title: ACR Appropriateness Criteria Fever Without Source or Unknown Origin-Child.
abstract: The cause of fever in a child can often be determined from history, physical examination, and laboratory tests; infections account for the majority of cases. Yet in 20%, no apparent cause can be found, designated as fever without source (FWS). The yield of chest radiography in children with FWS is low, and it is usually not appropriate. However, in children with respiratory signs, high fever (>39°C), or marked leukocytosis (≥20,000/mm(3)), chest radiography is usually appropriate, as it has a higher yield in detecting clinically occult pneumonia. In newborns with FWS, there is higher risk for serious bacterial infection, and the routine use of chest radiography is controversial. In children with neutropenia, fever is a major concern. In some clinical circumstances, such as after hematopoietic stem cell transplantation, chest CT scan may be appropriate even if the results of chest radiography are negative or nonspecific, as it has higher sensitivity and can demonstrate specific findings (such as lung nodule and "halo sign") that can guide management. In a child with prolonged fever of unknown origin despite extensive medical workup (fever of unknown origin), diagnosis is usually dependent on clinical and laboratory studies, and imaging tests have low yield. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts. Electronic address: swestra@partners.org.
authors.forename: Sjirk J
authors.initials: SJ
authors.lastname: Westra
authors.affiliation: Riley Hospital for Children, Indiana University, Indianapolis, Indiana.
authors.forename: Boaz K
authors.initials: BK
authors.lastname: Karmazyn
authors.affiliation: Children's Healthcare of Atlanta, Atlanta, Georgia.
authors.forename: Adina L
authors.initials: AL
authors.lastname: Alazraki
authors.affiliation: Texas Scottish Rite Hospital for Children, Dallas, Texas.
authors.forename: Molly E
authors.initials: ME
authors.lastname: Dempsey
authors.affiliation: C. S. Mott Children's Hospital, Ann Arbor, Michigan.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Dillman
authors.affiliation: Division of General and Hospital Pediatrics, Columbia, South Carolina, American Academy of Pediatrics.
authors.forename: Matthew
authors.initials: M
authors.lastname: Garber
authors.affiliation: Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Sheila G
authors.initials: SG
authors.lastname: Moore
authors.affiliation: Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.
authors.forename: Molly E
authors.initials: ME
authors.lastname: Raske
authors.affiliation: Duke University Medical Center, Durham, North Carolina, American Pediatric Surgical Association.
authors.forename: Henry E
authors.initials: HE
authors.lastname: Rice
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
authors.forename: Cynthia K
authors.initials: CK
authors.lastname: Rigsby
authors.affiliation: Emory University Hospital, Atlanta, Georgia.
authors.forename: Nabile
authors.initials: N
authors.lastname: Safdar
authors.affiliation: Children's Healthcare of Atlanta, Atlanta, Georgia.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Simoneaux
authors.affiliation: C. S. Mott Children's Hospital, Ann Arbor, Michigan.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Strouse
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Trout
authors.affiliation: University of California Davis Medical Center, Sacramento, California.
authors.forename: Sandra L
authors.initials: SL
authors.lastname: Wootton-Gorges
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Coley
mesh_terms: D000067576:Child Health / Q000592:standards; D019411:Clinical Laboratory Techniques / Q000592:standards*; D003952:Diagnostic Imaging / Q000592:standards*; D005335:Fever of Unknown Origin / Q000175:diagnosis* / Q000209:etiology; D010372:Pediatrics / Q000592:standards; D011014:Pneumonia / Q000150:complications / Q000175:diagnosis*; D017410:Practice Guidelines as Topic; D011871:Radiology / Q000592:standards; D018805:Sepsis / Q000150:complications / Q000175:diagnosis*; D014481:United States
keywords: Appropriateness Criteria; fever of unknown origin; fever without source; infants and children imaging; occult pneumonia; sepsis workup