A longer duration of cough, fever, and leukocytosis increased the likelihood of radiographic pneumonia in these children. The practice of routinely obtaining a chest radiograph has been challenged. Korones et al [61] evaluated 54 children with cancer who were hospitalized for hundreds of episodes of fever and neutropenia. They found an incidence of radiographic pneumonia of only 3% to 6%. The children without respiratory findings had no evidence of pneumonia on chest radiographs, and children who did not have chest radiographs showed no significant outcome differences from those who did. Philips et al [62] confirmed in a meta-analysis the low use of routine chest radiographs in this setting but stated that in those with a predisposition to pneumonia and those not responding to a short empiric course of antibiotics, chest radiographs should be performed despite the absence of clinical signs of a lower respiratory tract infection. Children with neutropenia and FWS often undergo advanced imaging, but there is little evidence-based data about which studies are most efficacious. In their 2002 guidelines (not pediatric specific), the Infectious Diseases Society of America noted that one-half of febrile neutropenic patients with normal chest radiographs will have evidence of pneumonia on chest CT [63]. Archibald et al [36] evaluated the performance of CT in 83 neutropenic pediatric cancer patients who had 109 instances of fever lasting 4 days or more. Rates of positive CT findings varied by body region: head and neck, 8%; paranasal sinus, 41%; chest, 49%; and abdomen, 19%. Findings on paranasal sinus and chest CT led to changes in therapy in 24% and 30% of cases, respectively. However, they added that CT was rarely abnormal in the absence of localizing signs or symptoms and that in the absence of symptoms, CT findings rarely lead to therapeutic changes.
Fever Without Source or Unknown Origin Child. A longer duration of cough, fever, and leukocytosis increased the likelihood of radiographic pneumonia in these children. The practice of routinely obtaining a chest radiograph has been challenged. Korones et al [61] evaluated 54 children with cancer who were hospitalized for hundreds of episodes of fever and neutropenia. They found an incidence of radiographic pneumonia of only 3% to 6%. The children without respiratory findings had no evidence of pneumonia on chest radiographs, and children who did not have chest radiographs showed no significant outcome differences from those who did. Philips et al [62] confirmed in a meta-analysis the low use of routine chest radiographs in this setting but stated that in those with a predisposition to pneumonia and those not responding to a short empiric course of antibiotics, chest radiographs should be performed despite the absence of clinical signs of a lower respiratory tract infection. Children with neutropenia and FWS often undergo advanced imaging, but there is little evidence-based data about which studies are most efficacious. In their 2002 guidelines (not pediatric specific), the Infectious Diseases Society of America noted that one-half of febrile neutropenic patients with normal chest radiographs will have evidence of pneumonia on chest CT [63]. Archibald et al [36] evaluated the performance of CT in 83 neutropenic pediatric cancer patients who had 109 instances of fever lasting 4 days or more. Rates of positive CT findings varied by body region: head and neck, 8%; paranasal sinus, 41%; chest, 49%; and abdomen, 19%. Findings on paranasal sinus and chest CT led to changes in therapy in 24% and 30% of cases, respectively. However, they added that CT was rarely abnormal in the absence of localizing signs or symptoms and that in the absence of symptoms, CT findings rarely lead to therapeutic changes.