Fever without source in infants and young children: dilemma in diagnosis and management

Ahmed Farag Elhassanien,1 Hesham Abdel-Aziz Alghaiaty,2 Fawaz Alrefaee3 1Pediatric Department, Elmansoura University, Elmansoura, Egypt; 2Pediatric Department, Benha University, Benha, Egypt; 3Pediatric Department, Al-Adan Hospital, Kuwait City, Kuwait Background: There is controversy surrounding the management of young children who have a fever without a source (FWS). Several strategies have been designed with the purpose of managing children with FWS. Aims: To assess the applicability of a standardized guideline for children up to 36 months of age with FWS. Setting: Pediatric emergency unit, Al-Adan Hospital, Kuwait City, Kuwait, from May 2011 to October 2011. Design: Prospective, cross-sectional study. Methods and materials: The study involved children with FWS up to 36 months of age. The guideline classifies the risk of serious bacterial infection (SBI) according to the age of the child, the presence or absence of toxemia, clinical presentation, and laboratory screening tests. Results: A total of 481 children were included in the present study, but only 385 cases completed the study; 3.9% of patients had toxemia at the initial evaluation. We found 26 children with SBI (6.8%); 12 patients with SBI did not present with toxemia. In all, 40.4% of studied newborns were diagnosed as having a urinary tract infection, and 42.7% of patients as self-limited probable viral etiology. Of the 109 young infants without toxemia, 53.2% were classified as being at high risk of SBI. Of the 163 toddlers without toxemia, 72.4% were treated with antibiotics; 48.4% of patients received therapeutic treatment and 25.8% received empirical treatment. Conclusion: The guideline followed in our pediatric emergency unit seemed to be appropriate in following up with these children using simple laboratory tests. The most frequent SBI in this sample was urinary tract infection. Keywords: fever without source, serious bacterial infection, young children, sepsis, infant

Congenital chloride diarrhea: a review of twelve Arabian children

Fawaz Elrefae,1 Ahmed Farag Elhassanien,2 Hesham Abdel-Aziz Alghiaty3 1Pediatric Gastroenterology, Al-Adan Hospital, Kuwait; 2Faculty of Medicine, Elmansoura University, El Mansoura, El Dakahleya, Egypt; 3Faculty of Medicine, Benha University, Egypt Background: Congenital chloride diarrhea (CCD), a rare autosomal recessive disorder, is characterized by sustained watery diarrhea (due to defect of active Chloride/HCO3 exchange in the ileum and colon) with high fecal chloride. Objective: To spotlight the common presentation of CCD for early management and prevention of complications. Subjects and methods: This is a retrospective case series study of patients diagnosed as CCD who were followed up in the pediatric department of Al-Adan Hospital, Kuwait. Results: Twelve patients diagnosed with CCD were born to consanguineous parents; had antenatal history of intrauterine growth retardation (IUGR); polyhydramnios; and distended hypoechoic fetal bowel; and presented with abdominal distension, hypotonia and muscle wasting. 90% of patients had maternal hypertension and 75% of patients had absence of normal meconium at birth. Our patients showed a decrease in serum sodium, potassium, chloride and urine chloride. Conclusion: A high level of suspicion for an early diagnosis of CCD should be considered for any infant presenting with chronic diarrhea, especially in the presence of consanguineous marriage, and the characteristic features in antenatal ultrasound. Thus, allowing for early investigations and appropriate management. Keywords: congenital chloride diarrhea, children, chronic diarrhea, metabolic alkalosis, prenatal diagnosi