The presentation of appendicitis in preadolescent children.

PURPOSE: We describe the clinical presentation of appendicitis in preadolescent children and differences in symptoms among age-stratified subgroups. METHODS: This is a retrospective analysis of a prospectively collected de-identified data set of patients 3 years or older and patients younger than 12 years presenting to a pediatric emergency department during a 21-month period with symptoms suspicious for appendicitis. The rates of appendicitis, perforation, negative appendectomy, as well as sensitivities, specificities, and positive likelihood ratios for historical and clinical variables associated with appendicitis were calculated for the entire cohort and for 3 age-stratified subgroups. RESULTS: Of 379 children, 121 (32%) had appendicitis, 75 (62%) were male, 24 (20%) had a perforated appendix, and 16 (12%) had a negative appendectomy. The perforation rate was highest (53%) in the youngest subset of patients (3-5.99 years). Patients with appendicitis presented with inability to walk (82%), maximal right lower quadrant tenderness (82%), nausea (79%), pain with percussion, hopping, coughing (79%), and anorexia (75%). Fewer patients with appendicitis presented with a history of vomiting (66%), fever (47%), or diarrhea (16%), and these findings were not associated with the diagnosis. The youngest subset of patients (3-5.99 years) presented to the emergency department with fever; however, within this age subset, there was no significant difference in temperatures between patients with and without appendicitis. Fever was an indicator for perforation. Psoas, Rovsing, and obturator signs were infrequent but very specific for appendicitis (0.86-0.98 depending on age). CONCLUSIONS: Nausea, right lower quadrant tenderness, inability to walk, and elevated white blood cell and neutrophil counts are sensitive indicators of appendicitis in preadolescent children. Although peritoneal signs are infrequently elicited, when present, they substantially increase the likelihood of appendicitis. Fever, vomiting, and diarrhea are not associated with appendicitis in preadolescent children.

Evaluation of the precision of emergency department diagnoses in young children with fever.

OBJECTIVE. To characterize causes of fever in children presenting to a pediatric emergency department (ED). METHODS. One-year retrospective review of ED records. Inclusion criteria were 2 to 36 months of age with a documented temperature ≥ 39°C. Exclusion criteria were elopement, repeat visit, and underlying diagnosis with a predisposition to infection. Medical records were reviewed using a predefined, study-specific, data abstraction tool. Based on diagnosis and pathogen detection, visits were assigned to 3 groups, laboratory confirmed pathogen and focal or nonfocal diagnosis without confirmed pathogen. RESULTS. A total of 1091 visits met inclusion criteria. Fourteen percent had a pathogen detected, 56% had a focal diagnosis without a confirmed pathogen, and 30% had a nonfocal diagnosis without confirmed pathogen. CONCLUSIONS. In a cohort of febrile children 2 to 36 months of age, only 14% had a confirmed pathogen. New rapid viral diagnostic techniques may provide an opportunity to improve diagnostic certainty in young children presenting with fever.

Detection of viruses in young children with fever without an apparent source.

OBJECTIVE: Fever without an apparent source is common in young children. Currently in the United States, serious bacterial infection is unusual. Our objective was to determine specific viruses that might be responsible. METHODS: We enrolled children aged 2 to 36 months with temperature of 38°C or greater without an apparent source or with definite or probable bacterial infection being evaluated in the St Louis Children's Hospital Emergency Department and afebrile children having ambulatory surgery. Blood and nasopharyngeal swab samples were tested with an extensive battery of virus-specific polymerase chain reaction assays. RESULTS: One or more viruses were detected in 76% of 75 children with fever without an apparent source, 40% of 15 children with fever and a definite or probable bacterial infection, and 35% of 116 afebrile children (P < .001). Four viruses (adenovirus, human herpesvirus 6, enterovirus, and parechovirus) were predominant, being detected in 57% of children with fever without a source, 13% of children with fever and definite or probable bacterial infection, and 7% of afebrile children (P < .001). Thirty-four percent of 146 viral infections were detected only by polymerase chain reaction performed on blood. Fifty-one percent of children with viral infections and no evidence of bacterial infection were treated with antibiotics. CONCLUSIONS: Viral infections are frequent in children with fever without an apparent source. Testing of blood in addition to nasopharyngeal secretions expanded the range of viruses detected. Future studies should explore the utility of testing for the implicated viruses. Better recognition of viruses that cause undifferentiated fever in young children may help limit unnecessary antibiotic use.