ACR Appropriateness Criteria Fever Without Source or Unknown Origin—Child

Sjirk J. Westra*, Boaz K. Karmazyn, Adina L. Alazraki, Molly E. Dempsey, Jonathan R. Dillman, Matthew Garber, Sheila G. Moore, Molly E. Raske, Henry E. Rice, Cynthia K. Rigsby, Nabile Safdar, Stephen F. Simoneaux, Peter J. Strouse, Andrew T. Trout, Sandra L. Wootton-Gorges, Brian D. Coley

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


The cause of fever in a child can often be determined from history, physical examination, and laboratory tests; infections account for the majority of cases. Yet in 20%, no apparent cause can be found, designated as fever without source (FWS). The yield of chest radiography in children with FWS is low, and it is usually not appropriate. However, in children with respiratory signs, high fever (>39°C), or marked leukocytosis (≥20,000/mm3), chest radiography is usually appropriate, as it has a higher yield in detecting clinically occult pneumonia. In newborns with FWS, there is higher risk for serious bacterial infection, and the routine use of chest radiography is controversial. In children with neutropenia, fever is a major concern. In some clinical circumstances, such as after hematopoietic stem cell transplantation, chest CT scan may be appropriate even if the results of chest radiography are negative or nonspecific, as it has higher sensitivity and can demonstrate specific findings (such as lung nodule and “halo sign”) that can guide management. In a child with prolonged fever of unknown origin despite extensive medical workup (fever of unknown origin), diagnosis is usually dependent on clinical and laboratory studies, and imaging tests have low yield. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Original languageEnglish (US)
Pages (from-to)922-930
Number of pages9
JournalJournal of the American College of Radiology
Issue number8
StatePublished - Aug 1 2016


  • Appropriateness Criteria
  • fever of unknown origin
  • fever without source
  • infants and children imaging
  • occult pneumonia
  • sepsis workup

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging


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