“Over the last few weeks I just keep getting these night sweats. I’m all achy and tired… I just don’t feel good. I’ve checked my temperature and it’s gone over 101 degrees several times in the last few weeks.” Mrs. Brown looked moderately ill, but after a physical exam the only abnormalities were her usual heart murmur, maybe a little louder than usual, and some mild tenderness around her low back. Blood work came back mostly normal except for a slightly high level in her sedimentation rate (sed rate – a general marker for inflammation or infection in the body), and a borderline high white blood count (WBC), also usually an indicator of infection.
So, we were left with rather general symptoms, an unremarkable physical exam, and a couple of general abnormal lab findings, but no specific source for the infection. Though it’s not always ideal, sometimes an initial course of a broad spectrum antibiotic is given to see if this clears the fever and other symptoms or whether a further work-up will be needed. This was done with Mrs. Brown and she came back stating she felt much better and that the fever and night sweats had cleared. Likewise her WBC and sed rate were nearly normal. We told her to get back to us if the symptoms returned once she was off the antibiotic, and sure enough, they did.
Mrs. Brown generally fell into a category called fever of unknown origin (FUO). Basically, FUO’s are described as a recurrent fever of 101 or greater over a course of 3 or more weeks with no obvious source despite an adequate workup to find one. FUOs may be caused by infections (30-40%), tumors (20-30%), rheumatologic diseases like rheumatoid arthritis or lupus (10-20%), and numerous miscellaneous diseases (15-20%). In studies, between 5 and 15% of FUO cases remain undiagnosed despite extensive studies.
Some of the specific causes of FUO’s include heart valve infections, tuberculosis, lupus, urinary tract infections, abscesses (sometimes on internal organs), bone infections, HIV, fungal infections, parasites, long-acting viruses, lymphoma, leukemia, solid tumors, fevers caused by medications, and a long list of even more uncommon causes.
When, as in Mrs. Brown’s case, the symptoms are rather general and vague, the workup can be difficult and the answer elusive. Over time, Mrs. Brown complained more about her low back being particularly painful as her fever kept recurring and her sed rate continued to climb. An x-ray and then an MRI of the lumbar (lower) spine showed an uncommon infection of a disc between two vertebrae, an infection called, discitis. Likewise one of a few blood cultures that were drawn grew out a type of Strep bacteria. Sometimes this type of bacteria first infects a heart valve, having gotten there through the blood stream from the mouth, perhaps after some dental work. If so, the bacteria will damage the heart valve as well as traveling from there to other places in the body, like a disc in the spine.
At any rate, Mrs. Brown ended up needing intravenous antibiotics to clear this serious infection, and may need back surgery as well. The bottom line is that some FUO’s turn out to be relatively minor viral infections while others are markers for much more serious illnesses. Hopefully you’ll never experience weeks of unexplained fever, but if you do, best to get it investigated sooner rather than later.
Here is the next post in the series I did for A Musing Maralee’s blog. I answer some of her reader questions concerning the common cold and influenza infections. You can find the original blog post here.
What is the biggest mistake you see parents making in treating the common cold or flu?
If a child has a cold, when would it be necessary to see a doctor? If they have the flu, when would it be necessary?
What are the pros and cons of cold medicine for children?
The common cold and influenza are both caused by viral infections of the respiratory tract. That’s about where the similarities end. The common cold is caused by over 200 different strains of viruses while influenza only has a couple predominant strains each year. The common cold causes a runny nose, congestion, a sore throat, cough, and often a mild fever. Influenza on the other hand can be devastating. It causes a violent infection of the upper respiratory tract (the nose and throat) as well as usually infecting the lower respiratory tract (the trachea, bronchi, and lungs). Fevers up to 104F are typical. The common cold hits its stride during the fall and winter months but can be a problem all year long. Influenza tends to come in mini-epidemics for individual communities. January through mid February is the peak season for my town.
The biggest mistake I see parents making in treating the common cold or influenza is seeking medical care at the wrong time. For most of the year when a child gets a fever and has a runny nose or sore throat that’s just a symptom of the common cold. A lot of TLC and chicken noodle soup will help them along until the body clears that infection in about 7-10 days. No amount of medication will change that time frame. If the common cold infection causes enough disruption in the body’s normal defenses, bacteria that are always around trying to invade will take the opportunity to set up shop. A new fever, new pain, and focusing of symptoms to the affected spot would be an indication that something different is occurring. This could be fluid build up in the middle ears, the sinuses, and even just the nose. Bacteria grow and cause an ear infection, a sinusitis, or a rhinitis. Medical attention would be a good idea at that time.
During influenza season a new pronounced fever (>102F) especially if there is a known exposure should prompt an evaluation right away. After about 48-72 hours of symptoms antiviral medications that help limit influenza’s spread don’t work. The person just has to ride it out at that point which is often a two week process.
I classify the common cold as a ‘desert island disease’. If you have the common cold and are stuck on a desert island, then you are still stuck on a desert island. No matter what you do or what medicine you take you will get better. That is often not the case for influenza which sadly has claimed the lives of several people in my town already this year.
In choosing medications or therapies to help with the common cold we should pick options with low possibility of side effects. Since the cure will come from ourselves we need to realize that nothing we do is strictly necessary to get better. That will happen anyway.
That being said I like using medications for specific symptoms. If I have a congested cough then I’ll take an expectorant. If I have nasal congestion I’ll take a decongestant. There are many preparations available for multisymptom treatment. I don’t like those as much but that’s just my personal preference. Since these drugs are not curative and can have side effects if used too much, I try to take as little as possible to obtain some relief and for as short a time as possible. Less really is more in these situations.
Generally you should avoid cold medications in children under two years of age. They don’t really work anyway at that age and aren’t necessary for getting better either. We all want to make our kids feel good but we don’t want to put them at unnecessary risk however slight it may be.
Fever and pain treatment are amazingly helpful in keeping kids feeling better while their body does its job. Acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) are useful medications to relieve these aches and pains from infections and are good fever reducers. Remember not to use ibuprofen in children under six months of age.
I was recently asked by Maralee Bradley, host of a great blog on adopting, parenting, and fostering children entitled A Musing Maralee, to answer some of her reader generated questions on fevers, the common cold, and influenza. I’ve had the privilege to do this before for her on a series of questions regarding vaccinations. It was a great experience for me and her audience asked some really fantastic questions. You can find those posts starting here. Years ago I had the opportunity to work with Maralee and her husband, Brian, in caring for their son. They have since moved, grown their household with more wonderful children, and continue to ask challenging questions of me.
The original post from her website is at Ask the Pediatrician: What should I know about fevers? I’ll repost the future Q&A’s as they get posted on her site.
What is a fever? When does it become a problem? How should I treat it?
We use body temperature as one of many tools to help understand how sick a person is. Any number on a thermometer, in and of itself, doesn’t provoke a certain diagnosis or a specific set of therapies. It only tells us information we then use to help decide why the person has an atypical body temperature and if anything needs to be done.
Core body temperatures fluctuate during the day and often reach their peak in the late afternoon. A healthy adult might reasonably be measured at 99-100°F between 4-5pm. Women attempting to time ovulation know their body temperatures change over the course of their menstrual cycle. It all has to do with what temperature is appropriate for the situation. One of the most critically ill children I ever cared for in the emergency room had a core body temperature of 94°F. He had a brain infection that was so severe he couldn’t even maintain a normal body temperature. While people are individual in what their body temperature normally runs this doesn’t change how we define a fever. People who really are sick enough to manifest a fever still get about 100.4°F.
So when do we worry about a rising body temperature? In infants we have to be more diligent because they lack many of the other signs and abilities we rely on in older children and adults to help point out the cause. An infant may be cranky or sleepy as a sign of their infection but lots of infants are occasionally extra fussy or take long naps. Unusual body temperatures help us tell the difference.
An infant less than 3 months old who develops a body temperature above 100.4°F should be evaluated by a physician in a matter of hours. They are at much higher risk of serious infections such as meningitis, urinary tract infections, and bacterial infections of the blood stream. As such, we must be all the more diligent to prove their fever isn’t of great concern. Hours matter in these situations so I often advise my patients who call in the middle of the night to seek emergency care if their infant has a fever. We must prove their health as the risk of fatal infection is so great.
In older children we move the ‘worry point’ to 102°F. When children under three years of age but older than three months develop a fever they often display more evidence of why the fever occurs and if we need to try and fix it. They can report ear pain or sore throat. They may be potty trained and then suddenly develop accidents because of an urinary tract infection. They stop eating and complain of belly pain with appendicitis. In these situations we are able to focus in on the cause of their over all problem of which fever is simply one manifestation. I typically recommend to parents that children under three years of age be evaluated by a physician as soon as possible. Often the next day in the office is just fine as long as there are no other red flag symptoms like shortness of breath or uncontrolled abdominal pain. Emergency care may still be necessary. When in doubt contact your physician for advice on what to do for your particular situation.
As to everyone older than three years of age, it all depends on the circumstances. For instance, we are currently in the mini-epidemic of our seasonal influenza infections. In this case, anyone with a fever and symptoms at all suggestive of influenza ought to be evaluated. Early diagnosis and therapy can make a big difference in influenza outcomes. However, most of the year when otherwise healthy people have a modest fever such as 101 F, I recommend a watchful waiting approach. Respiratory tract infections typically are self-cured in seven days or so and other more serious infections will manifest with other symptoms that will help guide our diagnosis and therapy options.
A word on how to take an accurate temperature. What we want to know is what the temperature inside the body is. Rectal temperatures are by far the most accurate and it is what I recommend to parents caring for infants. As children age, oral temperatures are very good as children can hold the thermometer under their tongue consistently. Remember not to eat or drink anything for about 5-10mins prior as that can alter the result. If your kids are asleep it doesn’t matter what their temperature is really. I certainly wouldn’t wake them up to test it. Under arm or axillary temperatures are pretty good also. Lots of people suggest adding a degree to those readings. I’ve never seen good data to show that should be done so I always just ask parents how they took the temperature.
Ear thermometers and forehead thermometers seem like a great idea but I’ve seen many inaccurate readings. I once saw a healthy, playful 5 year old boy with ear pain who was reported to have a temperature of 108°F! Turns out the ear they checked the temperature in was infected. His body didn’t have a fever but his ear sure did.
So once you’ve found a fever and appropriate therapy is underway, whether that’s letting to body do its thing or using proper medication to kill off an invading pathogen, the question becomes “Should we reduce the fever?” I think the answer really depends on the person. Many kids can run around and play normally with all manner of fevers while others of us tend to feel really run down. I would say treat a fever when, after you know what’s causing it, you need it to go away. I don’t know of any real advantage to leaving the fever just for the fever’s sake. Sure many bacteria grow best in normal body temperatures so changing that might slow them down. In my experience though the body is so fantastic at doing what it needs to do that the body temperature doesn’t play the deciding factor.
If you are a patient at Trinity then feel free to drop us an email or call us. Together we can decide how and when to treat a fever.
So it’s 2A.M. and your son wakes you up crying. As you touch him you notice he is burning up. What should you do and (more importantly) why should you do it?
Here’s a good article written by American Academy of Pediatrics on dealing with fever. Hopefully it will help answer some of your questions on fever and when to worry.
Fever Without Fear – HealthyChildren.org.