A 6-year-old male with daily fever accompanied by nausea and abdominal pain.

A6-year-old boy was well until 7 weeks prior to admission at the Ann & Robert H. Lurie Children’s Hospital of Chicago, when he developed daily fever accompanied by nausea, abdominal pain, phonophobia, and photophobia. He was admitted to an outside hospital where an abdominal X-ray was notable for heavy stool burden. He underwent an intestinal “clean out,” which resulted in improved abdominal pain, and he was discharged home. Because of persistent headaches, nausea, and fever, he was treated with valproic acid with only mild initial improvement. There was no history of rash, arthritis, conjunctivitis, diarrhea, or other symptoms. Family history was negative. The patient’s family lives in rural central Illinois. There is one dog at home. There is no significant travel history, although they do have a neighbor who travels occasionally to Macedonia. Two months previously, the patient visited a friend’s farm where he fed horses and was in contact with cows and chickens. The patient’s medical history is interesting in that he had an episode of Epstein-Barr virus (EBV)-associated infectious mononucleosis 9 months earlier that was characterized by fever, fatigue, enlarged cervical lymphadenopathy, and splenic enlargement. His evaluation prior to transfer included hemoglobin of 11.5 g/dL, white blood cell count of 9,800/mm3 with 59% neutrophils and 34% lymphocytes, and platelet count of 439,000/ mm3. C-reactive protein and erythrocyte sedimentation rate were normal. Serum chemistries, hepatic transaminases, and pancreatic enzyme levels were normal. Respiratory viral panel and two blood cultures were negative. Antinuclear antibodies were present at level of 1:320. EBV viral capsid antigen (VCA)-immunoglobulin (Ig) M, and EBV VCA-IgG, and EBV nuclear antigen (EBNA) antibodies were all positive. Growth parameters and physical examination were entirely normal. Robert Listernick, MD, moderator: Let’s start out interpreting the EBV serology. Anne Rowley, MD, pediatric infectious disease physician: Most of the time, simply ordering EBV-IgM and EBV-IgG VCA is sufficient for diagnosis. Both may be positive at the start of symptoms; IgM usually wanes after 3 months. EBNA antibodies usually don’t become positive for 6 to 12 weeks following onset of symptoms; their presence generally signifies past infection. EBNA antibodies remain present for life. Julie Stamos, MD, pediatric infectious disease physician: I agree, although I’ve seen the EBV-IgM remain positive for as long as 6 months. Overall, I believe that these results are most consistent with his history of past infection. Dr. Listernick: He has a true fever of unknown origin (FUO). How should we proceed? Robert Tanz, MD, academic general pediatrician: Most importantly, he needs a thorough history and physical examination. Specific questions to be asked include a history of various exposures, such as tuberculosis (foreign travelers, inmates, homeless shelters, family members with chronic cough, etc), foreign travel (both the patient’s travel history as well as exposure to foreign travelers), animals, and raw/unpasteurized milk or meat. Dr. Listernick: What would be your initial evaluation? Dr. Tanz: If the history or physical examination pointed to a specific diagnosis, I first would home in on that specific test. If not, a more genA 6-Year-Old Male with Daily Fever Accompanied by Nausea and Abdominal Pain