Журнал «Здоровье ребенка» 4 (55) 2014

The description of widespread children’s diseases, which can initially manifest as fever of unknown origin (FUO) is continued in the second part of the article. The most important clinical information in the unified form (refer to part I) about the following diseases is represented:

1) Systemic diseases of connective tissue (juvenile rheumatoid arthritis, Wissler-Fanconi syndrome, systemic lupus erythematosus, dermatomyositis, periarteritis nodosa (Kussmaul's disease), scleroderma);

2) Miscellaneous group of diseases (diencephalic syndrome (vegetovascular variant), hyperthyroidism (Graves' disease), acquired granulocytopenia, terminal ileitis (Crohn's disease), granulomatous hepatitis, sarcoidosis (Boeck's disease).

Apart from that several other causes of FUO are mentioned (iatrogenic infectious process, psychogenic fever, false fever (tomomania), medicinal fever).

The subsequent groups of drugs, whose certain representatives can provoke increase of body temperature, are indicated: antibiotics, including antituberculous medicines, cytostatic agents, antiarrhythmic and antihypertensive drugs, neuroleptics, antidepressants and anticonvulsants, nonsteroid anti-inflammatory agents, including even aspirin and ibuprofen, diuretics, anticoagulants, immunomodulators, H₁-, H₂-blockers et al.

Several stages of diagnostic search for general practitioners in FUO are suggested:

1) Careful history taking, which would include finding out of the following moments: patient’s complains at present and in recent past, information about all the past diseases, including operations, transfusions of blood and its substitutes, injuries, mental abnormalities, contact with infectious patients, animals (first of all cats and birds), family anamnesis regarding infectious diseases or fever, data about conducted vaccinations, visiting countries which are precinctive concerning tropical diseases, mosquito or tick bites, intake of food ingredients without sufficient thermic processing, taking different medicines which can be inductors of fever et al.

2) Detection of such symptoms as body weight loss, regional or systemic lymphadenopathy, skin rash, icteritiousness of cutaneous covering and mucous membrane, hepatomegaly, splenomegaly, neurologic symptomatology, inflammatory changes in joints, enlargement of abdomen et al.

3) The interpretation of routine laboratory examination results: clinical blood count, urine analysis, biochemical blood analysis (liver function test, protein fractions, proteins of acute phase et al.).

4) The prescription of special laboratory or instrumental examinations on the grounds of three previous stages results of diagnostic search.

5) The decision on reasonability and first priority of subspecialty doctors, who can also recommend different additional examinations.

6) The realization of empiric treatment.

Regarding the latter item, the issue about reasonability of empiric treatment in majority cases doesn’t have any unambiguous decision. It should be considered individually depending on specific clinical situation. The matter is that under quite weighty arguments for such treatment, it stops to be empiric. On the other hand, if a doctor administers empiric treatment without any serious reasons, then considerable complications may arise concerning the interpretation of its results and the probability of diagnostic pitfalls increases. For example, the efficiency of glucocorticoids and inefficiency of antibiotics can be considered as one of arguments in favour of systemic inflammatory diseases of connective tissue. At the same time it should be kept in mind that glucocorticoids are capable of body temperature dropping in lymphoproliferative tumours. Besides, administering these drugs should be avoided in high probability of tuberculous or suppurative processes.

Summing up, we understand that the diseases, mentioned in this article, don’t exhaust all the range of possible reasons of FUO which can be met in pediatric practice. Article format of specialized pediatric magazine doesn’t allow of revealing all the aspects of this complicated multidisciplinary problem. At the same time we hope that the represented information will permit pediatricians and general practitioners to systematize their knowledge about FUO, narrowing the range of diagnostic search for each particular clinical case as much as possible, and to determine its first-priority optimal directions. Eventually the success of FUO diagnostics will depend on many different factors, among which doctor’s professional skills, experience and intuition seem to be the most important. Apart from that it is very essential that the confidence between a pediatrician and his/her patient’s parents should exist. This condition will permit to realize diagnostic measures sequentially and fully.