Mr. and Mrs. X brought their nine-month-old son, Jason to the office because of a fever. It started four days ago with a temperature of 101.4 degrees. He had no other symptoms and mom thought it might be from teething, so she gave him Tylenol which seemed to help.
The next day when he woke up, fussy and again with a fever of 102 degrees, she became worried. She took him to the emergency room. The doctors examined him and found no source for the fever. They felt that no labs were warranted and told mom to continue cooling measures. Jason probably had a virus. Since he had such a normal exam, they told her it could be roseola. Roseola is a virus that virtually all infants get. It causes a high fever that lasts anywhere from 2-5 days. While the infant has the fever, the striking element is the absence of any specific symptoms or physical findings. Then the fever breaks, followed by a viral looking rash. As Jason had the high fever and no physical finding, roseola was a reasonable thought.
Mom went home a bit reassured, but something inside made her uneasy. He seemed fussy, and she just felt there was something wrong. It was that extra sense that mom’s possess. I have come to have the utmost respect for that sense. When a mom tells you that something just isn’t right, you better listen carefully.
Mom brought Jason to me on the fourth day. He did have a fever of 101. Although he had a normal exam I agreed with mom that he just didn’t look right. She told me what had transpired in the ER and we discussed some of the things that were said. First of all, one should NOT get a fever with teething. This is a common myth that has been passed from generation to generation. There is no physiological basis for this. Babies certainly can be fussy, drool, pull at their ears and not want to eat when they teethe, but they should not get a fever.
Roseola was a good thought, but one would not know it until the fever broke and the baby got the rash. It is a diagnosis that is made after the fact. The one thing that could be the cause of the fever was a urinary tract infection (UTI). Unfortunately, there was no way to determine this from a physical exam. We would need to check his urine.
She then asked, “Wouldn’t it be unlikely for him to have urinary tract infection, being a boy? I thought it was mostly in girls.” I commended her for such a thoughtful question and then went on to explain that in the newborn period (the first month of life) urinary tract infections are actually more common in boys. This has to do with certain anatomical issues. From two months until one year of age urinary tract infections occur equally in boys and girls. After one year of age, they occur almost exclusively in females. So the fact that Jason was nine months old and a male did not make a UTI less likely.
We collected a urine sample and did a urinalysis. Sure enough, it showed bacteria, traces of blood and other results that pointed to a UTI. I sent the urine to the lab for a culture, whereby the lab will grow and identify the bacteria. This takes a good 48 hours for the results, so I started Jason on an antibiotic while we waited. I explained to mom that because he had a UTI WITH a fever, his actual diagnosis was pyelonephritis. This means that he had a kidney infection as opposed to a simple bladder infection. Since Jason was taking fluids well and would perk up when the fever would come down, I felt comfortable treating him with an oral antibiotic. But I told mom that it was imperative that I see him the next day.
When she brought him in the next day his fever was down and he looked more like him usual self. I called the lab and the bacteria had already grown after 24 hours. So it was a true infection. By the next day mom said that he was completely back to normal and without any fever. After checking with the lab the bacteria was identified. The tests showed that the bacteria was susceptible to the antibiotic he was on. Jason completed a full 10 days of antibiotics. After this was done, I told mom that we needed to get an ultrasound of the kidneys. We wanted to be sure that the anatomy was normal and that he did in fact have two normal kidneys. I went on to explain that this was the standard of care for any young child with their first UTI. There was nothing different about Jason.
When I saw him a few weeks later for his nine month well visit, mom commented about what an education the whole process was. She had learned about roseola, all about urinary tract infections, and fact that young children should have an ultrasound after a UTI, and the fact that a bladder infection and a kidney infection are not really the same. All this from a simple fever of 101 degrees.