PG Textbook of PEDIATRICS

Jaypee Brothers PG Textbook of PEDIATRICS Volume 2 INFECTIONS AND SYSTEMIC DISORDERS

Piyush Gupta MD FAMS FIAP Professor Department of Pediatrics University College of Medical Sciences and Guru Teg Bahadur Hospital New Delhi, India

PSN Menon MD FIAP Siddarth Ramji MD FNNF Consultant and Head Director-Professor Department of Pediatrics Department of Neonatology Jaber Al-Ahmed Armed Forces Hospital Maulana Azad Medical College Kuwait and Associated Lok Nayak Hospital New Delhi, India

Rakesh Lodha MD Additional Professor JaypeeDepartment ofBrothers Pediatrics All India Institute of Medical Sciences New Delhi, India

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PG Textbook of Pediatrics (3 Volumes)

First Edition: 2015 ISBN: 978-93-5152-955-2 Printed at Contents

Volume 1: General Pediatrics and Neonatology

3.3 Urea Cycle Disorders 73 PART I: Pediatrics—Yesterday, Today, Tomorrow Sunita Bijarnia-Mahay Section 1: INTRODUCTION TO PEDIATRICS 3.4 Organic Acidemias 80 Neerja Gupta Section Editors Piyush Gupta, PSN Menon 3.5 Fatty Acid Oxidation Defects 86 1.1 Evolution of Pediatrics 1 Manisha Goyal, Seema Kapoor KN Agarwal 3.6 Mitochondrial Disorders 90 1.2 20 Milestones in the History of Pediatrics 5 Sheffali Gulati, Biswaroop Chakrabarty Santosh K Bhargava 3.7 Peroxisomal Disorders 95 1.3 Status of Child Health 7 Madhulika Kabra, Neerja Gupta RN Srivastava 3.8 Lysosomal Storage Disorders 99 1.4 Millennium Development Goals for Child Health 10 IC Verma Raju C Shah, Pratima Shah, Kunal Ahya 3.9 GM1 and GM2 Gangliosidosis 106 1.5 Evidence-based Care in Pediatrics 14 Parag M Tamhankar Joseph L Mathew 3.10 Gaucher Disease 109 Mamta Muranjan PART II: Basic Sciences as Applied to Pediatrics 3.11 Niemann-Pick Disease 118 Section 2: GENETICS AND GENETIC DISORDERS Ashwin Dalal Section Editor Shubha R Phadke 3.12 Fabry Disease 122 Ratna Dua Puri 2.1 Gene, Genome and Genetic Basis of Diseases 19 Girisha KM 3.13 Defects of Carbohydrate Metabolism 126 Kausik Mandal 2.2 Patterns of Inheritance 24 Prajnya Ranganath, Shubha R Phadke 3.14 Glycogen Storage Diseases 132 Priya S Kishnani, Stephanie Austin 2.3 Clinical Dysmorphology: An Approach to Bedside Diagnosis 31 3.15 Pompe Disease 136 Ratna Dua Puri Mari Mori, Priya S Kishnani 2.4 Chromosomal Disorders 36 3.16 Mucopolysaccharidoses 139 Jaypee BrothersGirisha KM Shagun Aggarwal, Ashwin Dalal 2.5 Management of Genetic Disorders 3.17 Approach to Hypoglycemia 143 and Genetic Counseling 46 Meenakshi Bothra, Vandana Jain Shubha R Phadke 3.18 Porphyrias 149 2.6 Prevention of Genetic Disorders 52 Meenal Agarwal, Shubha R Phadke Neerja Gupta, Madhulika Kabra 3.19 Newborn Screening 153 Seema Kapoor, Madhulika Kabra Section 3: METABOLIC DISORDERS Section Editors Madhulika Kabra, Neerja Gupta Section 4: IMMUNITY, IMMUNE DISORDERS 3.1 Approach to Inborn Errors of Metabolism 57 AND ALLERGY Chitra Prasad, CA Rupar Section Editors Surjit Singh, Amit Rawat 3.2 Defects of Amino Acid Metabolism 65 4.1 Basics of Immunology 157 Anil B Jalan, Ketki V Kudalkar Amit Rawat, Biman Saikia vi 4.2 Laboratory Diagnosis of Immune-mediated 7.4 Pediatric Advanced Life Support 233 Diseases 163 Banani Poddar Biman Saikia, Deepti Suri 4.3 Primary Immunodeficiency Disorders 170 Section 8: INTENSIVE CARE Manisha Madkaikar Section Editor Rakesh Lodha 4.4 Therapy for Primary Immunodeficiency 8.1 Pediatric Intensive Care Unit 244 Disorders 177 Dhiren Gupta, Neeraj Gupta, Manpreet Sethi Revathi Raj, Surjit Singh 8.2 Shock 247 4.5 Intravenous Immunoglobulin 178 Srinivas Murthy, Niranjan Kissoon Sujoy Khan, Surjit Singh 8.3 Acute Respiratory Distress Syndrome 253 4.6 Approach to a Child with Allergic Disorder 183 Venkat Shankar H Paramesh 8.4 Respiratory Failure 259 Lokesh Guglani Section 5: FLUID AND ELECTROLYTES 8.5 Mechanical Ventilation 266 Section Editor Rakesh Lodha Dinesh Raj, Rakesh Lodha 5.1 Body Fluids 186 8.6 Sedation and Analgesia 274 Raghuvamsi Chaitra, Suchitra Ranjit Venkat Shankar 5.2 Maintenance Fluid Therapy 190 Banani Poddar, Kirti M Naranje Section 9: POISONING AND ENVENOMATION 5.3 Acid-Base Equilibrium 194 Section Editor Rakesh Lodha PG Textbook of Pediatrics Textbook PG Dinesh Raj, Rakesh Lodha 9.1 Clinical Approach to a Poisoned Child 280 5.4 Abnormalities of Acid-Base Balance 198 P Ramesh Menon Dinesh Raj, Rakesh Lodha 9.2 Poisonings by Common Drugs 285 5.5 Sodium and Related Disorders 203 Indumathy Santhanam, Sharada Sathish Andrew C Argent, Mignon I McCulloch 9.3 Hydrocarbon Poisoning 292 5.6 Potassium 208 Jayashree M, Karthi N Virendra Kumar 9.4 Poisoning in the Household 294 5.7 Magnesium Balance 211 Narayanan P, Harikrishnan KN Virendra Kumar 9.5 Corrosive Poisoning 302 Urmila Jhamb Section 6: DRUGS AND THERAPEUTICS Section Editor Sandeep B Bavdekar 9.6 Snakebite 306 S Mahadevan, R Ramesh Kumar 6.1 Principles of Drug Therapy 214 9.7 Scorpion Sting 316 Sandeep B Bavdekar S Mahadevan, R Ramesh Kumar 6.2 Administration of MedicationsJaypee 218 Brothers Jeeson C Unni Section 10: CHILDHOOD INJURIES Section Editor Rakesh Lodha PART III: Intensive Care and Emergencies 10.1 Trauma: Stabilization, Triage and Transport 323 Shruti Kant, Manu Madhok Section 7: ACUTELY ILL CHILD AND 10.2 Drowning/Submersion Injuries 328 RESUSCITATION Arun Bansal Section Editor Rakesh Lodha 10.3 Animal Related Injuries 330 7.1 Assessment and Triage 223 Arun Kumar Baranwal Jayashree M, Sunit Singhi 10.4 Pediatric Burns 334 7.2 Cardiopulmonary Resuscitation 226 K Mathangi Ramakrishnan, V Jayaraman, Utpal Bhalala, Vijay Srinivasan T Mathivanan, V Srinivasan 7.3 Basic Life Support 230 10.5 Cold Injuries 342 Shalu Gupta Manu Madhok, Shruti Kant PART IV: The Newborn Infant Section 14: HIGH-RISK NEWBORN vii Section Editor Siddarth Ramji Section 11: NEONATAL PHYSIOLOGY AND 14.1 Recognition of High-risk Neonate 421 ORGANIZATION OF CARE Niranjan Thomas, Vijay Gupta Section Editor Siddarth Ramji 14.2 Birth Injuries 429 11.1 Fetal Physiology and Growth 349 Neeraj Gupta Deepak Chawla 14.3 Jaundice in the Newborn 435 11.2 Maternal Influence on the Fetus 352 Sheila S Mathai, Kannan Venkatnarayan Jayashree Mondkar, Swati Manerkar 14.4 Infant of Diabetic Mother 445 Srinivas Murki, Tejo Oleti Pratap

11.3 Transition of the Fetus to Newborn 355 Contents Siddarth Ramji 14.5 Neonatal Hypoglycemia 449 11.4 Neonatal Mortality and Morbidities: Shiv Sajan Saini, Praveen Kumar An Overview 358 14.6 Anemia and Polycythemia 455 Aparna Chandrasekaran, M Jeeva Sankar Venkataseshan Sundaram, Bikramjit Das 11.5 Organization of Neonatal Care 363 14.7 The Bleeding Neonate 463 Subhash Chandra Shaw, Vinod K Paul Arun Kumar Section 12: NORMAL NEWBORN 14.8 Hemorrhagic Disease of the Newborn 468 Section Editor Siddarth Ramji JN Sharma 12.1 Delivery Room Care of the Newborn 368 14.9 Thrombocytopenia in the Newborn 470 Siddarth Ramji Pradeep Sharma 12.2 Assessment of the Newborn 372 14.10 Cyanosis in the Newborn 471 Harish Chellani, Sugandha Arya K Anil Kuruvilla, Vijay Gupta 12.3 Care of the Normal Newborn 379 14.11 Necrotizing Enterocolitis 478 Somashekhar Nimbalkar Krishna Kumar Diwakar 12.4 Maintenance of Temperature 382 14.12 Retinopathy of Prematurity 484 Suksham Jain, Ravish Singhal Ashish Jain, Veeraraja B Sathenahalli, Karobi Lahiri Coutinho 12.5 Breastfeeding and Lactation Management 387 NB Mathur 14.13 Neonatal Transport 489 Neelam Kler, Anup Thakur Section 13: DISORDERS OF WEIGHT 14.14 Follow-up of the High-Risk Neonate 494 AND GESTATION Shuchita Gupta Section Editor Siddarth Ramji 13.1 Low Birthweight: ClassificationJaypee and Etiology 392 BrothersSection 15: NEONATAL INFECTIONS Ruchi Nimish Nanavati Section Editor Siddarth Ramji 13.2 Prematurity and Intrauterine Growth Restriction 396 15.1 Neonatal Sepsis 503 Ashok Kumar, Sriparna Basu Suman Chaurasia, Ramesh Agarwal 13.3 Feeding of Low Birthweight 401 15.2 Superficial Infections 509 Kanya Mukhopadhyay Sriparna Basu, Ashok Kumar 13.4 Long-term Outcome of Low Birthweight 406 15.3 Meningitis in the Newborn 514 Suman Rao PN, Nikhil Kulkarni Kumutha Jayaraman, Manigandan Chandrasekaran 13.5 Postmaturity 410 15.4 Deep-seated Infections 520 Reeta Bora, Pranay Phukan Kumutha Jayaraman, Manigandan Chandrasekaran 13.6 Large for Gestational Age 413 15.5 Neonatal Tetanus 524 Rhishikesh Thakre Mala Kumar, Shalini Tripathi 13.7 Multiple Gestations 416 15.6 Intrauterine Infections 526 Mamta Jajoo Sriparna Basu, Ashok Kumar viii Section 16: NEUROLOGICAL PROBLEMS PART V: The Childhood Years OF THE NEWBORN INFANT Section Editor Siddarth Ramji Section 19: GROWTH: NORMAL AND 16.1 Seizures in the Neonates 534 ABNORMAL Amit Upadhyay, Pranjali Saxena Section Editor Anju Seth 16.2 Hypoxic Ischemic Encephalopathy 539 19.1 Normal Growth 635 B Vishnu Bhat, B Adhisivam Ruchi Mishra, Vandana Jain 16.3 Intraventricular Hemorrhage and White Matter Injury 546 19.2 Factors Affecting Growth 638 Shamik Trivedi, Amit M Mathur Devi Dayal, Anil Kumar Bhalla 19.3 Assessment of Physical Growth 641 Section 17: RESPIRATORY PROBLEMS Anju Seth, Rajni Sharma OF THE NEWBORN INFANT 19.4 Dental Development and Anomalies 667 Section Editor Siddarth Ramji Sunanda Roychoudhury, Shakil Ahmed Nagori, 17.1 Approach to a Neonate with Respiratory Ajoy Roychoudhury Distress 553 19.5 Bone Age and Predicted Final Height 676 Swarna Rekha Bhat M Vijayakumar, Anju Seth 17.2 Neonatal Apnea 556 Manoj Modi 19.6 Failure to Thrive 678 Sudha Rao Chandrashekhar 17.3 Neonatal Ventilation 559 19.7 Overweight and Obesity 684

PG Textbook of Pediatrics Textbook PG Sourabh Dutta Rajesh Khadgawat, Aashima Dabas 17.4 Hyaline Membrane Disease 564 Praveen Kumar, Anuj Bhatti 19.8 Abnormalities of Stature 691 17.5 Transient Tachypnea of the Newborn 571 Senthil Senniappan, Leena Patel Srinivas Murki 17.6 Meconium Aspiration Syndrome 573 Section 20: DEVELOPMENT AND Naveen Jain DEVELOPMENTAL DELAY 17.7 Pulmonary Air Leaks in the Newborn 575 Section Editors Anand Pandit, Sudha Chaudhari Manish Balde, Sanjay Wazir 20.1 Introduction to Development, Laws of 17.8 Persistent Pulmonary Hypertension 580 Development, and Factors Affecting Neeraj Gupta Development 701 17.9 Pulmonary Hemorrhage 587 Satnam Kaur Emily F Fishman, Rakesh Rao 20.2 Normal Development 704 17.10 Bronchopulmonary Dysplasia in Newborn 592 Ujjwal Nene Samir Gupta, Sunil K Sinha 20.3 Approach to Diagnosis of Developmental Jaypee BrothersDelay: Development Screening and Section 18: NEONATAL MALFORMATIONS Surveillance 710 Section Editor Siddarth Ramji Sudha Chaudhari 18.1 Esophageal Atresia and Tracheoesophageal 20.4 Global Developmental Delay 717 Fistula 597 Madhuri Kulkarni, Mona P Gajre Yogesh Kumar Sarin, Shalini Sinha 20.5 Intellectual Disability 721 18.2 Diaphragmatic Hernia and Eventration 601 Suja Koshy Shalini Sinha, Yogesh Kumar Sarin 18.3 Gastrointestinal and Abdominal Malformations 606 20.6 Visual Impairment 730 Satish Kumar Aggarwal Nikhil Rishikeshi, Sucheta Kulkarni 18.4 Genitourinary Malformations 616 20.7 Hearing Impairment 732 Satish Kumar Aggarwal Neelam Vaid 18.5 CNS Malformations 625 20.8 Cerebral Palsy 736 Nidhi Sugandhi, Veereshwar Bhatnagar Sharmila Banerjee Mukherjee Section 21: BEHAVIOR AND LEARNING 22.6 Pathophysiology of Undernutrition 834 ix Section Editors Monica Juneja, Devendra Mishra OP Mishra 22.7 Protein Energy Malnutrition 836 21.1 Moral Development 750 KE Elizabeth Prahbhjot Malhi, Rajalakshmi Iyer 22.8 Severe Acute Malnutrition 841 21.2 Sleep Hygiene and Disorders of Sleep 752 Praveen Kumar, Preeti Singh Suresh Kotagal 22.9 Vitamin A 848 21.3 Common Behavioral Problems 758 Neetu Sharma, Piyush Gupta Praveen Suman 22.10 Vitamin B Complex Deficiency 853 21.4 Enuresis and Encopresis 761 Vineeta Gupta Piyush Gupta, Ruchi Mishra 22.11 Vitamin C and Scurvy 857 Contents 21.5 Breath-holding Spells 766 Tejinder Singh, Shaveta Kundra Sumaira Khalil, Devendra Mishra 22.12 Vitamin D, Nutritional Rickets and 21.6 Common Speech, Language and Hypervitaminosis D 860 Communication Disorders 768 S Balasubramanian Prathibha Karanth 22.13 Iodine Deficiency Disorders 864 21.7 Autism Spectrum Disorder 774 Umesh Kapil, Neha Sareen Monica Juneja, Rahul Jain 22.14 Zinc in Child Health 867 21.8 Rett Syndrome 779 Shashi Ajit Chiplonkar Monica Juneja, Rajni Khajuria 22.15 Trace Elements in Nutrition and Health 871 21.9 Attention Deficit Hyperactivity Disorder 782 P Leelakumari, KE Elizabeth Rajesh Sagar, Rohit Verma 22.16 Fluorosis 873 21.10 Oppositional Defiant and Conduct Disorders 788 Sunil Kumar Gupta Rajesh Sagar, Rajeev Ranjan 22.17 Enteral and Parenteral Nutrition 878 21.11 Learning Disabilities 792 Ashish Bavdekar Nandini Mundkur, Chitra Sankar 22.18 Nutrition in the 21st Century 883 21.12 Anorexia Nervosa and Bulimia 795 Gouri Rao Passi, Piyush Gupta Koushik Sinha Deb, Rajesh Sagar 22.19 National Nutrition Programs 886 21.13 Anxiety Disorders 798 Dipty Jain, Veena Kamat, Vinit Warthe Shoba Srinath, Preeti Kandasamy 21.14 Evaluation of Mental Well-being 800 Section 23: IMMUNIZATION Manju Mehta, Sneh Kapoor Section Editors Vipin M Vashishtha, Ajay Kalra 21.15 Management of Psychological Illness 802 23.1 Basic Concepts of Vaccination 889 Paul Russell Chandrakant Lahariya Jaypee 23.2Brothers Vaccine Administration Practices 897 Section 22: NUTRITION AND Satish V Pandya NUTRITIONAL DISORDERS 23.3 Scheduling of Vaccines 900 Section Editors KE Elizabeth, Piyush Gupta Vipin M Vashishtha 22.1 Nutrient Groups and Nutritional Requirements 807 23.4 Vaccine Storage and Cold Chain 906 KE Elizabeth, S Bindusha Karan Singh Sagar, Manish Jain 22.2 Nutritive Values of Foods 811 23.5 Adverse Events Following Immunization 911 Neetu Sharma, Piyush Gupta Ajay Kalra 22.3 Infant and Young Child Feeding 820 23.6 BCG Vaccine 915 JP Dadhich Sangeeta Sharma 22.4 Feeding during Childhood and Food Allergy 824 23.7 Poliovirus Vaccines 918 KE Elizabeth, S Bindusha Puneet Kumar, Vipin M Vashishtha 22.5 Undernutrition: Prevalence and Etiology 827 23.8 Diphtheria, Tetanus and Pertussis Vaccines 923 Piyush Gupta, Neetu Sharma Puneet Kumar, Vipin M Vashishtha x 23.9 Hepatitis B Vaccine 927 Ajay Kalra PART VI: The Adolescent 23.10 Haemophilus influenzae Type B (HIB) Vaccines 930 Section 24: ADOLESCENT DEVELOPMENT AK Patwari Section Editor MKC Nair 23.11 Measles Vaccine 932 24.1 Adolescence and Adolescent 973 Sumit Mehndiratta, AP Dubey MKC Nair, Paul Russell 23.12 Rubella and Mumps Vaccines 934 24.2 Sexual Development and Sexuality 976 Aashima Dabas, Piyush Gupta Chandrika Rao 23.13 Typhoid Fever Vaccines 936 24.3 Psychosocial Development 980 Sushant Sahastrabuddhe, Mohammad Imran Khan Yamuna S 23.14 Japanese Encephalitis Vaccine 939 VG Ramachandran Section 25: HEALTH ISSUES IN ADOLESCENCE 23.15 Rabies Vaccines 941 Section Editor MKC Nair Anuradha Bose 25.1 Factors Influencing Adolescent Health 987 23.16 Pneumococcal Vaccines 944 Sukanta Chatterjee Puneet Kumar, Vipin M Vashishtha 25.2 Adolescent Nutrition 992 23.17 Rotavirus Vaccines 948 Preeti M Galagali Gagandeep Kang 25.3 Mental Health 998 Priya Mary Mammen

PG Textbook of Pediatrics Textbook PG 23.18 Cholera Vaccines 950 Monjori Mitra 25.4 Injuries, Violence and Suicide 1003 Srikanta Basu 23.19 Varicella Vaccine 951 Rakesh Kumar 25.5 Menstrual Disorders and Polycystic Ovary Syndrome 1010 23.20 Hepatitis A Vaccine 953 Amita Suneja, Richa Aggarwal Vikram Gagneja, AJ Chitkara 25.6 Sexually Transmitted Infections 1018 23.21 Meningococcal Vaccine 955 Newton Luiz Jaydeep Choudhury 25.7 Teenage Pregnancy 1022 23.22 Seasonal and Pandemic Influenza Vaccines 956 Amita Suneja, Richa Aggarwal Shobha Broor 23.23 Human Papillomavirus Vaccines 961 Section 26: CARE OF ADOLESCENTS Srinivas G Kasi Section Editor MKC Nair 23.24 Yellow Fever Vaccine 965 26.1 Promoting Health of Adolescents 1025 Parang N Mehta Harish K Pemde, Kamlesh Harish 23.25 Combination VaccinesJaypee 966 Brothers26.2 Adolescent Counseling 1029 Niranjan Shendurnikar, Sheila Aiyer Atul M Kanikar 23.26 Immunization in Special Situations 969 26.3 Adolescent Friendly Health Services 1036 Panna Choudhury Rajesh Mehta, Neena Raina, Patanjali Dev Nayar

Volume 2: Infections and Systemic Disorders

PART VII: Infectious Diseases 27.2 Laboratory Diagnosis of Infection 1046 Sankar Sengupta

Section 27: BASIC CONCEPTS 27.3 Antimicrobial Resistance 1050 Section Editors Jaydeep Choudhury, Piyush Gupta Anuradha De 27.1 Epidemiology of Infectious Diseases 1041 27.4 Infection Control and Prevention 1056 VG Ramachandran, Piyush Gupta Jaydeep Choudhury Section 28: FEVER 29.17 Relapsing Fever 1120 xi P Ramachandran Section Editor Piyush Gupta 29.18 Lyme Disease 1122 28.1 Approach to a Child with Fever 1061 P Ramachandran Bhavna Dhingra, Piyush Gupta 29.19 Nocardiosis 1124 28.2 Fever: General Principles of Management 1063 Subhasish Bhattacharyya Piyush Gupta, Bhavna Dhingra 29.20 Actinomycosis 1126 28.3 Fever without Focus 1066 Subhasish Bhattacharyya Piyush Gupta, Bhavna Dhingra 29.21 Helicobacter pylori 1127 28.4 Fever of Unknown Origin 1068 John Matthai, Sarah Paul

Bhavna Dhingra, Piyush Gupta Contents 29.22 Anaerobic Infections 1129 Rekha Harish, Anuj Bhatti Section 29: BACTERIAL INFECTIONS Section Editors Jaydeep Choudhury, Piyush Gupta Section 30: MYCOBACTERIAL INFECTIONS 29.1 Natural History of Bacterial Infection 1071 Section Editor Soumya Swaminathan VG Ramachandran, Piyush Gupta 30.1 Antitubercular Drugs 1132 29.2 Principles of Antibiotic Therapy 1073 Geetha Ramachandran Anita Shet 30.2 Tuberculosis 1136 Soumya Swaminathan, N Pooranagangadevi, 29.3 Diphtheria 1080 Ben J Marais Prerna Batra, Piyush Gupta 30.3 Atypical Mycobacterial Infections 1145 29.4 Pertussis 1084 C Padmapriyadarsini, Soumya Swaminathan Piyush Gupta, Prerna Batra 30.4 Leprosy 1149 29.5 Tetanus 1087 Rajeshwar Dayal, Manoj Kumar Singh Jaydeep Choudhury 29.6 Typhoid Fever 1088 Section 31: VIRAL DISEASES Apurba Ghosh, Monjori Mitra Section Editors Ashok Kumar Dutta, Piyush Gupta 29.7 Nontyphoidal Salmonellosis 1092 31.1 Epidemiology of Viral Infections 1153 Thangavelu Sangaralingam, Janani Ravi VG Ramachandran, Piyush Gupta 29.8 Haemophilus influenzae B Infections 1095 31.2 Poliomyelitis 1155 Somu Sivabalan Ashok Kumar Dutta 29.9 Pneumococcal Infections 1098 31.3 Measles 1157 Meenu Singh, Nishant Jaiswal Shilpa Khanna Arora, Piyush Gupta 29.10 Streptococcal Infections 1100 31.4 Mumps 1161 Pramod Sharma Jaypee BrothersShilpa Khanna Arora, Piyush Gupta 29.11 Staphylococcal Infections 1103 31.5 Rubella 1164 Zaki Syed Pooja Dewan, Piyush Gupta 29.12 Neisseria Infections 1108 31.6 Varicella 1167 Vidushi Mahajan Piyush Gupta, Aashima Dabas 29.13 Pseudomonas Infections 1110 31.7 Parvoviral Infections 1170 Nupur Ganguly Jagdish Chandra, Anu Maheshwari 29.14 Leptospirosis 1112 31.8 Roseola Infections 1175 Janani Sankar Swati Singhal 29.15 Plague 1114 31.9 Viral Hepatitis 1177 Baldev S Prajapati, Rajal B Prajapati, Piyush Gupta Amit Goel, Chhavi Nanda 29.16 Brucellosis 1117 31.10 Rabies 1181 Sriram Krishnamurthy Jaydeep Choudhury xii 31.11 Japanese Encephalitis 1184 32.13 Filariasis 1263 Rashmi Kumar, Piyush Tripathi Ajay Gaur 31.12 Infectious Mononucleosis 1188 32.14 Intestinal, Liver and Lung Flukes 1267 Rashmi Ranjan Das Vikas Jain 31.13 Enteroviral Infections 1192 32.15 Tapeworm Diseases 1270 Annapurna Sudarsanam Ruchi Rai 31.14 Herpes Simplex Infections 1196 32.16 Hydatid Disease: Echinococcosis 1274 Niranjan Mohanty, Pradeep S SK Gupta 31.15 Influenza 1200 32.17 Schistosomiasis 1277 Sonal Kansra, Alison Scott Ritabrata Kundu, Devdeep Mukherjee 31.16 Dengue 1203 Piyush Gupta, Aashima Dabas Section 33: FUNGAL INFECTIONS Section Editor Piyush Gupta 31.17 Chikungunya Fever 1210 Rajniti Prasad 33.1 Fungi 1280 VG Ramachandran, Piyush Gupta 31.18 Viral Hemorrhagic Fevers 1212 Nigam Prakash Narain, Priya Verma 33.2 Antifungal Therapy 1280 Arunaloke Chakrabarti, Prashant Sood 31.19 HIV and Acquired Immunodeficiency Syndrome 1215 33.3 Candidiasis 1285 Milind S Tullu, Chhaya Divecha Kheya Ghosh Uttam

PG Textbook of Pediatrics Textbook PG 33.4 Aspergillosis 1288 Section 32: PARASITIC INFECTIONS Kana Ram Jat AND INFESTATIONS 33.5 Cryptococcosis 1291 Section Editors Ritabrata Kundu, Piyush Gupta Ankit Parakh 32.1 Epidemiology of Parasitic Infections 1230 33.6 Coccidioidomycosis 1294 Piyush Gupta, VG Ramachandran James Homans, Yee Aye 32.2 Malaria 1232 33.7 Blastomycosis 1299 Ritabrata Kundu G Raghurama Rao 32.3 Leishmaniasis 1237 33.8 Histoplasmosis 1300 Shyam Sundar, Jaya Chakravarty S Nivedhana, S Balasubramanian 32.4 Amebiasis 1243 33.9 Pneumocystis jirovecii Piyush Gupta, Aashima Dabas (previously classified as P. carinii) 1303 32.5 Giardiasis 1247 Ira Shah, Khushnuma Mullanfiroze Aashima Dabas, Piyush Gupta 32.6 Cryptosporidiosis 1249 Section 34: RICKETTSIAL AND OTHER Aashima Dabas, Piyush GuptaJaypee BrothersINFECTIONS 32.7 Ascariasis 1250 Section Editors S Balasubramanian, Piyush Gupta Sutapa Ganguly 34.1 Epidemiology, Classification, and Approach 32.8 Hookworm Infestation 1253 to Diagnosis of Rickettsial Infections 1306 Maitreyi Basu, Sutapa Ganguly Narendra Rathi 32.9 Trichuriasis 1256 34.2 Spotted Fevers 1309 Sutapa Ganguly Atul A Kulkarni 32.10 Enterobiasis 1257 34.3 Scrub Typhus 1312 Dhrubojyoti Mridha, Sutapa Ganguly Veena R Parmar 32.11 Strongyloidiasis 1259 34.4 Epidemic Typhus 1314 Ravi Ambey, Tripty Naik Sunil Vaidya, Atul A Kulkarni 32.12 Trichinosis 1261 34.5 Murine Typhus (Endemic Typhus) 1315 Akash Bang, Puja Hingorani Govind Benakatti, LH Bidari 34.6 Mycoplasma Infections 1317 35.19 Abdominal Tuberculosis 1375 xiii Tanu Singhal Yogesh Waikar 34.7 Chlamydial Infections 1319 35.20 Ascites 1376 Sulochana Putali Bai Malathi Sathiyasekeran, R Ganesh 35.21 Intestinal Obstruction 1380 PART VIII: Systemic Disorders Ketan Parikh 35.22 Intussusception 1382 Section 35: GASTROINTESTINAL DISORDERS Ketan Parikh Section Editors A Riyaz, John Matthai 35.23 Appendicitis 1384 Prakash Agarwal 35.1 Anatomy and Physiology 1321 S Arivu Selvan 35.24 Testicular Torsion 1386 Contents Prakash Agarwal 35.2 Common Symptoms of Gastrointestinal Diseases 1325 35.25 Inguinal Hernia 1387 Prakash Agarwal Sarah Paul, John Matthai 35.3 Cleft Lip and Cleft Palate 1327 Section 36: DIARRHEAL ILLNESSES VS Akbar Sherif, Sayed Mohammed Akbar Section Editor AK Patwari 35.4 Dental Caries 1329 Madhu S 36.1 Acute Watery Diarrhea 1389 AK Patwari 35.5 Recurrent Parotitis 1333 Prakash Agarwal 36.2 Dysentery 1396 AKM Iqbal Kabir, Lazina Sharmin 35.6 Vomiting 1334 Sumathi Bavanandam 36.3 Cholera 1400 Piyush Gupta, Rashi Singhal 35.7 Infantile Hypertrophic Pyloric Stenosis 1337 36.4 Persistent Diarrhea 1404 Ketan Parikh Shinjini Bhatnagar, Aashima Dabas, Dheeraj Shah 35.8 Gastroesophageal Reflux 1338 36.5 Chronic Diarrhea 1409 Elsie Jazmin Foglio, Dinesh S Pashankar BR Thapa, Srikanth KP, Babu Lal Meena 35.9 Umbilical Hernia 1342 36.6 Antibiotic Associated Diarrhea 1427 Prakash Agarwal Seema Alam, Vikrant Sood 35.10 Constipation 1343 Praveen Kumar, Preeti Singh Section 37: HEPATOBILIARY DISEASES 35.11 Hirschsprung Disease 1347 Section Editor Surender Kumar Yachha Ketan Parikh 37.1 Applied Anatomy and Physiology of Liver 35.12 Chronic Abdominal Pain 1348 and Biliary Tract 1432 B Bhaskar Raju, Sumathi BavanandamJaypee BrothersVishnu Biradar 35.13 Acid Peptic Disease 1352 37.2 Liver Function Tests 1435 R Bhanu Vikraman Pillai Neelam Mohan, Sakshi Karkra 35.14 Pancreatitis 1354 37.3 Neonatal Cholestasis 1440 A Riyaz, Geeta M Govindaraj Surender Kumar Yachha, Moinak Sen Sarma 35.15 Practical Approach to Malabsorption 1359 37.4 Portal Hypertension 1448 VS Sankaranarayanan Surender Kumar Yachha, Moinak Sen Sarma 35.16 Specific Malabsorption Syndromes 1362 37.5 Gastrointestinal Bleeding 1462 Srinivas S Nishant Wadhwa 35.17 Inflammatory Bowel Disease 1364 37.6 Liver Abscess 1468 Rishi Bolia, Anshu Srivastava Upender Shava, Anshu Srivastava 35.18 Celiac Disease 1370 37.7 Acute Hepatitis 1472 Lalit Bharadia Barath Jagadisan xiv 37.8 Chronic Liver Disease 1476 38.18 Other Clotting Factor Deficiencies 1599 Seema Alam, Rajeev Khanna Sunil Gomber, Archana Kashyap 37.9 Hepatic Encephalopathy 1489 38.19 Thrombocytopenia 1603 Moinak Sen Sarma, Surender Kumar Yachha Amita Trehan 37.10 Acute Liver Failure 1497 38.20 Immune Thrombocytopenic Purpura 1608 Anupam Sibal, Vidyut Bhatia, Akshay Kapoor Jagdish Chandra, Dinesh Yadav 37.11 Liver Tumors 1500 38.21 Platelet Function Defects 1616 Karthick Sundaram, Naresh P Shanmugam Neelam Varma 38.22 Thrombotic Disorders 1620 Sidharth Totadri, Deepak Bansal, RK Marwaha Section 38: DISORDERS OF HEMATOPOIETIC 38.23 Disseminated Intravascular Coagulation 1628 SYSTEM VK Khanna, Tarangini D, Anupam Sachdeva Section Editor VP Choudhry 38.24 Blood Component Therapy 1633 38.1 The Hematopoietic System 1506 Anupam Verma, Hemlata, Nabajyoti Choudhury Praveen C Sobti, Shruti Kakkar 38.25 Stem Cell Transplantation 1636 38.2 Approach to Diagnosis of Anemia 1515 Mammen Chandy MR Lokeshwar, Swati Gupta, Swati Kanakia 38.26 Myelodysplastic Syndromes 1641 38.3 Anemia: Etiology and Classification 1522 Tathagata Chatterjee, VP Choudhry Nitin Shah, Sunil Udgire Section 39: RESPIRATORY DISEASES 38.4 Congenital Bone Marrow Failure 1526 PG Textbook of Pediatrics Textbook PG Maitryee Bhattacharya, Meet Kumar Section Editors Varinder Singh, GR Sethi 38.5 Aplastic Anemia 1531 39.1 Anatomy and Physiology of Respiration 1645 Amita Mahajan Pankaj C Vaidya 38.6 Iron Deficiency Anemia 1535 39.2 Approach to Diagnosis of a Respiratory Mamta Manglani Disorder 1652 Soumya Tiwari, Varinder Singh 38.7 Megaloblastic Anemia 1541 Sangeeta Mudaliar, Bharat Agarwal 39.3 Congenital Malformations of the Upper Respiratory Tract 1656 38.8 Approach to Hemolytic Anemia 1547 D Vijayasekaran VP Choudhry 39.4 Epistaxis 1659 38.9 Hemoglobinopathies 1553 Jagdish Chinnappa HP Pati, Deepti Mutreja 39.5 Allergic Rhinitis 1660 38.10 Thalassemia 1556 Ankit Parakh, Varinder Singh VP Choudhry, JS Arora 39.6 Otitis Media 1663 38.11 Sickle Cell Disease 1565 Jagdish Chinnappa Vibhawari S Dani, Dipty JainJaypee Brothers 39.7 Approach to a Child with Cough 1668 38.12 RBC Membrane Defects 1570 NK Subramanya, Vidya K Nitin Shah, Khushnuma Mullanfiroze 39.8 Common Cold and Acute Pharyngitis 1671 38.13 Red Blood Cell Enzyme Defects 1574 Satnam Kaur, GR Sethi Manoranjan Mahapatra 39.9 Sinusitis 1675 38.14 Immune Hemolytic Anemia 1578 SD Subba Rao Nita Radhakrishnan, Anupam Sachdeva 39.10 Tonsils and Adenoids 1678 38.15 Physiology of Hemostasis 1583 Pallab Chatterjee Renu Saxena, Neha Singh 39.11 Obstructive Sleep Apnea 1682 38.16 Bleeding and Coagulation Disorders 1588 Zeynep Seda Uyan, Refika Ersu Tulika Seth 39.12 Congenital Malformations of the Lower 38.17 Hemophilia 1592 Respiratory Tract 1686 Pravas Mishra D Vijayasekaran 39.13 Stridor and Croup 1691 40.3 The Heart and Circulation 1768 xv Shalu Gupta Munesh Tomar, Savitri Shrivastava 39.14 Approach to a Child with Fast Breathing 1695 40.4 Genetic Basis of Heart Diseases 1771 Soumya Tiwari, Varinder Singh Sumaira Khalil, Seema Kapoor 39.15 Approach to a Child with Wheeze 1697 40.5 Systemic Disorders with Heart Disease 1775 Soumya Tiwari, Varinder Singh Anita Khalil 39.16 Bronchiolitis 1699 40.6 Cardiovascular Examination 1778 Ilin Kinimi M Zulfikar Ahamed 39.17 Alpha-1 Antitrypsin Deficiency 1704 40.7 Electrocardiogram 1783 Kana Ram Jat, Rakesh Lodha, SK Kabra BRJ Kannan

39.18 Aspiration Syndromes 1706 40.8 Chest Skiagram in Heart Disease 1791 Contents Mahesh Babu Ramamurthy, Michael Lim Teik Chung BRJ Kannan 39.19 Preschool Wheeze and Bronchial Asthma 1709 40.9 Echocardiography 1797 KR Bharath Kumar Reddy, Samatha Sonnappa Balu Vaidyanathan 39.20 Aerosol Therapy 1718 40.10 Cardiac Catheterization 1802 Bruce K Rubin, Ronald W Williams Duraisamy Balaguru 39.21 Pneumonia 1720 40.11 Cardiac Malpositions 1807 Swati Dublish, Varinder Singh P Syamasundar Rao 39.22 Parapneumonic Effusion and Empyema 1729 40.12 Ventricular Septal Defects 1816 Kamal Kumar Singhal, GR Sethi IB Vijayalakshmi 39.23 Pneumothorax and Air Leaks 1731 40.13 Atrial Septal Defects 1822 Mandeep Walia, Abhishek Somasekhara Aradhya K Sivakumar 39.24 Persistent and Recurrent Pneumonia 1734 40.14 Atrioventricular Septal Defects 1826 Ankit Parakh, Varinder Singh Snehal Kulkarni, Tanuja Karande 39.25 Interstitial Lung Disease 1738 40.15 Patent Ductus Arteriosus 1829 A Bush K Sivakumar 39.26 Hemoptysis and Alveolar Bleeds 1741 40.16 Anomalous Left Coronary Artery Meenu Singh, Nandini Paul from Pulmonary Artery, Coronary 39.27 Primary Ciliary Dyskinesia 1743 Arterial Fistula and Ruptured Ada Y Yip, Daniel K Ng Sinus of Valsalva 1833 MS Ranjith 39.28 Cystic Fibrosis 1747 SK Kabra, Kana Ram Jat, Rakesh Lodha 40.17 Pulmonary Stenosis 1835 Shreepal Jain, Bharat Dalvi 39.29 Bronchiectasis 1751 Lokesh Guglani 40.18 Coarctation of Aorta 1840 Kshitij Sheth, Bharat Dalvi 39.30 Lung Abscess Jaypee1755 Brothers Kana Ram Jat, Meghna Sharma 40.19 Aortic Stenosis 1844 Smita Mishra 39.31 Tracheobronchial Foreign Body Aspiration 1757 Varinder Singh, Ankit Parakh 40.20 Clinical Approach to Infants and Children with Cyanotic Congenital Heart Disease 1850 39.32 Central Hypoventilation 1759 M Zulfikar Ahamed Mahesh Babu Ramamurthy, Daniel YT Goh 40.21 Tetralogy of Fallot and Variants 1853 Section 40: CARDIOVASCULAR DISORDERS Anita Saxena Section Editors S Srinivasan, M Zulfikar Ahamed 40.22 Tricuspid Atresia 1861 P Syamasundar Rao 40.1 Historical Aspects and Advances in Pediatric Cardiology 1762 40.23 Transposition of Great Arteries 1870 S Srinivasan R Suresh Kumar, Navaneetha Sasikumar 40.2 Development of the Heart 1764 40.24 Truncus Arteriosus 1873 S Srinivasan Duraisamy Balaguru xvi 40.25 Ebstein Anomaly, Pulmonary Arteriovenous 40.33 Congestive Heart Failure 1909 Fistula, Corrected Transposition of Great Parvathi U Iyer, Harsheen Kaur, Neeraj Awasthy Arteries 1876 40.34 Infective Endocarditis 1919 Sunita Maheshwari Shakuntala Prabhu, Sumitra Venkatesh 40.26 Admixture Lesions 1878 Neeraj Awasthy, S Radhakrishnan 40.35 Myocardial Diseases: Myocarditis and Cardiomyopathies 1925 40.27 Hypoplastic Left Heart Syndrome 1884 Ronak Naik, Nishant Shah Joseph John Vettukattil 40.36 Diseases of the Pericardium 1937 40.28 Pulmonary Arterial Hypertension 1887 Manoj Kumar Rohit, Ankur Gupta Nageswara Rao Koneti 40.29 Acute Rheumatic Fever 1892 40.37 Cardiac Dysrhythmias 1940 B Anjaiah Ramandeep S Ahuja, Rajnish Juneja 40.30 Rheumatic Heart Disease and Lesions 40.38 Cardiac Emergencies 1957 of the Mitral Valve 1896 Umesh Dyamenahalli R Krishna Kumar 40.39 Surgical Considerations in Congenital 40.31 Rheumatic Aortic Valve Disease 1904 Heart Diseases 1961 Savitri Shrivastava R Benedict Raj, S Srinivasan 40.32 Takayasu Arteritis 1907 40.40 Preventive Cardiology in the Young 1965 Biswajit Bandyopadhyay S Sivasankaran

PG Textbook of Pediatrics Textbook PG Volume 3: Systemic Disorders and Social Pediatrics

Section 41: DISORDERS OF THE KIDNEY 41.9 Proteinuria 1999 AND URINARY TRACT Sushmita Banerjee Section Editors Arvind Bagga, Aditi Sinha 41.10 Nephrotic Syndrome 2001 Arvind Bagga, Aditi Sinha 41.1 Anatomy and Physiology 1971 M Vijayakumar, Arvind Bagga 41.11 Acute Kidney Injury 2009 Anil Vasudevan 41.2 Investigations for Kidneys and Urinary Tract 1974 Susan Uthup, Jyoti Sharma 41.12 Renal Replacement Therapy for Acute Kidney Injury 2013 41.3 Congenital Anomalies of Kidneys Sidharth Kumar Sethi, Rupesh Raina and Urinary Tract 1978 41.13 Hemolytic Uremic Syndrome 2015 Shilpa Sharma, Aditi Sinha Aditi Sinha, Arvind Bagga 41.4 Cystic Kidney Diseases 1984 41.14 Renal Tubular Acidosis 2018 Shina Menon Arvind Bagga, Aditi Sinha 41.5 Hematuria Jaypee1986 Brothers41.15 Tubular Disorders 2023 Rajiv Sinha Kamran Afzal 41.6 Glomerulonephritis 1989 41.16 Renal Calculi 2028 • Acute Nephritic Syndrome 1989 Indira Agarwal Amarjeet Mehta 41.17 Refractory Rickets 2031 • Rapidly Progressive Glomerulonephritis 1990 Abhijeet Saha Arvind Bagga, Shina Menon 41.18 Hypertension 2034 • Immunoglobulin A Nephropathy 1992 Swasti Chaturvedi Manisha Sahay 41.19 Urinary Tract Infection and Vesicoureteric 41.7 Systemic Vasculitis and Lupus Nephritis 1993 Reflux 2039 Ashima Gulati, Arvind Bagga Pankaj Hari 41.8 Alport Syndrome and Related Disorders 1997 41.20 Dysfunctional Voiding 2045 Mukta Mantan Madhuri Kanitkar, Suprita Kalra 41.21 Chronic Kidney Disease 2048 42.20 Inflammatory Demyelinating Disorders 2166 xvii Erica Winnicki, Lavjay Butani, Stephanie Nguyen Bindu PS 41.22 End-Stage Renal Disease 2051 42.21 Autoimmune and Paraneoplastic Encephalitis Kirtida Mistry, Asha Moudgil and Encephalopathies 2172 Lokesh Lingappa, Sirisharani Siddaiahgari Section 42: NEUROLOGICAL DISORDERS 42.22 Headache 2176 Section Editors Satinder Aneja, Suvasini Sharma Devendra Mishra 42.1 Approach to Neurological Disorders 2054 42.23 Movement Disorders 2182 Suvasini Sharma, Satinder Aneja Debabrata Ghosh 42.2 Cerebrospinal Fluid and Neurophysiology 2059 42.24 Childhood Ataxia 2189

Anita Choudhary Asuri N Prasad Contents 42.3 Neuroimaging 2064 42.25 Neurometabolic Disorders 2195 Atin Kumar, Jyoti Kumar Mahesh Kamate 42.4 Neural Tube Defects and Spinal Cord 42.26 Neurodegenerative Disorders 2200 Malformations 2073 Naveen Sankhyan Sujata Kanhere 42.27 Spinal Cord Disorders 2209 42.5 Brain Malformations 2079 Vykunta Raju KN Jatinder S Goraya 42.28 Pseudotumor Cerebri 2215 42.6 Neurocutaneous Disorders 2084 Anaita Udwadia-Hegde, Omkar P Hajirnis Maya Thomas, Renu George, Karthik Muthusamy 42.7 Hydrocephalus 2093 Daljit Singh, Hukum Singh Section 43: NEUROMUSCULAR DISORDERS Section Editors Sheffali Gulati, J Andoni Urtizberea 42.8 Seizures and Epilepsy 2098 Puneet Jain, Lakshminarayanan Kannan 43.1 Approach to Diagnosis of Neuromuscular Disorders 2217 42.9 Treatment of Seizures and Epilepsy 2105 Sheffali Gulati, Jaya Shankar Kaushik, Gopinath Musuwadi Subramanian J Andoni Urtizberea, MC Sharma 42.10 Febrile Seizures 2109 43.2 Floppy Infant 2231 Sangeetha Yoganathan Anaita Udwadia-Hegde, Shilpa Kulkarni 42.11 Status Epilepticus 2112 43.3 Acute Flaccid Paralysis 2238 Ravindra Arya, Katrina Peariso Biswaroop Chakrabarty, Sheffali Gulati 42.12 Nonepileptic Paroxysmal Disorders 2119 43.4 Guillain-Barré Syndrome 2242 Hema Patel, David W Dunn Vrajesh Udani 42.13 Coma, Raised Intracranial Pressure 43.5 Spinal Muscular Atrophy 2246 and Brain Death 2124 Soumya Sundaram, Muralidharan Nair Gurpreet Singh Kochar, SuvasiniJaypee Sharma Brothers 43.6 Muscular Dystrophies 2251 42.14 Stroke 2132 Satish V Khadilkar, Rakhil S Yadav Ramesh Konanki 43.7 Congenital Muscular Dystrophy 2261 42.15 Pyogenic Meningitis 2141 Sunil Pradhan, AK Meena B Talukdar 43.8 Congenital Myopathies 2274 42.16 Tuberculosis of the Central Nervous System 2144 Kimberly Amburgey, Michael W Lawlor, Chandrakanta, Rashmi Kumar James J Dowling 42.17 Viral Encephalitis 2151 43.9 Neuromuscular Transmission Disorders 2279 Mary Iype Venkateswaran Ramesh 42.18 Neurocysticercosis 2155 43.10 Hereditary Motor and Sensory Neuropathies 2283 Pratibha Singhi V Viswanathan 42.19 Brain Abscess 2160 43.11 Autonomic Neuropathies 2285 Prashant Jauhari, Jitendra Kumar Sahu Rachana Dubey, Ashok Jaryal, Sheffali Gulati xviii Section 44: DISORDERS OF THE 44.21 Cryptorchidism and Micropenis 2371 ENDOCRINE GLANDS Aparna Limaye Section Editors PSN Menon, Vijayalakshmi Bhatia 44.22 Classification of Diabetes Mellitus 2374 Aspi Irani 44.1 Principles of Endocrinology and Hormone Action 2294 44.23 Type 1 Diabetes Mellitus 2378 Khalid Hussain Aspi Irani 44.2 Physiology of Neuroendocrinology 2298 44.24 Acute and Chronic Complications Priyanka Gupta, Vijayalakshmi Bhatia of Diabetes Mellitus 2384 KG Ravikumar 44.3 Growth Hormone Deficiency and Resistance 2302 Arpita K Vyas, Ram K Menon 44.25 Bone Mineral and Hormone Physiology 2388 44.4 Polyuria, Diabetes Insipidus and Syndrome Philip G Murray, M Zulf Mughal of Inappropriate Secretion of ADH 2308 44.26 Calcium Disorders 2391 Tushar Godbole, PSN Menon Shaila Sukthankar, Raja Padidela 44.5 Thyroid Hormone Physiology 2312 44.27 Metabolic Rickets 2394 Anna Simon Shaila Sukthankar, Raja Padidela 44.6 Hypothyroidism and Thyroiditis 2313 44.28 Disorders with Bone Fragility 2398 Palany Raghupathy M Zulf Mughal 44.7 Newborn Screening for Congenital 44.29 Monogenic Obesity 2401 Hypothyroidism 2318 Leena Priyambada Anna Simon

PG Textbook of Pediatrics Textbook PG 44.30 Hyperlipidemia 2405 44.8 Hyperthyroidism 2319 Nisha Bhavani Sobha Kumar 44.31 Endocrine Consequences of 44.9 Goiter and Nodules 2321 Thalassemia Major 2408 Lalitha Kailas, Riaz I Archana Dayal Arya 44.10 Normal Puberty 2324 Ruchi Parikh, Meena Desai 44.32 Endocrine Effects of Radiation and Cancer Chemotherapy 2411 44.11 Delayed Puberty 2328 Margaret Zacharin Vijaya Sarathi, Nalini S Shah 44.33 Adult Consequences of IUGR and Prematurity 2413 44.12 Precocious Puberty 2332 Sarah Mathai, Paul Hofman Prisca Colaco 44.13 Gynecomastia 2337 Section 45: MALIGNANCIES IN CHILDREN Anju Virmani Section Editors Brijesh Arora, Shripad Banavali 44.14 Normal Development and Physiology 45.1 Epidemiology of Cancers in Children 2416 of the Adrenal Gland 2339 Ramandeep Singh Rajesh Joshi Jaypee Brothers45.2 Acute Lymphoblastic Leukemia 2420 44.15 Congenital Adrenal Hyperplasia 2341 Revathi Raj, Deenadayalan M Anurag Bajpai, PSN Menon 44.16 Adrenal Insufficiency and Polyglandular 45.3 Acute Myeloid Leukemia 2426 Failure 2345 Akash Nahar, Yaddanapudi Ravindranath M Vijayakumar 45.4 Chronic Myelogenous Leukemia 2432 44.17 Cushing Syndrome 2351 Arathi Srinivasan, Julius Xavier Scott Maha Elhassan, Michael A Wood 45.5 Myelodysplastic Syndrome and Juvenile 44.18 Endocrine Hypertension 2356 Myelomonocytic Leukemia 2437 Praveen VP Sangeeta Mudaliar, Archana Swami 44.19 Glucocorticoid Use and Withdrawal 2360 45.6 Hodgkin Lymphoma 2441 VK Bhardwaj Vishal Sondhi, Brijesh Arora 44.20 Disorders of Sexual Development 2362 45.7 Non-Hodgkin Lymphoma 2445 Ganesh S Jevalikar, Preeti Dabadghao Nirav Thacker, Vikramjit S Kanwar, Tipu Nazeer 45.8 Neuroblastoma 2453 Section 47: COMMON EYE ABNORMALITIES xix Maya Prasad, PA Kurkure Section Editor Kirti Singh 45.9 Wilms Tumor 2459 47.1 Common Visual Problems 2566 Sajid Qureshi, Monica Bhagat Kirti Singh 45.10 Brain Tumors 2466 47.2 Congenital Anomalies 2570 Anaita Udwadia-Hegde, Omkar P Hajirnis, Karobi Lahiri Coutinho Girish Chinnaswamy 47.3 Refractive Errors 2573 45.11 Retinoblastoma 2481 Kirti Singh, Divya Jain Anirban Das, Deepak Bansal 47.4 Cornea and Conjunctiva 2579 45.12 Soft Tissue Tumors 2488 Ritu Arora, Aditi Manudhane Sandeep Jain, Gauri Kapoor 47.5 Uveitis 2585 Contents 45.13 Histiocytic Disorders 2493 SR Rathinam, Prachi Agashe Gaurav Narula, Nirmalya D Pradhan 47.6 Cataract and Lens-related Issues 2590 45.14 Bone Tumors 2499 Abhay R Vasavada, Sajani K Shah Ashish Gulia, Tushar Vora 47.7 Glaucoma 2597 45.15 Oncological Emergencies and Supportive Care 2504 Kirti Singh, Savleen Kaur Anand Prakash, ATK Rau 47.8 Optic Nerve and Pupil 2603 45.16 Hematopoietic Stem Cell Transplant 2513 Digvijay Singh, Pradeep Sharma Satyendra Katewa, Satya Prakash Yadav 47.9 Strabismus and Motility Disorders 2608 AK Amitava, Shivani Grover Section 46: RHEUMATOLOGICAL DISORDERS 47.10 Eyelid, Orbit and Lacrimal Sac 2618 Section Editors Surjit Singh, Anju Gupta Apjit Kaur 46.1 Approach to a Child with Rheumatological 47.11 Ocular Injuries 2624 Disorder 2522 Kalpana Narendran, Sandra C Ganesh Anand Prahalad Rao 47.12 Ocular Manifestations of Systemic Disorders 2628 46.2 Laboratory Investigations for Rheumatological Koushik Tripathy, Pradeep Venkatesh Disorders 2526 47.13 Visually Impaired Child 2637 Anju Gupta, Tapas Kumar Sabui Kirti Singh, Ankush Mutreja 46.3 Juvenile Idiopathic Arthritis 2529 Sujata Sawhney Section 48: COMMON SKIN PROBLEMS 46.4 Large Vessel Vasculitis: Takayasu Arteritis 2535 Section Editors Sandipan Dhar, Raghubir Banerjee, Anju Gupta Rajib Malakar, Apurba Ghosh 46.5 Medium Vessel Vasculitis: Kawasaki 48.1 Skin of the Newborn: Physiological and Disease and Polyarteritis Nodosa 2539 Pathological Changes 2644 Sikha Agarwal, Surjit Singh Keshavmurthy A Adya, Arun C Inamadar 46.6 Small Vessel Vasculitis: ANCAJaypee Associated 48.2Brothers Care of Skin in the Newborn 2651 Vasculitis and Henoch-Schönlein Purpura 2542 S Sacchidanand, Preeti Sheth Nutan Kamath, Rakesh Mondal 48.3 Infections and Infestations 2654 46.7 Juvenile Dermatomyositis 2548 S Criton Priyankar Pal 48.4 Congenital Vascular and Melanocytic 46.8 Systemic Lupus Erythematosus: Malformations 2662 Clinical Manifestations 2551 Manish K Shah Sathish Kumar 48.5 Vitiligo and Other Hypopigmentary Diseases 2664 46.9 Management of Systemic Lupus Tarun Narang, Amrinder Jit Kanwar Erythematosus 2556 48.6 Atopic Dermatitis 2671 Aruna Bhat Deepak A Parikh, Abhijit Saha 46.10 Juvenile Scleroderma 2559 48.7 Contact Dermatitis 2673 Suma Balan Raghubir Banerjee, Sandipan Dhar 46.11 Antiphospholipid Syndrome 2563 48.8 Urticaria and Mastocytosis 2674 Jasmina Ahluwalia, Anju Gupta Deepika Pandhi, Rahul Arora xx 48.9 Cutaneous Drug Reactions 2680 Rajib Malakar, Sandipan Dhar PART IX: Child in the Social Milieu 48.10 Cutaneous Manifestations of Nutritional Section 50: VULNERABLE CHILDREN Deficiency Diseases 2682 Vibhu Mendiratta Section Editor Sanjay Chaturvedi 48.11 Cutaneous Manifestations of Collagen 50.1 Vulnerability 2772 Vascular Diseases 2685 Dheeraj Shah, Piyush Gupta Yogesh S Marfatia 50.2 Street Children 2773 48.12 Neurocutaneous Syndromes 2689 Pranab Chatterjee, Sanjay Chaturvedi Resham J Vasani 50.3 Child Labor 2777 48.13 Vesiculobullous Disorders 2693 SR Banerjee Bhawna Wadhwa, Rashmi Sarkar 50.4 Child Abuse and Neglect 2779 48.14 Papulosquamous Diseases 2696 Kiran Aggarwal Ravi Hiremagalore, Subhash Lokre, Priya Bishnoi 50.5 Adoption: Medical and Legal Issues 2786 48.15 Ichthyosis 2703 Samir H Dalwai Deepika Pandhi, Deepashree Daulatabad 48.16 Genetic Cutaneous Disorders 2708 50.6 Rights of the Child 2788 Manjyot Manish Gautam Swati Y Bhave, Piyush Gupta 48.17 Hair Disorders 2711 Tarang Goyal Section 51: COMMUNITY PEDIATRICS Section Editor Piyush Gupta PG Textbook of Pediatrics Textbook PG Section 49: DISORDERS OF BONES AND JOINTS 51.1 Indicators of Child Health 2792 Section Editor Harish S Hosalkar Piyush Gupta, Dhulika Dhingra 49.1 Assessment of the Locomotor System 2715 51.2 Environment and Child Health 2798 Jayanth Sundar Sampath, Harish S Hosalkar Dhulika Dhingra, Piyush Gupta 49.2 Osteomyelitis 2721 51.3 Lead Poisoning 2803 Mandar V Agashe, Harish S Hosalkar Dhulika Dhingra, Piyush Gupta 49.3 Septic Arthritis 2724 51.4 Programs for Child Health 2804 Mandar V Agashe, Harish S Hosalkar Amir Maroof Khan, Piyush Gupta 49.4 Neck Problems 2727 Vijay HD Kamath, Harish S Hosalkar 51.5 Integrated Management of Neonatal and Childhood Illness 2807 49.5 Scoliosis and Kyphosis 2734 AK Patwari Vijay HD Kamath, Harish S Hosalkar 49.6 Developmental Dysplasia of the Hip 2743 Venkatadass K, Harish S Hosalkar PART X: Annexures 49.7 Legg-Calvé-Perthes Disease 2747 Venkatadass K, Harish S HosalkarJaypee BrothersLABORATORY VALUES AND DRUG DOSES 49.8 Osgood-Schlatter Disease 2749 Section Editor Pooja Dewan Joana Manuel Ferreira Freitas, Harish S Hosalkar Annexure A: Laboratory Reference Values 2822 49.9 Congenital Talipes Equinovarus 2751 Nidhi Bedi, Pooja Dewan Mandar V Agashe, Harish S Hosalkar Annexure B: Drug Doses 2830 49.10 Skeletal Dysplasias 2754 Pooja Dewan, Nidhi Bedi Kuldeep Singh, Abhay Elhence 49.11 Arthrogryposis 2769 Index I-1–I-32 Jayanth Sundar Sampath, Harish S Hosalkar Section 28 FEVER

Section Editor Piyush Gupta

• Exogenous pyrogens include the bacterial cell wall compo­ Chapter 28.1 nent lipopolysaccharide (LPS), enterotoxins, and exotoxins. Exogenous pyrogens can induce production of endogenous Approach to a Child with Fever pyrogens via activation of Toll signaling, and both endogenous Bhavna Dhingra, Piyush Gupta and exogenous pyrogens stimulate the synthesis of prosta­ glandins (PG). Prostaglandin E2 (PGE2) is the ultimate endogenous pyrogen. It resets the temperature of the hypo­ thalamus. Fever, in common parlance, is an elevation of body temperature Fever is the result of a series of events that begins peripherally above normal, but not all causes of temperature elevation constitute with the synthesis and release of IL-1 and other cytokines by fever (e.g., heat stress and heat illness). Fever is an elevation of phagocytic cells in the blood or tissues. Flow chart 1 illustrates the core body temperature as part of a specific biological response, pathophysiology of fever. mediated by cytokines and controlled by the central nervous system (CNS). It is a characteristic feature of many diseases, both infectious and noninfectious, and it involves activation of various ADVANTAGES OF FEVER physiological, endocrinological and immunological systems. The survival of some pathogenic bacteria or viruses is impaired Normal body temperature follows a circadian rhythm and at temperatures in the range of 40°C (104°F). Many pathogenic varies between 36.6°C in the morning to 37.9°C in the evening. bacteria require iron for their growth, and fever is associated with Body temperature is controlled by the thermoregulatory center a decrease in serum iron and a simultaneous increase in the iron- located in the preoptic anterior hypothalamus, which balances binding protein, ferritin, resulting in low levels of free iron in the heat production, derived primarily from metabolic activity in blood. It has been suggested that this response is a coordinated muscle and the liver, with heat dissipation from the skin and lungs host defense mechanism meant to deprive bacteria of free iron. to maintain the temperature in a steady range. Oral temperature Enhancement of several human immunologic functions occurs is generally 0.6°C (1.0°F) lower than rectal temperature because of mouth breathing, which is particularly important in patients Flow chart 1 Pathophysiology of fever with respiratory infections and rapid breathing. Lower esophageal temperature reflects core temperature, and tympanic membrane (TM) temperature readings also approximate to core temperature. Beyond the newborn period, infants and young children generally have higher body temperatures due to the greater surface area to body weight ratio and the higher metabolic rate than older children and adults.

DEFINITION A clinically significant fever is generally defined as a rectal tem­ perature of 38°C (100.4°F) or higher. This is equivalent to an oral temperature of 37.5°C (99.5°F), andJaypee axillary (armpit) temperature Brothers of 37.2°C (99°F). Fever above 41.5°C (107°F) is called hyperpyrexia and may lead to irreversible organ damage.

PATHOPHYSIOLOGY OF FEVER Fever is induced by pyrogens. Bacteria, fungi, viruses, malignancies, connective tissue disorders, certain drugs, and trauma may endogenously stimulate production of pyrogens. • Common endogenous pyrogens include interleukin 1 (IL-1), tumor necrosis factor (TNF) and interferon. Other endogenous pyrogens include IL-6, IL-11, leukemia inhibitory factor (LIF), ciliary neurotropic factor (CNTF) and oncostatin-M. Large amounts of IL-6 circulate in nearly all febrile diseases, and IL-6, induced by IL-1 or by the combination of IL-1 and TNF, accounts for most clinical fevers. at moderately elevated temperatures, e.g., increased lymphocyte 1062 Identify the Etiology of Fever transformation response to mitogen, increased bactericidal activity Short duration fever Fever of less than 2 weeks duration is usually of polymorphonuclear leukocytes, and increased production of infectious in origin, and due to viruses, bacteria or protozoa. interferon with increasing temperature. Beyond 40°C, most of the Many of these patients recover completely, even before a precise functions decline below baseline levels. diagnosis is made or treatment is given. These children may present with or without localizing manifestations. Every effort should be

VII DISADVANTAGES OF FEVER made to identify and localize the system involved, based on the Fever is associated with an increased metabolic rate, increased localizing symptoms, as shown in Table 1. oxygen consumption, increased carbon dioxide production, and Prolonged fever Fever lasting for more than 2 weeks requires a PART increased demands on the cardiovascular and pulmonary systems. different approach. Infections still remain the most important Fever often makes patients uncomfortable. Fever can precipitate cause of prolonged fever; however, noninfectious causes are also febrile convulsions in children between 6 months and 5 years of responsible. Common causes of prolonged fever are listed below: age. Fever can aggravate cerebral injury. • Infections: Tuberculosis, HIV, urinary tract infections, chronic fungal infections, etc. ETIOLOGY OF FEVER Fever is probably the most common presenting complaint in pediatric practice and is associated with a wide variety of illnesses. Table 1 Determining etiology of fever based on presenting features The most common cause of fever in children is a viral infection. Cough and coryza Viral fever In viral infection, fever is usually short-lived and signs are usually more generalized than those with bacterial infection. Common Rash Exanthematous illnesses like measles, rubella, chickenpox, erythema viral and bacterial illnesses like upper respiratory infections (URI), infectiosum, roseola infantum, gastroenteritis, ear infections, croup, and bronchiolitis are the most herpes simplex; other illnesses like likely illnesses known to cause fevers of short duration. Viral fevers meningococcemia, dengue, Henoch- Infectious Diseases usually resolve in about a week, persistence of fever beyond this Schönlein purpura, leukemia, and time requires a detailed work-up. Bacterial URIs may be difficult Kawasaki disease to distinguish from viral URIs but the presence of pus points in the Ear pain Acute suppurative otitis media tonsil and unilateral involvement of ears points towards a bacterial (ASOM) etiology. Other common infective causes that need to be looked into are malaria, urinary tract infections, sepsis, abscesses, etc. Skin boils Abscess, pustules, cellulitis, impetigo Seborrheic dermatitis (±ear Langerhans cell histiocytosis EVALUATION OF A FEBRILE CHILD discharge) Periungual desquamation with Kawasaki disease Performing a detailed and thorough history and physical strawberry tongue examination is the first and most important component of the Throat pain, difficulty in Pharyngotonsillitis diagnostic evaluation of a febrile child. The next steps are to swallowing, cervical nodes (i) localize the fever to a particular organ system by presenting complaints; and to (ii) identify the probable etiology of fever, Stridor, dysphonia Laryngitis, tracheitis, croup, depending upon its duration, pattern and clinical examination. epiglottitis, diphtheria Fast breathing and cough, Pneumonia, bronchiolitis, pleural History wheezing, chest in drawing, effusion, tuberculosis The history should include questions regarding characteristics of chest pain fever (onset, intensity, duration, frequency and pattern of fever— Joint swelling, pain or limited Septic arthritis, rheumatic fever, continuous, remittent or intermittent); how was the temperature movements tubercular arthritis, connective tissue assessed-perceived manually or documented by a thermometer diseases along with the site of documentation; localizing symptoms of Vomiting Gastritis, gastroenteritis, viral fever; recent exposures like vaccination, animal/insect bites, or hepatitis, meningitis, enteric fever, receipt of blood transfusion or Jaypeebiological product; exposure to a BrothersUTI family member with fever or any infectious disease; past history Diarrhea Gastroenteritis, enteric fever, of any significant illnesses such as tuberculosis, urinary infections, dysentery congenital heart disease, and surgical procedure; any history of Jaundice Hepatitis, cholecystitis, malaria travel in the recent past; history of an underlying chronic disease, and medication history. History of recurrent episodes of fever may Pallor, rash, bleeding, Leukemia, infectious mononucleosis give a clue to certain cyclic causes of fever. Ask for other system- lymphadenopathy related symptoms. Enquiry about specific symptoms may help in Urinary frequency, burning Urinary tract infection, cystitis localizing the disease to a particular system. micturition, crying during micturition, hematuria Examination Chills or pallor or jaundice Malaria, hepatobiliary causes The physical examination should begin with a general assessment Altered sensorium, seizures, Meningoencephalitis (bacterial, viral, of the patient’s appearance, activity, vital signs, and growth neurological deficits, tubercular), cerebral malaria, enteric parameters. It is a good idea to evaluate the child during febrile meningeal signs encephalopathy, brain abscess period as the presence or absence of few signs during the febrile phase may provide certain clues to diagnosis, e.g., absence of Abdominal pain Gastroenteritis, appendicitis, liver sweating in anhidrotic ectodermal dysplasia. Absence of malaise abscess, hepatitis, cholecystitis, cholangitis, intra-abdominal/pelvic or other generalized signs in a child with a history of high fevers abscess, pyelonephritis can signal factitious fever. • Inflammatory disorders: Rheumatoid arthritis, systemic lupus 1063 erythematous, Kawasaki disease and other connective tissue IN A NUTSHELL disorders including polyarteritis nodosa, Behcet disease, 1. Fever is a symptom of an underlying disease, which may be Wegner granulomatosis. infective or noninfective. • Malignancies: Lymphoma (including Hodgkin disease), 2. Fever results due to a change in the set point of hypothalamic SECTION 28 leukemia, hepatoblastoma, Wilms tumor, neuroblastoma, thermoregulatory center. brain tumors. 3. The most common cause of fever in the young child is usually • Endocrine causes: Thyrotoxicosis, diabetes insipidus. a self-limiting viral infection. • Hematological and immune deficiency disorders:Spherocytosis, 4. A detailed and thorough history and physical examination is agranulocytosis, hemolytic anemia; Langerhans cell histio­ the most important component in the evaluation of a febrile cytosis, disorders of T- or B-cells; disorders of phagocytosis. child. • Neurologic disorders: Familial dysautonomia, hypothalamic 5. Duration of fever and associated symptoms aided by appro­ and third ventricle lesions; anhidrotic ectodermal dysplasia. priate investigations can help in localizing cause of fever. • Miscellaneous causes: Drug fever, periodic fever, factitious fever. Fever Box 1 provides a detailed list of common causes of fever MORE ON THIS TOPIC associated with hepatosplenomegaly, rash, or lymphadenopathy. Hamilton JL, John SP. Evaluation of fever in infants and young children. Am When fever has been persistent for a week, and no cause has been Fam Physician. 2013;87:254-60. found, serious consideration should be given to hospital admission Sherman JM, Sood SK. Current challenges in the diagnosis and management to confirm pyrexia and initiate investigations. Appropriate of fever. Curr Opin Pediatr. 2012;24:400-6. laboratory testing as per the merit of each case may include: Wing R, Dor MR, McQuilkin PA. Fever in the pediatric patient. Emerg Med Clin complete blood counts with peripheral smear, ESR, CRP, urinalysis North Am. 2013;31:1073-96. and urine culture, blood cultures and serologic tests when appropriate (e.g., for enteric fever, malaria, dengue, leptospirosis, TORCH infections, rickettsial infections, Coccidioides immitis, Cryptococcus neoformans, Borrelia burgdorferi, Treponema Chapter 28.2 pallidum, and HIV). Radiological investigations may include X-ray chest; ultrasonography, CT and MRI, as indicated. Other common Fever: General Principles though invasive investigations include bone marrow examination, lumbar puncture, cytopathology, and examination of ascitic/ of Management pleural/joint fluids. Piyush Gupta, Bhavna Dhingra

BOX 1 Etiology of fever with rash, lymphadenopathy and hepatosplenomegaly All fevers do not need to be treated, and when treated, the primary objective of treating fever should be to make the child comfortable, Fever with Hepatosplenomegaly and not the normalization of body temperature. Antipyresis can • Infectious causes: Malaria, enteric fever, kala-azar, tuberculosis, be achieved by nonpharmacological measures and/or drugs. infectious mononucleosis, brucellosis, echinococcosis, rickettsial Antipyretics may help in overall management of a febrile child but diseases, TORCH infections, dengue, septicemia, and infective endocarditis do not appear to affect the recurrence of febrile seizures. • Malignancies: Leukemias, lymphomas, histiocytosis, infantile heman- gioendothelioma, hepatoblastoma, and metastases NONPHARMACOLOGICAL ANTIPYRESIS • Connective tissue diseases: Systemic lupus erythematosus (SLE); Nonpharmacological methods include environmental modi­ systemic juvenile idiopathic arthritis (JIA), sarcoidosis, scleroderma, fications, increased fluid intake, and mechanical cooling. and rheumatic fever • Chronic hepatitis/chronic liver disease: Autoimmune hepatitis, chronic hepatitis B/C, and Wilson disease. Environmental Modifications Place the child in cool and airy environment (21–22°C) which Fever with Rash Jaypee enhancesBrothers heat loss by convection. Minimal clothing; i.e., dressing • Infectious causes: Meningococcemia, dengue, measles, rubella, the child in only one layer, is advocated to enhance heat loss. Some varicella, roseola infantum, erythema infectiosum, herpes simplex, theories support a gentle body massage to dilate the cutaneous and lupus vulgaris • Malignancies: Leukemia and histiocytosis blood vessels which further increases heat dissipation. • Vasculitis: Henoch-Schönlein purpura, Kawasaki disease, rheumatic fever, systemic JIA, and SLE. Hydration Fever with Lymphadenopathy As fever increases, the metabolic rate of the body also goes up. For each 1°C rise of temperature above 37.2°C, there is an increase in • Suppurative lymphadenitis (bacterial, often accompanying pharyn­ gitis, tonsillitis, dental infections, scalp infections) insensible water loss of 7 mL/kg body weight/day. Hence, extra • Tuberculosis fluid intake is advised in febrile patients. For each °1 C of increase • Lymphoma (Hodgkin and non-Hodgkin lymphomas) in temperature, a 12% increase in fluid intake is recommended. • Histiocytosis • Acute lymphoblastic leukemia (ALL) Mechanical Cooling (Hydrotherapy or Sponging) • HIV infection It is considered the mainstay of nonpharmacological antipyresis. • Connective tissue disorders such as systemic JIA or sarcoidosis External cooling lowers the temperature of febrile patients by • Kawasaki disease evaporation, conduction, and convection. Evaporation is rated as • Rosai-Dorfman disease. the most effective physical mean of promoting heat loss in febrile children because it has the least capacity to induce shivering. Commonly used agents to achieve antipyresis include para­ 1064 External cooling acts by impairing the overwhelming effect or cetamol, ibuprofen, and aspirin. Aspirin was the first antipyretic mechanisms evoked by elevated thermoregulatory set point, used in children. However, after reports of its association with rather than by lowering the elevated set point. The capacity of causation of Reye syndrome, aspirin is not recommended for external cooling to lower core temperature is limited because it controlling fever in children. Mefenamic acid and nimesulide are induces both cutaneous vasoconstriction and shivering. Therefore, the other drugs used infrequently to control fever.

VII unless concomitant antipyretic therapy or other pharmacological methods are used to abolish shivering, external cooling is vigorously Mechanism of Action opposed in febrile patients by thermoregulatory mechanisms The antipyretic medications act via the arachidonic acid pathway

PART endeavoring to maintain elevated temperature. (Flow chart 1). Arachidonic acid is a substrate for both cyclo- External cooling with ice is the treatment of choice for heat­ oxygenase-2 (COX-2) and a second isoform of the enzyme, stroke and other forms of heat illness, but is more discomforting. COX-1. COX-2 is the principal mediator of the inflammatory For fever, external cooling is indicated only in specific situations, response, resulting in production of prostaglandin2 (PGE2). and with tepid rather than cold water. Some infants with infection COX-1 products, on the other hand, function primarily in renal may also have a component of heat illness from over-wrapping, function, vascular homeostasis and gastrointestinal cytopro­ dehydration, or drugs such as atropine. Sponging should be done tection. Central inhibition of COX is responsible for the antipyretic by continuous wiping of the body with tepid water (28–30°C) from effects of paracetamol. Relatively weaker inhibition of splenic head to toe for 15–20 min. Sponging action ensures that water film COX accounts for its relatively poor anti-inflammatory response. is constantly moving thus maximizing heat conduction. Tepid Paracetamol is nearly as effective as aspirin and 10% as effective sponging acts by conduction of heat from the warm skin to water. as indomethacin in inhibiting central COX but only 5% as effective An absorbent towel should be soaked, rinsed and placed on the as aspirin and 0.02% as effective as indomethacin in inhibiting legs, trunk and forehead in order to reduce the body temperature. peripheral COX. Hydrotherapy should be continued till the body temperature Ibuprofen is a competitive inhibitor of the COX enzymes, in comes down to 38°C. Indications for sponging is summarized in that it competes with arachidonic acid for binding to the catalytic Infectious Diseases Box 1. Studies indicate that hydrotherapy alone is clearly inferior site on COX, thereby preventing prostaglandin synthesis. This is a to antipyretics for reduction of fever for periods longer than reversible process. Unlike paracetamol, ibuprofen acts peripherally 30 min after initiation of treatment. External cooling may, however and lacks specificity for either COX isomer. Ibuprofen therefore has potentiate the activity of antipyretics. antipyretic, analgesic and anti-inflammatory actions. Results of randomized trials comparing the combination of antipyretics and physical methods with antipyretics alone have Dosing and Toxicity provided mixed results. In 4 out of 7 such studies the combination treatment was superior to use of antipyretics alone for reduction Paracetamol of temperature during first 30 min of initiation of therapy and Paracetamol is recommended in a dose of 15 mg/kg at 4–6 hourly overall. In other 3 studies both modes of treatments were equally intervals not exceeding 60 mg/kg/day. Antipyretic effect begins effective in lowering temperature. It is recommended to administer within 30–60 min, approximately 80% of children will experience antipyretic drugs at least 30 min before sponging. a decreased temperature within this time frame. Paracetamol The main disadvantage of hydrotherapy is patient discomfort reduces the temperature by 1–2°C after 2 hour of intake. The and shivering. Shivering not only impedes cooling during fever rate of fall of temperature is directly related to the degrees above but also imposes considerable metabolic burden. Studies in which initial temperature was above baseline. Greater the initial volunteers have shown that shivering increases the oxygen temperature, greater is the fall after drug intake and vice versa. consumption, respiratory minute volume, respiratory quotient, Hence, drug administration in low grade temperature may not lead increase in percentage of carbon dioxide in exhaled air during to any significant fall and antipyretic treatment in high grade fevers exposure to cold and increase in mean arterial pressure. Perhaps (> 104°F) would result in reduction of temperature by less than 1°C, in febrile patients with cardiovascular disease external cooling can failing to touch the baseline. cause coronary artery vasoconstriction by cold press or response and thus decrease coronary perfusion. Sponging, though rapid in reduction of temperature, has anJaypee ill sustained effect. BrothersFlow chart 1 The arachidonic acid metabolism pathway PHARMACOLOGICAL ANTIPYRESIS Antipyretic agents are administered to provide symptomatic relief in children with fever. Keeping in mind that fever results from change in the set temperature of the hypothalamic thermoregulatory center, it seems logical to bring down the temperature by restoring the hypothalamic set-point to normal.

BOX 1 Indications for sponging with lukewarm water in fever • Febrile delirium • Febrile seizure • Fever > 41.1°C • Patients with neurologic disorders, because many of these children have abnormal temperature control and respond poorly to antipyretic agents • Children with hypersensitivity to antipyretic agents • Children with severe liver disease. and caregivers is a must. Parents need to be explained that fever is a Ibuprofen 1065 Ibuprofen can also be used as a first line antipyretic. Efficacy of protective response of body and helps to fight the disease. Medical paracetamol and ibuprofen has been compared in a number personnel need to emphasize and deal with issues, such as what of studies, and some have shown greater antipyretic effect with is fever, what is high grade fever, advantages and disadvantages of SECTION 28 10 mg/kg of ibuprofen as compared to 15 mg/kg of paracetamol. fever, when and which fever should be treated and how, the danger Ibuprofen has the advantage of longer duration of antipyresis (8 h) signs associated with fever, and when to seek medical help. as compared to paracetamol (4 h). Recent evidence indicates that there is no difference in the safety and effectiveness of paracetamol HEAT HYPERPYREXIA and ibuprofen in the care of a generally healthy child with fever. Heat hyperpyrexia is not an unusual cause of fever in tropical There is evidence that combining these 2 drugs is more effective than countries where ambient temperature may go as high as 45°C. Heat using them alone. However, this should not be followed as a routine hyperpyrexia may occur even without exposure of the child to the because of associated risk of inappropriate dosages. The practice of direct sunlight. The predisposing factors include high temperature alternating ibuprofen and paracetamol has limited value. and humidity in the environment, unsuitable clothing, dehydration

and debilitating illness, such as malaria, pneumonia, measles, and Fever Nimesulide renal disorders. Invariably, heat hyperpyrexia is associated with Nimesulide has a superior efficacy when compared to paracetamol, cessation of sweating. Children with ectodermal dysplasia and aspirin, naproxen and mefenamic acid. Also the advantage of absence of sweat glands are more prone to develop episodes of reduced frequency of dosing (2–3) exists with its use. However, heat hyperpyrexia. use of nimesulide in children is associated with potentially fatal The onset of high fever may be quite sudden. The rectal adverse effects resulting in hypothermia, hepatotoxicity, and renal temperature may exceed 42°C to 43°C. The skin appears hot and dry damage. (without sweating). Tachycardia and tachypnea are present. The loss of consciousness occurs early. The patient may develop peri­ Mefenamic Acid pheral circulatory failure and hemorrhages. Headache, faintness, Mefenamic acid is a reversible competitive inhibitor of COX-1 abdominal discomfort and delirium are usually complained of. The and COX-2 enzymes and has analgesic, antipyretic, and anti- liver and kidney failure may complicate heat hyperpyrexia. inflammatory properties. It is very effective in control of high fever in a dose of 6–7 mg/kg/dose (20 mg/kg/day in three divided Management doses), usually a single dose suffices and can later be followed When the temperature exceeds 41°C, body of the child below by paracetamol after 6–8 hour. Its main side effects are diarrhea, the neck should be immersed in the cold water without further hemolytic anemia, thrombocytopenia and drowsiness. delay to prevent irreversible brain damage. The parents should be reassured that this seemingly drastic measure will not induce Choice of Antipyretic shock. Ice cold bath does not cause significant vasoconstriction. The decision regarding the choice of antipyretic should be based The rectal temperature should be recorded continuously and the on personal experience, scientific data regarding efficacy, safety, hydrotherapy should be discontinued as the temperature falls duration of effect, and cost. In therapeutic dosages aspirin is more below 38°C. toxic and causes gastritis, gastrointestinal bleeding, impaired platelet function, diminished urinary excretion of sodium, Reye syndrome and blunted immune response. These side effects are IN A NUTSHELL known to occur less frequently with ibuprofen and none with 1. Fever per se is just a symptom of underlying illness and not a paracetamol. Paracetamol can be safely used in children with disease itself. asthma, with sensitivity to aspirin or ibuprofen, coagulation 2. All fevers do not need treatment. The aim of treating fever is disorders, peptic ulcer or reflux esophagitis. Thus paracetamol is not normalization of body temperature. considered to be the safest antipyretic in children at therapeutic 3. Febrile children should be advised to drink plenty of water dosages. Hepatotoxicity appears to be the most serious and and wear loose comfortable clothing. well-documented toxicity associated with use of paracetamol 4. Medicines should be used only when indicated. Paracetamol in children. Concern has been raised over the gastrointestinal (15 mg/kg) is the safest antipyretic in children. Ibuprofen is disturbance and nephrotoxicity withJaypee ibuprofen; hence caution is Brothersan alternative. Aspirin and nimesulide should not be used in encouraged when using ibuprofen in children with dehydration. children. In the overdose situation, the toxicity of paracetamol is not only 5. Hydrotherapy with tepid water may be useful when used in reached much earlier, but is also more severe and more difficult to combination with pharmacological antipyresis. manage as compared with an overdose of ibuprofen. 6. Explain to parents that febrile seizures occur in minority of The most commonly used and preferred mode of adminis­ children, are benign and do not cause any permanent brain tration of antipyretics is the oral route. Rectal suppositories may damage or epilepsy. be used in children with febrile seizures or unconscious patients. 7. Close monitoring is required in children with past history of Parenteral (intramuscular or intravenous) administration of febrile seizures. paracetamol may be used in cases where quick relief of fever is 8. Parents should be taught the emergency management of required or when oral administration is not possible, e.g., comatose febrile seizures. children. The dose of intravenous paracetamol is 7.5 mg/kg/dose (max. 30 mg/kg/day) for neonates and infants and 15 mg/kg/dose for older children (max. 60 mg/kg/day) to be given as an infusion. MORE ON THIS TOPIC Parental Education Bartfai T, Conti B. Fever. Scientific World Journal. 2010;10:490-503. Fever is the most common complaint for which medical attention Cunha BA. Fever myths and misconceptions: the beneficial effects of fever is sought by the caregivers. It also causes considerable parental as a critical component of host defenses against infection. Heart Lung. anxiety and concern; therefore, appropriate counseling of parents 2012;41:99-101. Gupta H, Shah D, Gupta P, et al. Role of paracetamol in treatment of childhood temperature and adequate hydration with increased frequency of 1066 Fever: a double-blind randomized placebo controlled trial. Indian Pediatr. breastfeeding, if the baby is still febrile—possibility of SBI should 2007;44:903-11. be entertained even in an apparently healthy neonate. All such Hay AD, Redmond NM, Costelloe C, et al. Paracetamol and ibuprofen for the neonates should be subject to a septic screen which includes treatment of fever in children: the PITCH randomised controlled trial. complete blood counts with band form count, urine microscopy, Health Technol Assess; 2009. pp.1-163. blood culture, urine culture, chest X-ray, and peripheral smear Hoover L. AAP reports on the use of antipyretics for fever in children. Am Fam for malarial parasite. Lumbar puncture and cerebrospinal fluid VII Physician. 2012;85:518-9. Kiekkas P. Peak fever: helpful or harmful? Heart Lung. 2011;40:272-3. analysis (cell counts, glucose, protein, Gram stain and culture) McIntyre J. Management of fever in children. Arch Dis Child. 2011;96:1173-4. should be undertaken in children with lethargy or refusal to

PART Sherman JM, Sood SK. Current challenges in the diagnosis and management breastfeeding. of fever. Curr Opin Pediatr. 2012;24:400-6. van den Anker JN. Optimising the management of fever and pain in children. Etiology Int J Clin Pract Suppl. 2013;178:26-32. Haemophilus influenzae B and Streptococcus pneumoniae are Walsh A. Available evidence does not support routine administration of the two most important causes of SBI in India, besides Klebsiella, antipyretics to reduce duration of fever or illness. Evid Based Nurs. Staphylococcus aureus, and Escherichia coli. Listeria monocytogenes 2011;14:58-9. Young PJ, Saxena MK, Beasley RW. Fever and antipyresis in infection. Med J and perinatally acquired Herpes simplex virus (HSV) infection have Aust. 2011;195:458-9. also been implicated. Malaria should also be considered a strong possibility in endemic areas.

Management Chapter 28.3 After obtaining relevant investigations, empirical antibiotic therapy should be initiated at the earliest with combination of ampicillin Fever without Focus and cefotaxime or monotherapy with ceftriaxone (100 mg/kg per day) and modified later as per the reports of the sepsis screen and Infectious Diseases Piyush Gupta, Bhavna Dhingra cultures.

Fever without focus in a child is defined as a rectal temperature of Fever in the Young Infant 1–3 Months of Age 38°C or higher as the only presenting symptom and can be sub- Self limited seasonal viral illnesses are the most common cause categorized into fever without localizing signs (FWLS) and fever of of fever without localizing signs in this age group. The possibility unknown origin (FUO). of SBI should always be entertained in any febrile child between 1 month and 3 months of age and the following conditions FEVER WITHOUT LOCALIZING SIGNS should be ruled out: otitis media, pneumonia, skin and soft tissue Children presenting with history of acute onset of short duration infections, omphalitis and urinary tract infections especially in fever (usually less than a week) as the only presenting complaint uncircumcised boys and children with urinary tract anomalies. without any signs or symptoms localizing to any organ system are categorized as having fever without localizing signs. This presents a Risk Stratification diagnostic challenge in children less than 36 months of age. These Febrile infants less than or equal to 3 months with diminished children represent an important group because of higher risk of spontaneous activity, lethargy, respiratory compromise (tachyp­ occult bacteremia and serious bacterial infections (SBI) (range nea, chest retraction and grunting), diminished muscle tone, 5–20%). Therefore, it may sometimes become essential to start mottled cool extremities, irritability, weak sucking are at high- specific and empirical treatment without establishing an etiological risk. Infants 1–3 month of age with fever who appear well and had diagnosis. As the etiology of this entity and risk of SBI is variable in been previously healthy, and have a normal physical examination, different age groups, these children are usually subclassified into can be categorized as at low-risk or high-risk for serious bacterial the following three categories: infections by certain investigations. Table 1 lists the various criteria 1. Neonates (up to 1 month of age). used for identifying children 1–3 months at low-risk of SBI. 2. Infants, 1–3 months of age. 3. Infants, 3–36 months of age.Jaypee BrothersEtiology There are certain high-risk groups of children who are at The most common implicated organisms are Group B Streptococcus, increased risk of SBI and require a more aggressive outlook. These E. coli, S. aureus, S. pneumoniae, H. influenzae, Neisseria meningi­ include children presenting with: hyperpyrexia (> 40°C); fever with tides and enterococci. Pyelonephritis is the most common SBI and petechiae; and immunocompromised patients with asplenia, sickle may be seen in well appearing as well as ill appearing children cell disease, complement deficiency states, agammaglobulinemia, between 1 month and 3 months of age presenting with fever hypogammaglobulinemia, congenital heart disease, malignancy, without localizing signs. or AIDS. Management Neonates (Birth-1 Month of Age) Febrile children, 1–3 months of age who present with fever without Newborns presenting with fever without localizing signs present localizing signs must be evaluated for sepsis by complete blood a diagnostic dilemma for the treating clinician. They have a very count, lumbar puncture, blood culture, urinalysis, urine culture limited number of signs of infection and that too are nonspecific. and chest radiograph. Ill appearing infants require immediate Immune response is also not mature. It is difficult to differentiate hospitalization and prompt institution of empirical parenteral between dehydration fever, a self-limited viral illness, and SBI. SBI antimicrobial therapy. Ampicillin with either cefotaxime or ranges from occult bacteremia, pneumonia, meningitis, urinary ceftriaxone is an effective combination. Vancomycin should be tract infection, and enteritis, to osteomyelitis, and septic arthritis. included if possibility of meningitis with penicillin resistant S. Any newborn or young infant presenting with fever should pneumoniae is suspected. Antimicrobials can be modified as per be hospitalized and after control of ambient environmental the culture and sensitivity reports. Table 1 Low-risk criteria in 1–3 months old children with fever without localizing signs 1067 Philadelphia protocol Pittsburgh guidelines Rochester criteria Boston criteria General appearance Well Well Well Well SECTION 28 Physical examination Normal Normal Normal Normal Complete blood count WBC/mm³ < 15,000 5000–15000 5000–15000 < 20,000 I:T neutrophil ratio absolute band count < 0.2 < 1500/mm³ < 1500/mm³ Urine examination < 10 WBC/HPF 9 WBC/mm³ < 10 WBC/HPF at 40X Negative leukocyte No bacteria on Gram stain No bacteria on Gram stain esterase Cerebrospinal fluid < 8 WBC/ mm³ 5 WBC/mm³ < 10 WBCs/mm3 No bacteria on Gram stain No bacteria on Gram stain

(If bloody tap) WBC:RBC ≤ 1:500 Fever Chest radiograph No infiltrates No infiltrates Stool examination No RBC, few or no WBC 5 WBC/HPF with diarrhea < 5 WBC/HPF if diarrhea Caretaker contactable telephonically Abbreviations: WBC: white blood cells; RBC: red blood cells; HPF: high power field; I:T, immature: total.

Flow chart 1 Management of fever without focus in young children (Reproduced from Gupta P. Textbook of Pediatrics. New Delhi: CBS; 2013)

Jaypee Brothers

*Determine risk based on history, examination, and laboratory studies: Low-risk: Normal history and physical examination; WBC 5000–15000/mm3; band cell < 1500/mm3 urine pus cells < 10/hpf; stool pus cells < 5/hpf; normal chest radiograph; and CSF < 8 lymphocytes/mm3. $Other tests include WBC count; urine and stool microscopy; chest X-ray; CSF Gram stain. Cultures include that of blood, urine, and CSF.

In well appearing infants a watchful observation without anti­ Fever without Localizing Signs in biotics may be planned and a sepsis screen obtained, although a 3–36 Months Old Children lumbar puncture may be deferred. A mandatory follow-up after 24 Viral infections are responsible for majority of children having hours must be ensured. Prior to initiation of antibiotics in the event nonlocalizing fever in this age group. Serious bacterial infection of clinical deterioration, a lumbar puncture should always be done. can also occur due to S. pneumoniae, Neisseria, and H. influenzae. Risk factors for occult bacteremia in these children include absent on admission but in whom a fever of 38°C or more occurs on 1068 rectal temperature > 39°C, WBC counts > 15000/mm3, raised ESR, several occasions, for at least a week. and elevated C-reactive protein. Rectal temperature > 40°C and Neutropenic FUO is defined as multiple readings of more WBC count > 25000/mm3 indicate a higher probability of serious than 38°C in a child with absolute neutrophil count less than bacterial infection. Important bacterial infections include otitis 500/mm3, after at least 3 days of investigations including at least media, pneumonia, sinusitis, enteritis, urinary tract infection, 48 hours of incubation of cultures. osteomyelitis and meningitis. Pneumococcal bacteremia can HIV-related FUO is defined as a temperature of more than VII resolve spontaneously in about one-third of cases or can lead to or equal to 38°C on multiple occasions for more than or equal to development of localized infections, e.g., meningitis, pneumonia, 3 weeks as an outpatient and more than 1 week as an inpatient in a

PART cellulitis, pericarditis, osteomyelitis or septic arthritis. Management patient with confirmed HIV infection. options are detailed in Flow chart 1. Infants with moderate to high Fever of unknown origin needs to be differentiated from fever risk factors should be treated with ceftriaxone (50–80 mg/kg/day in without localizing signs as their differential diagnoses and most one or two divided doses IV or IM). In infants below 4 weeks of age, frequent causes are distinct. Children with FWLS usually need ampicillin (50–100 mg/kg/day IM or IV two divided doses) should immediate evaluation and empirical antibiotic therapy, whereas also be added to cover Listeria monocytogenes and enterococci, those with FUO generally do not need an emergency assessment which are not sensitive to ceftriaxone. and antibiotics. The major hurdle in establishing a diagnosis is that the salient features rendering specific disorders clinically recognizable are absent or subtle. There is noone fits all algorithm IN A NUTSHELL available for evaluation and the clinician needs to work-up each 1. Children presenting with fever without localizing signs carry case on its own merit. high chances of occult bacteremia and serious bacterial infection (SBI). ETIOLOGY 2. Newborns or young infants with fever should be hospitalized Fever of unknown origin is usually an uncommon presentation of and dehydration fever ruled out, before starting empirical Infectious Diseases a common illness. Infectious diseases, connective tissue diseases therapy. and autoimmune disorders are the most common causes of FUO in 3. Well appearing, 1–3 months old febrile children should be children. Malignancies are responsible for a lesser number of cases categorized into low-risk and high-risk categories, based on as most children with malignancies present with other systemic certain criteria. signs or suggestive laboratory abnormalities. Drug fever, factitious 4. Empirical antibiotic therapy should be started in children at fevers and periodic fever syndromes are responsible for a few cases high-risk of serious bacterial infections/occult bacteremia. of FUO. Table 1 lists the common causes of FUO in children. Epidemiologically relevant infections must be considered MORE ON THIS TOPIC first in differential diagnosis and ruled out by appropriate clinical, laboratory and radiological evaluation. Hidden deep seated Aronson PL. Evaluation of the febrile young infant: an update. Pediatr Emerg abscesses, e.g., pelvic, subdiaphragmatic, perinephric, subphrenic, Med Pract. 2013;10:1-17. psoas, retroperitoneal, mediastinal, dental, brain and hepatic Arora R, Mahajan P. Evaluation of child with fever without source: review of should always be looked for and excluded. Subacute bacterial literature and update. Pediatr Clin North Am. 2013;60:1049-62. endocarditis should be high on the suspicion list especially in the Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and management of febrile setting of a pre-existing cardiac disease. infants (0-3 months). Evid Rep Technol Assess. 2012;205:1-297. Nosocomial infections with unusual organisms, e.g., anaerobic Hamilton JL, John SP. Evaluation of fever in infants and young children. Am bacilli should be considered in differential diagnosis of a patient Fam Physician. 2013;87:254-60. having received various antibiotics, especially aminoglycosides, for Harris JA. Managing fever without a source in young children: the debate continues. Am Fam Physician. 2007;75:1774-6. several days in the hospital. Factitious fever should be considered, Ishimine P. Risk stratification and management of the febrile young child. if fever persists for more than 6 months without diagnosis. Emerg Med Clin North Am. 2013; 31:601-26. Machado BM, Cardoso DM, de Paulis M, et al. Fever without source: evaluation APPROACH TO DIAGNOSIS of a guideline. J Pediatr. 2009;85:426-32. Sur DK, Bukont EL. Evaluating fever of unidentifiable source in young children. Unless the child is acutely ill, the evaluation for FUO generally Am Fam Physician. 2007;75:1805-11.Jaypee Brothersis done on an outpatient basis. If outpatient evaluation fails to disclose a cause for the fever, inpatient evaluation provides an opportunity to review the detailed history, physical examination, investigation reports and keep the child under close observation Chapter 28.4 with an ongoing assessment to establish the cause of fever.

Fever of Unknown Origin History Bhavna Dhingra, Piyush Gupta The history should include questions regarding characteristics of fever (onset, intensity, duration, frequency and pattern of fever). Intermittent fevers with a high spike and rapid defervescence Fever of unknown origin (FUO) is defined as fever (rectal suggest a pyogenic infection but can also be seen in tuberculosis, temperature > 38°C) documented by a health-care personnel, for lymphoma, and connective tissue disorders. Remittent fevers are which no cause is identifiable after 3 weeks of outpatient evaluation characterized by fluctuating peaks and a baseline that does not and after 1 week of evaluation as an inpatient that includes a return to normal and are seen most commonly with viral infections, careful history and physical examination and initial laboratory some bacterial infections (especially endocarditis), sarcoidosis, assessment. lymphoma, and atrial myxoma. Sustained fevers persist with little Nosocomial or health-care-associated FUO refers to hospital­ or no fluctuation but can appear to be intermittent if antipyretic ized children receiving acute care in whom infection or fever were agents are administered and are usually seen in enteric fever, Table 1 Common causes of fever of unknown origin (FUO) in children 1069 1. Infections Bacterial: Tuberculosis, typhoid, paratyphoid, brucellosis, listeriosis, meningococcemia, yersiniosis, Campylobacter, relapsing fever, Lyme disease

Viral: Infectious mononucleosis (Epstein-Barr-virus), human immunodeficiency virus (HIV)/AIDS, hepatitis, and cytomegalovirus (CMV) disease SECTION 28 Parasitic: Malaria, kala-azar, amebic abscess, hepatic amebiasis, giardiasis, toxoplasmosis, trypanosomiasis, and visceral larva migrans Rickettsia: Scrub typhus, Q fever, Rocky mountain spotted fever Fungal: Disseminated candidiasis, histoplasmosis, aspergillosis, blastomycosis, disseminated coccidioidomycosis, and cryptococcosis 2. Connective tissue and autoimmune disorders: Systemic lupus erythematosus (SLE), juvenile idiopathic arthritis (JIA), rheumatic fever, juvenile dermatomyosistis, chronic active hepatitis, polyarteritis nodosa, mixed connective tissue disorder, Behçet disease, and autoimmune thyroiditis 3. Hypersensitivity disorders: Drug fever, serum sickness, hypersensitivity pneumonitis, and Weber-Christian disease 4. Malignancies: Hodgkin disease, leukemia, lymphoma, inflammatory pseudotumors, pheochromocytoma, neuroblastoma, and Wilms tumor 5. Granulomatous disorders: Sarcoidosis, granulomatous hepatitis, inflammatory bowel disease Fever 6. Familial and hereditary syndromes: Familial dysautonomia, familial Mediterranean fever, anhidrotic ectodermal dysplasia, Ichthyosis, and hypertriglyceridemia 7. Hematologic causes: Hemophagocytic lymphohistiocytosis syndromes, cyclic neutropenias, immunodeficiency states, Kikuchi-Fujimoto disease, and Castleman disease 8. Endocrine causes: Addison disease, thyrotoxicosis, hypothalamic central fever, and diabetes insipidus 9. Miscellaneous causes: Factitious fevers, infantile cortical hyperostosis, pancreatitis, drug fevers, poisonings, thrombophlebitis, and pulmonary embolism

typhus, brucellosis, etc. Hodgkin disease has a typical Pel-Ebstein rectal, external genitalia, and pelvic examination (where indicated) type of fever (3–10 day cycles of febrile and afebrile periods). Fever should be performed. with chills and rigors suggest malaria, urinary tract infection, abscesses or nosocomial infections. Relapsing fever with periods Laboratory Tests during which patients are afebrile for one or more days between The laboratory and imaging evaluations for FUO should be febrile episodes may be seen with malaria, rat-bite fever, Borrelia directed toward the likely causes of fever based upon the infection, and lymphoma. patient’s age, duration of fever, history and findings from the The clinician needs to enquire about the way temperature was physical examination. Appropriate laboratory investigations assessed-perceived manually or documented by a thermometer such as complete blood counts with total leukocyte count, along with the site of documentation; localizing symptoms of differential leukocyte count, erythrocyte sedimentation rate (ESR), fever; recent exposures like vaccination or animal/insect bites or peripheral blood smear examination for malaria and filariasis receipt of any blood transfusion or biological products; exposure (night blood) are routinely performed. Table 2 lists the various to a family member with fever or any infectious disease, past hematological abnormalities which may be an indicator of a history of any significant illnesses such as tuberculosis, urinary specific disease condition. An elevated ESR more than 30 mm/ infections, congenital heart disease, any surgical procedure; any hour suggests inflammation. ESR and C reactive protein (CRP) history of travel in the recent past to specific disease endemic though nonspecific, can serve as prognostic markers and be used areas, history of exposure to any heavy metals or poisonous fumes for monitoring purposes. Simple serological tests for typhoid, and history of an underlying chronic disease and medication brucellosis, leishmaniasis, toxoplasmosis and amebiasis, and history. History of recurrent episodes of fever may give a clue to bacteriological culture of blood for Salmonella and Brucella should certain cyclic causes of fever, e.g., cyclic neutropenia, and may also be undertaken. be seen in immunodeficiency disorders, hyperimmunoglobulin Repeated microscopic examination and cultures of blood, D disease and central nervous system disorders of temperature urine, throat, sputum, and stool for bacterial and fungal infections regulation. Tick bites can lead to Rocky Mountain spotted fever, should be carried out at periodic intervals. Sterile pyuria can Jaypee beBrothers a clue to Kawasaki disease or genitourinary tuberculosis. ehrlichiosis, tularemia, tick-borne relapsing fever, or Lyme disease. Ingestion of raw meat or raw shellfish may lead to brucellosis, toxoplasmosis, tularemia, or hepatitis. Familial Mediterranean Table 2 Hematologic clues to specific disease states fever is generally seen in Jewish, Turkish, and Arab populations. Anemia Malaria, Infective endocarditis, Familial dysautonomia is common in Ashkenazi Jews. Inflammatory bowel disease, systemic lupus erythematosus, tuberculosis, etc. Examination Thrombocytosis Kawasaki disease A detailed clinical examination, which needs to be repeated Total white blood cell Serious bacterial infection frequently, so as not to miss any subtle or evolving signs, remains count >10,000/mm³ the most important clinical tool for diagnosis. While examining the child, particular attention should be paid to evaluation of Nonsegmented Serious bacterial infection skin, fundus, throat, lymph nodes, genitalia and sinuses. Detailed polymorphonuclear leukocytes > 500/mm³ eye inspection including that of cornea, conjunctiva, orbit, uveal tract and retina may point towards many infectious, collagen Eosinophilia Parasitic, fungal, allergic or vascular, malignant or metabolic disorders. Absence of sweating immunodeficiency states during fever may be noted in anhidrotic ectodermal dysplasia Immature band forms Leukemia and absence of malaise or other generalized signs in a child with a Activated lymphocytes Viral Infection history of prolonged high fevers can signal factitious fever. Careful Serum electrolytes, blood urea nitrogen (BUN), creatinine, and 1070 MANAGEMENT hepatic enzymes are obtained to evaluate renal and/or hepatic Empirical treatment with anti-inflammatory agents (except for involvement. Hypernatremia may be seen in diabetes insipidus, symptomatic relief in suspected JIA) or antibiotics should be elevated hepatic enzymes may be a clue to a viral infection. avoided as they may mask the diagnosis or alter the course of certain Bone marrow examination can help in diagnosing leukemia, conditions like infective endocarditis, meningitis or osteomyelitis lymphoma, histiocytic disorders, and hemophagocytic syndromes. and may also interfere with isolation of certain microorganisms If specifically indicated, cultures of bone marrow, cerebrospinal VII on cultures. Disease specific appropriate interventions should be fluid, gastric aspirate, lymph node aspirate and liver aspirate for initiated soon after establishing the diagnosis. aerobic and anaerobic bacteria, mycobacteria and fungi may prove

PART to be invaluable. Serum antinuclear antibody should be obtained for children with a strong family history of rheumatic disease. Serum IN A NUTSHELL concentrations of immunoglobulins (IgG, IgA, and IgM) should be measured in children with evidence of recurrent or persistent 1. Fever of unknown origin (FUO) is defined as fever (rectal fever and a negative initial evaluation. Hypogammaglobulinemia temperature > 38°C) documented by a health-care personnel, may indicate an immunodeficiency, while elevated levels may be for which no cause is identifiable after 3 weeks of outpatient seen in chronic infections, or autoimmune disorders. Serological evaluation and after 1 week of evaluation as an inpatient. tests should also be repeated to look for any rising antibody titers. 2. A detailed clinical history and examination, repeated fre­ Modern molecular diagnostic techniques; e.g., polymerase chain quently, is crucial for diagnosis of FUO. reaction (PCR) are now available for diagnosis of several infectious 3. Infectious diseases, connective tissue diseases and auto­ agents. A variety of immunological tests for detection of various immune disorders are the most common causes of FUO in autoantibodies is now available to rule out various autoimmune children. disorders. 4. Children with FUO generally do not need an emergency Diagnostic imaging of the nasal sinuses, mastoids, chest assessment or empirical anti-inflammatory agents and/or and gastrointestinal (GI) tract by radiography, barium studies, antibiotics. Infectious Diseases ultrasonography, computerized tomographic (CT) scans and magnetic resonance imaging (MRI) as indicated, should initially be performed for specific indications, but may be done in children in MORE ON THIS TOPIC whom FUO persists without a cause being established. Endoscopic evaluation of respiratory, genitourinary and gastrointestinal tract Chow A, Robinson JL. Fever of unknown origin in children: a systematic review. World J Pediatr. 2011;7:5-10. may help positron emission tomography (PET) scanning and Joshi N, Rajeshwari K, Dubey AP, et al. Clinical spectrum of fever of unknown immunoscintigraphy may be helpful in patients with persistent origin among Indian children. Ann Trop Paediatr. 2008;28:261-6. FUO who remain without a diagnosis after initial evaluation. Rigante D, Esposito S. A roadmap for fever of unknown origin in children. Int J Lymphangiography can be resorted to, for demonstrating Immunopathol Pharmacol. 2013;26:315-26. retroperitoneal, iliac and periaortic lymph nodes. Biopsy (e.g., Seashore CJ, Lohr JA. Fever of unknown origin in children. Pediatr Ann. 2011; of lymph nodes, bone marrow or liver) should be reserved only 40:26-30. for children with evidence of involvement of specific organs. If Tolan RW Jr. Fever of unknown origin: a diagnostic approach to this vexing indicated, skin, pleura, muscle, kidneys, etc. can also be biopsied. problem. Clin Pediatr. 2010;49:207-13.

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