Clinical significance of physical examination findings* in children with fever of unknown origin

Finding	Possible causes
General assessment
Labile blood pressure	Familial dysautonomia
Tachypnea	Pneumonia Systemic lupus erythematosus
Relative bradycardia^¶	Babesiosis Dengue fever Legionella Leptospirosis Malaria Psittacosis Q fever Rocky Mountain spotted fever Typhoid fever Typhus Viral hemorrhagic fever Yellow fever
Weight loss	Diabetes insipidus Inflammatory bowel disease Malignancy Systemic illness
Short stature or deceleration of linear growth	Endocrine disorder Inflammatory bowel disease
Skin and scalp
Petechiae	Bacteremia Infective endocarditis Rickettsial infection (eg, Rocky Mountain spotted fever) Viral infection
Papular lesions	Cat scratch disease
Eschar	Tularemia
Erythema migrans or erythema migrans-like rashes	Lyme disease, Southern tick-associated rash illness
Rose spots	Typhoid fever
Salmon-pink rash with fever	Systemic juvenile idiopathic arthritis
Malar erythema	Systemic lupus erythematosus
Palpable purpura	Vasculitis (eg, polyarteritis nodosa)
Erythema nodosum	Infection Inflammatory bowel disease Juvenile idiopathic arthritis Malignancy Systemic lupus erythematosus
Urticarial and/or serpiginous macular rash or band of erythema on the sides of the hands and feet	Serum sickness
Seborrheic rash or scalp lesions	Langerhans cell histiocytosis
Lack of sweat during fever	Dehydration (possibly related to diabetes insipidus) Ectodermal dysplasia Familial dysautonomia (Riley-Day syndrome)
Sparse hair	Hypohidrotic ectodermal dysplasia
Blotchy skin with multiple areas of trauma	Familial dysautonomia
Eyes
Conjunctivitis
Palpebral conjunctivitis	Coxsackievirus infection Infectious mononucleosis Measles Newcastle disease^Δ Tularemia
Bulbar conjunctivitis	Kawasaki disease Leptospirosis Tularemia
Phlyctenular conjunctivitis	Tuberculosis
Abnormal funduscopic examination
Ischemic retinopathy Ischemic optic neuropathy	Polyarteritis nodosa
Choroid tubercles	Miliary tuberculosis
Raised yellow-white cottony lesions in nonvascular distribution	Toxoplasmosis
Perivascular sheathing	Vasculitis
Other findings
Conjunctival hemorrhage	Infective endocarditis
Absent pupillary constrictor response	Autonomic dysfunction Hypothalamic dysfunction
Absent tears, absent corneal reflex	Familial dysautonomia
Sinuses
Tenderness	Rhinosinusitis
Oropharynx
Oral ulcers	Inflammatory bowel disease Behçet syndrome Systemic lupus erythematosus
Pharyngeal hyperemia without exudate	Infectious mononucleosis (EBV or CMV) Leptospirosis Toxoplasmosis Tularemia
Dental abscess	May be complicated by other infections (eg, sinusitis, brain abscess, etc)
Hypodontia, adontia, or conical ("peg") teeth	Anhidrotic ectodermal dysplasia
Smooth tongue without fungiform papillae and/or excessive salivation	Familial dysautonomia
Gingival hypertrophy or inflammation	Langerhans cell histiocytosis Leukemia
Lymph nodes
Lymphadenopathy/lymphadenitis	Refer to UpToDate content on peripheral lymphadenopathy in children
Chest
Tachypnea, crackles (rales) decreased or bronchial breath sounds, bronchophony, whispered pectoriloquy, tactile fremitus, dullness to percussion	Pneumonia
Cardiac murmur (new onset)	Infective endocarditis
Pericardial rub	Pericarditis (a manifestation of systemic lupus erythematosus and other disorders)
Abdomen
Hepatomegaly or splenomegaly	Brucellosis Cat scratch disease Hemophagocytic lymphohistiocytosis Infectious mononucleosis Infective endocarditis Leukemia/lymphoma Malaria Salmonellosis Childhood leukemia Non-Hodgkin lymphoma
Tenderness with palpation of the liver edge	Cat scratch disease Liver abscess
Abdominal mass	Malignancy (neuroblastoma, Wilms tumor, lymphoma, germ cell tumor)
Musculoskeletal
Bony tenderness	Infantile cortical hyperostosis Osteomyelitis Malignant infiltration of the bone marrow
Muscle tenderness	Arboviral or other viral infection Dermatomyositis Polyarteritis nodosa Trichinellosis
Abnormal deep tendon reflexes	Hyperactive: Hyperthyroidism Hypoactive: Familial dysautonomia
Genitourinary
Perirectal tenderness or mass	Pelvic mass or tumor
Genital ulcers, urethral discharge	Sexually transmitted infection
Perianal fistulae, skin tags, or fissures	Inflammatory bowel disease
For sexually active females: Cervical motion tenderness, uterine or adnexal tenderness	Pelvic inflammatory disease
For males: Testicular tenderness	Brucellosis Vasculitis (polyarteritis nodosa, Henoch-Schönlein purpura)

EBV: Epstein-Barr virus; CMV: cytomegalovirus.

* Repeating the examination on multiple occasions is necessary to detect findings that develop or evolve after the initial assessment.

¶ Relative bradycardia: For patients ≥13 years with temperature ≥38.9°C (102°F), failure of the pulse to increase as expected with fever (approximately 10 beats per minute for each 0.6°C [1°F]).

Δ Newcastle disease is a viral infection associated with exposure to chickens or other birds.

Graphic 111285 Version 3.0

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Clinical significance of physical examination findings* in children with fever of unknown origin