for which fever is the cardinal feature and other associated symptoms are similar they are predictable i remember when mother said exactly the date and duration that on this particular day the again the fever will develop that decision is seen the duration of the episodes is days two weeks before the entering weeks to months complete well-being and episodes can have either the clock work or irregular periodicity and examples of malaria hilariouses and with the papa syndrome which is seen recently on pediatric practice coming to the point of this our today's topic it is you are parekhs of anunnari how we define these pyrex of androgology friends first always as i said defined really is the fever and for that is a documentation a health care provider is very very important that fever more than 100.4 degree fahrenheit on several occasions and for such a fever cross could not be identified after three weeks of evaluation as an outdoor patient or one week of variation as an indoor patient and the workup or variation is in the form of the detailed history thorough clinical examination and even the routine investigation still you don't have the answer so the friends remember any fear of few days is not to you number one documented fever definite fever is that and for that evaluation is done more than three mixes outdoor or more than one week as a indoor patient still if you don't have the answer such a patient be defined in the pyrex of origin what i was talking about without the source it is similar to this and that's why i thought that let me differentiate what is it i think almost the same i don't have the cost for the few one but the duration is less than one week and even after the one week i noticed the answer for the source of the infection for the fever and here we are trying to differentiate fear without source and fever of regime so they are saying that the diagnosis is not obvious to the clinician but those children whom fever duration falls short of the fear of origin they usually we say fewer without the source why we are differentiating because differential diagnosis and most frequent causes are different in both the categories infection being the most common evil fear without source by products of another in different regions are there very important point fewer without the source of short duration emergency testing is required here you have to go for evaluation very fast and even after the collection of the samples for the investigations we have to start the antibiotics by fear of unknown origin patients stable i am not in hurry i should go for first proper evaluation and then plan for the investigations and empirical antibiotics or empirical drugs are usually not warranted next question comes to your mind that what are the common causes of parents of angular origin and these are these most of the times they are inflammatory please remember inflammation is not necessarily always infection yes most common infection but there are other reasons for the inflammation and then infections collagen disorders malignancies drug fever and some other reasons for the inflammation infections commonly bacterial viral protocol or even fungal so many reasons collagen disorders examples you know systemic onset joint idiopathic arthritis sle majora's disease kawasaki foreign disease is most common in the children are leukemia lymphomas immunity neuroblastoma which may come with only fever can be drug fever if the entropy given for some pre-operative assessment or preoperative prerequisition may be due to some antibiotics or some other reasons like inflammatory bowel disease when hematomas hemophagocytic syndromes so many reasons non-inflammatory condition in terms of the ectodermal dysplasia familial dysautonomia heat hyperparexia again it is very common in our i will say india diabetes insipidus aerotoxicosis once you define that infection as i was talking bacterial infection very common surveillances tuberculosis cti bacter endocarditis osteobiotics procedures and streptospirosis can be either called the sinusitis mastoditis even the dental infection or abscess non-tuberculosis microbacteria abscesses are very common particularly the liver abscess sub-diaphragmatic abscesses perinephric acids pelvic capsules virulence of the abstinent bar cytomegalo hiv or your hepatitis b protects your most common malaria and other in the front of the client medial medication if fever is coming up and fungal particularly in the immunocompromised children friends which i was talking please keep in mind that any case of pyrex of bandung origin still infectiously is the is the most common cause almost in 50 to 60 percent next is rheumatology methodology and some of the even cases before we diagnose or come to the conclusion if you are being disappeared it also happens please friends remember what i want to share with you don't think the uncommon condition more likely an unusual presentation of a common disease rather than the uncommon disease and therefore even any case of perhaps always start to think is it malaria it is anti-fever the tuberculosis is it ureteral infection then you can think for the brusselos or even some other infections or even some other disorders so please keep in mind even in a case of parallax of non-origin most of the times most commonly it's a unusual presentation but disease is common so that's very important please always find out the reflex signs why we are interested to locate the red flux signs because potential is a serious condition we have to act very fast but if we act slow probably the progress of the disease may go for problems and complications and particularly when the history of prolonged appetite loss significant weight loss is there sleep disturbances also focal complaint is very very important and suppose if you get an examination if it is some skin rashes clubbing or some focal science i think these groups require the very proper actions very fast decisions so that before any problem or complication we identify the reason condition and we can start the treatment what is the approach once you are defined it's a case of video when this is very very important please keep in mind if i started from the first point very basic point documentation of people detailed history thorough clinical examination initial laboratory investigations and suppose still if you don't get the cause go for repeated history and i will say repeated history by the different people that is very important and clinical examination should be daily probably previously with science i have not seen now there will be the development of new sign and if i don't examine the patient very easily you can miss even some science will be transient it will be for few days and may disappear but it is a very important clue for the diagnosis it is very important that repeated history daily thorough clinical examination and interpret this basic laboratory investigations very intelligently and then decide for the additional test then let me share with you that what are the important points in the history it is which becomes a very important clue for the diagnosis of parex of fundamentality and that is the onset of the fever see i will say with the details of fever how it started whether it was the sudden or gradual onsite second by the intensity visited low grade viewer or high grade viewer and what is the duration exactly what is the frequency how many spikes in a day and go for the proper i will say in the in the chart you go for the proper documentation and see the pattern anyone with a response to anti-politics or not it is said that in the viral infection usually that is a good response to the antibiotics an inter-febrile period usually child is good reproduction usually or even child may not be able to eat properly may not be playful that means the sick looking in looking child probably favors that it is more likely particularly this vector line fractions associated symptoms become the very important clue for ditching the diagnosis so friends this is very important points regarding the femur other points you know history of recent vaccination because in the palette practice this is very very important it's about history of injection dpt that they may be the responsible for the people or even blood component therapy there may be the reason for this immortals contact is very important and therefore as for the now recent national tuberculosis elimination program the pediatric practice and any person suffering from the any form of the active tuberculosis in the last two years in very important component which becomes a strong point for me to investigate for the tuberculosis of course history of united infection may be due to some malformation congenital heart disease some surgical procedures some synthesis that is done ventricular peritoneal shunt is that and in that presence suppose fever is there the first my thought would be that infection related to the shrink history of travel is very important all of us know now know that this uh world has become very small the occasional disease we were not considering in the gujarat but now people are traveling from so many other states of our own country and when they come with this person also even in the gujarat you know it's not seeing the gujarat but i remember that some of the persons those who have come in the gujarat for work from i come across with the kalasa in such children so i think this this is very very important exposure to the heavy metals some poisonous fumes is also be considered in the history but the other points in the history pirates of it is said that more than six months galileo meters are automated a disease are more common and if personally if i quote over here i have seen the parex of three months six months even eight months one year and that becomes very difficult to reach the possibility but as even some of the guidelines some of the observations if i quote the default is a longer duration probably either the autoimmune or granulomatous disease and supposed response to the non-stimulated anti-inflammatory drugs and here there is no response then consider some non-inflammatory condition history of associated sweating even was fever intolerance and sweating favors the thyroid oxidases fever heat ill intolerance and absence of sweating may be a case of ectodermal dysplasia associated complaints we can go suppose spontaneously resolved they die which i was talking that sometimes a red eye has noted my only mother when the child is brought to me there is no red line but that can be the case of kawasaki diseases but persistent grade dripping eyes everything astonishing and persistent nasal discharge or weight check for the sinusitis so these points are very important please remember the threads some of the characteristics that support absence of sweating is part of the fever that can be in a case of dehydration the case of diabetes insipidus and hydraulic ectodermal dysplasia familiar dysautonomia are exposed to the atrophy so even simple point but with the fever chat whether the sweating is there or not and by chance if it is not there keep these conditions in mind what are the close particular diagnosis from the exposure what i was talking that it is very important point with infected or ill person in the family then check the diagnosis of the index case suppose the pets are dead like cats cats are responsible for the leptospirosis that's great disease toxicology dogs may be responsible for medication disease leptospirosis proxy karachitis even ticks particularly ticks are very important but in the forest or jungle suppose some person is visiting it can cause the richest disease and friends very strong quite important unpasteurized milk or milk products or in the raw meat that becomes the very important source of the bristolosis and of course toxoplasmosis pica is not uncommon in the pediatric practice that may be responsible for visceral larva migrants or even toxoplasmosis and it is said that whenever you don't have the clear-cut answer check the drug many a times drug itself is responsible for the fever and suppose some abdominal surgery has been performed and always thing for the intra-abdominal abscesses so friend these points are very important next similarly what are the important points on clinical examination in a case of you as i was talking thorough physical examination is very important please don't go for the shortcut whatever the time is spent for the examination of the patient is the good investment it's not the waste of time and here check the upper respiratory track and oral cavity coronary artery discharge may be due to sinusitis pharyngeal hyperemia with exudate may be in a case of infectious mononucleosis arrange arranging hyperemia without exodus exudate maybe in the case of leptospirosis as i was talking the conical t31 may be the very characteristic of an hydraulic active dysplasia and smooth tongue excess salivation the case of family disorder friends please remember certain conditions they present with the oral ulcers particularly assembly inflammatory bowel disease basically suppose if you come across keep in mind leukemia and histiocytosis eye examination is very informative in a case of pyrex of amino origin it is said that bulbar conjunctivity the characteristic of kawasaki alphabetical conjunctivities favors the infectious mononucleosis and reflecting your conductivity is the characteristic of tuberculosis ischemic retinopathy if you get it it's a it's a suggesting polyatomic stradosa absent tears and corneal reflux just i will say these two points are sufficient for me to say it's a table dysautonomia please friend check the eye in details and if you get the correct tubercles some mediary tuberculosis or sarcoidosis and those what you are going to get in a case of bacterial endocarditis uvitis is very important certain is connected tissue disorders sarcoidosis jonathiopathic arthritis sle kawasaki based disease so i think i examination and you should have the very good friend but you get the pediatric ophthalmologist to help us the trust may be in a case of hepatitis c viruses malaria and even the antique female and obviously some of the patient comes to the proptosis can be the neuroblastoma can be the thyroid psychosis vaginas disease or some orbital tumor so i think you know you can see that the simple points becomes a very important clue to clean synaptosis musculoskeletal points particularly the bony tenderness and that to particular nocturnal body tenderness not the joint joint tenderness i'm talking body tenderness that is very characteristic in a fever and sick child i think it's a case of leukemia can be in a case of osteomyelitis anywhere rare but coffee disease yes i come across in two patients that is the infantile cortical hyper hyperostrosis muscle tenderness in a case of fever may be the leptospirosis i think common condition other conditions may be the dermatomyositis or even the microplasma arthritis all of us know collagen vascular disease is common then braceless can come even anti cancer arthritis tuberculosis is known hive is known it is said that if you examine the tendon and particularly hyperactive tendon deflects weak fever i think thyroid toxicosis but hyperactive or absent tendency flux in the case of terminal desatonomia and trapezes standardness very characteristic clinical point i will say to say it's a sub diaphragmatic absence i remember that when we didn't have the ultrasonography these are the very characteristic i will say clinical examination which our teachers used to show the trapezius tenderness the point to say some diaphragmatic absence please remember in a case of you some deep-seated abscesses this is very common and i want your attention that always run out the deep-seated abscess in a case of pirate extrapolation can be the sub diaphragmatic can be the subclinic erythritis very well known to all of us detox peritoneal when mediastinal dental brain abscess particularly in a case of cyanotic heart disease like fellows or with the hepatic liver absence recently our resident has done this dissertation of their liver abscess and we got some 30 to 40 cases in years one so i think it's very common which we should keep in mind please don't miss the per rectal and pelvic examination it may be the only examination which will give you the idea regarding pelvic axis and other abscesses initial laboratory test usually we go for the cbc that is for examination this friend remember thrombocytosis is a very non-specific but acute phase reactant and in the kawasaki it is the very important observation using ophelia may be the visceral larva migrants or even the sarcoidosis sarcoidosis eosinophilia is very characteristic and polymorph nuclear nucleosides more than 10 000 per kilometer or band cells i think simpler bacterium infection and less than 5000 again indolent bacterial infection except the typo atypical lymphocytes if you get a peripheral smear it's a viral infection particularly the abstain part and immature lymphocytes blast cells the characteristic of leukemia it friends suppose if you get the parrots of origin and jupiter infections and lymphopenia is a constant observation always zeroed out with a deficiency disorder esr crp i think is esr usually commonly we don't give much importance but if it is more than handled in a case of pure what i will do i will go for the sr and with moderate hundred maybe the case of tuberculosis causation disease autoimmune disease or malignancy asr can be low even in the presence of infection if there is consumption of the fibrinogen and that is the complication in the form of the dic or a challenge very high esr in the presence of hypergamma human capital but friends high esr and normal crp i think that is very important sorry very characteristic please remember high esr normal crp and and even crp is raising and esr is coming down i think it's a complication of a challenge or even the dic during routine and culture is very very important particularly the young children never visit many a times for the parents of no regime urinary tract infection is the cause for younger children and if you get a sterile prior area it's a characteristic of kawasaki disease you make at interval process also chest action is very important mentalities we don't could routinely but yes in certain situations serological tests may not be common vidal but hiv yes blood culture is very very important very important hepatic enzymes blood video indirect rights these are the investigations additional tests that later on up as for the case you can plan for the brussels or recreational disease if you are thinking for some malignancy a challenge or even the elect uh tripod bruce losses go for the bone marrow examination and culture anti-nuclear antibodies and it's provided particularly for the collagen disorders axis are very important from the dental masculinities hospitalities and usgct mri they said that in a case of parents of undergoing ultrasonography of abdomen and city of the chest becomes a very important test and maybe the most additional tastes have been imaging as i was talking inflammatory bowel disease eating granulomas and or even non cases sarcoidosis fungal lubricant micro abscesses are very important in the split particular braceless ct scan as i was talking particularly for this miliary or small cavities bronchitises your cystic fibrosis it becomes a very informative and chest accession in lobar pneumonia may be the sequestered lung lung ceased or kct glyphon and ct mri of aids is very important particularly when you are suspecting of brain absence also so evaluation of a case of you use what i was talking later history may be the repeated history thorough clinical examination and please friend remember proper interpretation of the investigations it may be an evolve in condition examination repeated history you may get some important clue on evolving the situation a certain history as i was talking about the rewarding difficult investigations may be required initially probably in the case of leukemia bone marrow may not show anything later on bone marrow may show the picture of this cucumber so i think that if it requires certain investigations should be depicted so what actually i was talking please friend keep in mind this is very important which one usually i am following this in the practice and it is quite annoying that prefer the summary with important clothes in the history write down the important points on the paper just don't rely upon your memory then go for the positive findings and clinical examination you know sometimes you may not have the explanation for the positive clinical examination but still noting may become the important clinic important clue later on with the evolvement of the disease and positive as well as some negative lab investigations which will help you to strengthen certain possibilities and may exclude even some of them and then your conditions become very narrow and from that you can go for further planning for the investigations and that analysis will help you so here later on go for the analysis derive the possibilities and in the possibility always keep in mind most common first less common second than the uncommon and lasted please remember this is in the daily practice don't become the i will say smart or even over enthusiastic that i will take the credit that you are thinking for the rare conditions first i think that many times it will be disaster for you the most common past than the less common and then thing for other conditions and accordingly plan for the further investigations and it may require the dpd exercises and ultimately probably we may be able to reach the diagnosis so i think the nursing his academic exercise is very important very rewarding in the case of perhaps and as i was talking with you the diagnosis takes question many times come that should be treated and anti-piracy then which one i think anti-parrot is only parasitic at all it requires you will go for ibuprofen please don't go other antibiotics they are not rewarding on the country masking some important diagnosis and many times during the drug themselves are responsible for problems and complications and never round the clock with multiple antibiotics this is very commonly seen in the practice and i want your attention please don't go for this empirical anti-malaria you know that it is not allowed to us not even the antibiotics unless you have very strong clinical background to suspect as i was talking that never even shotgun antibiotics that the marrow permanent vancomycin without any idea dial of antiquity was therapy now you know with the additional elimination temperatures program by love you are not allowed and therefore very important never never ever steroids no unless you have defined the exact indication with the diagnosis and it is said that by chance if you decide to go for the steroids before that bone marrow is must the reason is you know you may miss the malignancy like leukemia and single cabinet of practitioner may call the remission and may misguide you and later on it presents with the worst picture so i think this this is very important point which i want to share with you please never go with this i think now with this idea let me share some of the clinical cases which i have come across in the practice and i'm sure with the examples illustrations you become more clear that how this exercise is rewarding in your daily practice these are the eight years old female presented with the fever of high grade 100 203 and weight loss of about 3 kg the last 2 months still appetite was good she was pain liberal general speed was 10 centimeter and no lymph node investigations including routine cbc peripheral smear and need for malaria vital mental taste blood culture hearing culture brussels hiv bone marrow everything was non-contaminatory and received all the medicines and this was the clinical picture and friends believe me this huge distension of abdomen due to the spring of my curry you can see some branding marks over the abdomen even which were tried by the parents in the rural place the mochamine was four count was low empty was negative lattice were significantly low x-ray was normal usd abdomen showed hepatitis c medically no scientists repeated detailed history and thorough clinical examination when different persons at certain intervals may be rewarding but here we were not knowing the exact cause and when i came to know the lg hospital almost 15 years back she has come from bihar for this illness the immediate point came to my mind that khalasha is one of the possibilities he went for the bone marrow and friends believe me my pathologist told me that first time he saw the lesbian attack bodies in the bone marrow so this is the point how it helps a lot these are the four years old male in less of three months and half months you are about to moderate occasionally hydrate sometimes kids skin rashes you know mother came with this video that these are skewness especially during the fever and it remains the very first very short time as the fever comes down the gases are fading away and disappears and pain at the thigh and there was no weight loss on the child was gaining the weight and child of the febrile error was said another point but no cardiac murmur investigations performing anemia hecocytosis thrombocytosis src more than hundred rest of the other investigations were negative respiratory was that nuclear biopsy was done which was showing hyperplasia bone marrow aspiration was done before referring to us no response to the all the drugs when anti-malaria iv immunoglobulin and meanwhile this was the picture that skin rashes but we can see on the upper activities over the food can see on the face and this was the very characteristic point that rashes particularly during the fever that is what is a transient rashes or advancement of the rashes is the very collapse of systemic onset juvenile idiopathic arthritis another case was silver we were uh seven years old female fewer of three months initially mild cough diarrhea pain in abdomen delicate patterns were stable velour was there liver has been both no lymphadenopathy routine investigations were not helping when the solography was showing the hepatitis for neuromegaly it went in the form of the antibiotics antibiotics anti-tumor drugs but bone marrow showed the culture of the salmonella and that was the case of anti-fever so friends bone marrow culture is very very important a case of people that you may get the growth of the salmonella because you know after a few weeks salmonella disappears in from the circulation and they go to the organs of irony system particularly liver skin and bone marrow and therefore bone marrow culture is quite rewarding in a case of you even you may get sometimes the this uh brucellosis of the culture so these points are very important this was the 10th on child in this of 17 days river then became high grade some frequency of stool generalized weakness and initially type of vision was detailed by family physicians then the consultant says murasa you can see this low count low plateaus rest of even hyponatremia was there potential was low petersburg and with this antibiotics were given still count came to the civilic opinion of nine hundred letters only 19 000 referred to us for further management when we examine patients with febrile tachycardia but the blood pressure and respiratory were maintained liver was speed was the last cervical liver property was there the hospitalized started including antibiotics we investigated almost the same picture and then we went for the analysis a ten years old child with the fever high grade organomechany cervical levels opinion crp is more than one day negative and for the hypo net via hypokalemia the part of this challenge went for the parity you can see the 28 000 triglycerides fibroblast and low led all the points were fulfilled and bone marrow was done that was a very classical picture of when the challenge and where the culture showed the growth of salmonella it almost strong diversity and therefore that are the patient of the anti-fever with hemophagocytic syndrome so i think this become the quite important methodological approach which i wanted to share with you again if i remind you common disease with unusual presentation and i want to share with you our blood culture experience in the case of anti-fury gcs medical college you can see that how many patients we significantly get and para type is coming up even we got the blood culture positive resources in three patients so and you know braceless blood culture will have to follow for more than the five to seven days sometimes you may get up to two weeks or three weeks positive so requested pathologies to follow blood culture for a long time when you are in a suspected process and ultimately this patient was showing these procedures these are the six months of child pure of seven weeks and develop the next swearing type of irritable injectivities diagnosis next cellulitis with the various antibiotics and refer to us you can see this leukocytosis is coming up thrombocytosis is coming up with the development of the vsd lymph node clinical examination february cardiac tachypnea alone [Music] csf examination 120 cells mri brain was deported as normal what is next and next we went for the eco and echo showed very classical kawasaki disease so here into the kawasaki aseptic meningitis particularly the hemiparesis very quite honest zone another case of the seven years main in less of 25 days it fever and what i want to share with you leukocytosis with the thrombocytosis again yes are more than 100 and on investigations not helping much routine we went for this uh very specific test accident abdomen he showed a multiple abscesses and even the history of these cellulitis over the chest the early phase we went for the workout which i want to share with you that this opacity ultimately we got the multiple spinach abscesses which we call the very important clue most common causes for multiple splenic abscess please keep in mind brucellosis cycling alcipuram and tree are the plague and here we went for this echo which showed even the vector endocarditis and blood culture also showed the growth ultimately turned out to be the complement deficiency here it was the case of bacterial endocarditis with multiple spreading abscesses due to this streptococcal pneumonia which is not is common and that was because of the c3 complement deficiency which makes the child vulnerable to develop these particularly the polysaccharide infections the problem is streptococcal manico cocoa and even the h influenza b which have become the common friends uh very ambitious spot diagnosis you can see the five years of y presented to us with fever but very classically if you see absence of slutting and conical truth and that was the obvious reason for the ectodermal dysplasia friends last actively one or two slides which i want to share with you please remember correction for numerical great challenge to the treating person it may be the frustrating and even several dilemmas to the dating person and therefore always first define it exactly as per the criteria whether is it any parents of unknown energy and the careful assessment of history and physical examination then plan for the potential diagnostic clause and targeted testing before application of non-focused diagnostic strategies parents of her knowledge is more like an unusual presentation of a common disease than an uncommon condition please keep in mind repeated thorough exploration of history examination basic investigations are very very important empirical treatment is discouraged unless very specific diagnosis is considered and no place to the empirical steroids are empirical anti-tuberculosis therapy acetaminophen should be used as an anti-piracy called snare species and not the round clock around the clock and not the very strong antibiotics to be given to the child with this i will end over here thank you friends for patient listening and thank you very much for giving me this opportunity i think i will stop sharing and back to dr aditya thank you very much dr adity and all the friends those who are attending us on this link thank you so much sir it was a wonderful lecture and we have a lot of our doubts cleared so now i request all the audience to post their questions in the comment box and we'll try to take as many questions as we can so sir first question from my side sir uh would you uh help us with the list of drugs that would uh usually cause the drug fever or the drug induced in pediatric population yeah i think uh one day term which always i say by down also any any diagnosis you have made and such a patient develops even not only fear but any unusual symptom or even the sign always check for the drug before you go for further workup or even the investigation or the treatment and particular in a case of parents of a new origin many times the antibiotics which you are giving may be responsible and therefore in such a case suppose if it is not required you can stop even entry i will support antique diagnosis i have seen several times that fever continues you are on completion of this antibiotics after action but just to stop this after exam in 48 hour your disappearance so this type of the condition is very calm many a times suppose atropine is given due to some reason or you have some patches even they are using for the local application that also attracted the absorb or even the eye drops containing the entropy may be responsible for the people so i think these are the examples which we should keep in mind thank you so much uh sir uh we'll take a question from dr tina goyle that apart from paracetamol which antibiotic can be given an eyelid something from my part sir that what is your role on recommendation on uh other antibiotics like mephenomic acid or other drugs that usually are given in private practice uh including new mesolite yeah i think you open the very big pandora uh please uh what uh dr adike has mentioned absolutely it is in the practice and i want to give a very clear message and to discourage for this practice because it is not helping you on the quantity you are inviting the trouble how you know if you get a very effective very i will say immense effect uh antibiotic like nemesis now fortunately you now keep and not available but c lock is there i see that people are getting i don't know how they are getting but you know what happens that due to the even the longer duration effect and even the very impressive impact he fever subsides and therefore it gives a false i will say security with the treating person and the patient and therefore very serious conditions like bacterial meningitis will be missed or diagnosed late and then there will be the problems and complications so therefore it is very very important that and diversity is having even lot many i will say adverse effects also dangerous even i have seen the hematomas the maturia therefore the drug there is no question somehow i don't know but that is the impression to the people that maphenomic acid is safe particularly when the hepatic cause is there or suppose in a case of jaundice but i have talked to several gastroenterologists they said that there is no evidence there is no base to consider it so i think we should come out from this mix and even mephanamic acid is also not that safe and therefore ultimately we have the choices of only two drugs parasitic number one if at all all of us know that parasite with a weak anti-parity it does not even the fever comes down immediately hardly probably the fever comes to normal but definitely it gives the compounds to the patient and if you try to bring it down probably you can but with some hazards if at all very high grade fever and if you want to go for the second drug i think i will prevent but again ibuprofen i know that if you continue for the very long time particularly the adults think that they give even for the arthritis or something particularly the orthopedic conditions and then this kidney injury is very common and therefore in pediatric practice also i will use the word a question that sufficient fluid is given there is no any acute kidney injury and by chance if you have to use you may be the ibuprofen but with this precautions i think in the nutshell paracetamol paracetamol paracetamol and nothing else thank you so much sir for the in detail and wonderful explanation next question by dr vinay kumar is that how common is which is disease in the how common is kikis this is in your experience for biology absolutely absolutely i think some experienced person must have put the question i think kikuchi disease you know uh i came to know almost seven eight years back in our andaman clinical meeting one of the pediatrician brought this patient of the fever of two three weeks with some lymphadenopathy they ruled out almost everything another lymph node biopsy some very competent familiar i will say pathologists told that it's a key kuti using motor disease and from that day if i recollect i must have come across at least four to five cases of the witty fijimoto disease and therefore any child comes with the fever if you don't have the answer particularly the it presents later on with its lymphadenopathy especially cervical lymphadenopathy and it is not the tuberculosis or even the lymphoma or even the malignancy if in mind which diffuses about the disease ramps are competent will be able to answer from the hysteropathy part again in the kikuchi feasibility is one word of the question it is said that these patients should be followed up long time some of them may develop sally later on even the following the kikuchi fusibility disease assembly is known to develop so go for the long term follow-up but yes it is seen in the practice thank you so much sir uh next question my doctor sheetal patil is that what are the point of care test that you recommend for diagnosis of infective po and one of the question from my side is that sir how common would you recommend on doing bone marrow biopsy as many patients in your practice have been diagnosed on bone marrow biopsy so what do you consider indications for doing bone marrow biopsy in a patient of you i think as i talk start from the history there is an important clue for me when i can suspect that it is going to be useful suppose in a case of fever childish sheep or response to the antibiotics such a patient they are not the hepatomegaly or even lymphadenopathy and by some of the bony tenderness particularly and if i go for the routine test investigation that cbc showing the high count lipocytosis low practice of thrombocytopenia and high esrcrp i think this is sufficient for me to suspect that this is possible of leukemia or malignancy in such a case without wasting the time i will go for the good nerve or any case where already i am suspecting supposed infection i don't have the answer that is i was talking or sharing with the bracelet or sister entry i remember in one of the patients which i received from the depo several years back it was not in my mind i was thinking that this is likely the question of leukemia because already one moon was done but when the low count low platelets i thought to repeat this bone marrow and my hematologist asked me that for what you asked for the bone marrow i said malignant he said forget the pregnancy there is no any evidence of americans but in a case of people i'm talking about almost 20 years back he said in a case of we should go for the culture and for that bone marrow i have stand for the culture but that was the learning point for me also almost 20 years back i said okay and friends believe me i got the message from the patriarchy the growth of the salmonella from the bone marrow and then we got it so you know this become the indication any suspicious of the americans any suspicious of a challenge any points interesting i will say and therefore even if you are not thought of any case of you if you don't have the answer go for the bone marrow and not only for the meteorological conditions but infections go for the culture and you may get the answer i remember one of the patients even several years back when i was in ba medical college probably 30 years back which we discussed use phenomena we discussed in the case of chronic myeloid leukemia or gorgeous disease or something the clinical case discussion somebody suggested bone marrow during that time in the bone where we got these malarial parasites mineral parasites so friends this is the beauty that how how we'll be able to get so this is right there for any patient of you particularly with this all the routine investigations don't miss the echo because it may be the bacterial locality even without any symptom of cardiac condition never miss the city of abdomen and thorax you may get the military shadows only in the city nowhere else or even some absence in the abdomen which will be detected by the city never even send the patient without the bone marrow and i am sure that if you make it ruin probably no condition should be missed so this is the thing which i wanted to share with you thank you so much sir in my view of limited time i will have to uh request you to wrap up the session sir and i apologize to everyone whose question we could not take and we'll definitely try to come back with another enriching session and we'll try to get most of your questions uh answered so thank you so much sir for the wonderful lecture it was a very enriching session and we got to learn a lot thank you so much sir and we also thank the team netflix for the initiative uh thank you very much dr aditya i've seen you as a presenter and now i can see you that how we are conducting the situation to be very fragile i'm highly impressed and uh and i take the opportunity to express a lot of gratitude to the inspiration for inviting me and giving this opportunity to interact with so many friends on this screen and i'm sure uh basically i will say this is my passion and i will never miss the opportunity to interact with the friends whenever i get particularly in any topic in the periodics thank you very much friends thanks a lot again i gave this opportunity and good night


Pyrexia of unknown origin (PUO) is a syndrome that has long put doctors to the test in terms of diagnosing patients. Patients with this illness are more difficult to diagnose by definition since they have already defied classification during baseline testing. Furthermore, investigating PUO necessitates a broad understanding of a variety of disorders from a variety of clinical specialties, as well as familiarity with less frequently used investigative methodologies. Join us as Dr. Baldev Prajapati, a pediatrician with more than three decades of expertise, discusses the aetiology of PUO, diagnostic tools for investigating it, and management.


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