WK 3 CASE 1

The differential diagnosis for Henry’s presentation is still very wide.

Vascular - Collagen vascular disorders such as Systemic Lupus Erythematosus and Juvenile Idiopathic Arthritis and other systemic vasculitis disorders such as Kawasaki’s disease can cause high fevers in childhood.

Infective/Inflammatory - The most common cause of fever in a child is infection, although you would be unable to certain at that stage if its cause is bacterial, viral, fungal or parasitic. The height of the fever is often not helpful in determining the cause. The symptoms so far are very non-specific and the source of possible infection needs to be searched for. It could be anywhere – a thorough head to toe examination is needed. Inflammatory disorders, like Inflammatory Bowel Disease can be associated with fevers although this would be very unusual in a child of Henry’s age.

Traumatic – unlikely to cause a fever unless secondary infection from a wound but can rarely follow significant head trauma particularly if damage to the hypothalamus occurs.

Autoimmune – Several autoimmune/autoinflammatory disorders can present with fever including JIA and periodic fever syndromes.

Metabolic – Rarely a metabolic disorder may cause fever eg acute porphyria but this would be exceedingly rare in Henry’s age group.

Iatrogenic/Idiopathic – Drug reactions can cause fever and are often, but not always, associated with other symptoms such as rash. Certain drugs can cause malignant hyperthermia and in a toddler accidental ingestion of toxic substances should always be considered, particularly if there is altered conscious level or other associated features.

Neoplastic – Certain malignancies may cause a fever for example lymphoma and leukaemia.

Congenital – rarely some children with developmental brain abnormalities e.g agenesis of the corpus callosum, can develop intermittent high fevers, likely through hypothalamic dysfunction.

Degenerative –less likely to cause fever but children with degenerative or neuromuscular conditions are often more prone to infections

Endocrine/Environmental – rarely infants with diabetes insipidus may present with fever, poor growth and unsettled behaviour.

Functional - factitious fever can occur

Remember, febrile illness can also cause decompensation in other conditions, for example, metabolic disorders, diabetes and hypopituitarism which may cause a child to have altered behaviour alongside a febrile illness.

By far the most likely cause is infective, but we need more information!

·          Viral Gastroenteritis

.Correct answer.

This is a common cause of fever and vomiting in preschool children.

·          Acute lymphoblastic leukaemia

·          Intussusception

.This is unlikely. It may present with abdominal pain, vomiting, listlessness and can be associated with fever. Abdominal examination would be important.   

·          Urinary tract infection

.This is possible.

·          Meningitis

.It would be very important to consider this as it can present non-specifically in children of his age.

·          Septicaemia

.It would be very important to consider this as it can present non-specifically in children of his age.

·          Kawasaki's disease

.This is unlikely given the duration of the fever and the associated symptoms. Kawasaki’s is a rare condition, mainly affecting children under 5 years, which typically causes a fever lasting more than 5 days, which is often high and unresponsive to antipyretics and antibiotics, accompanied by 4 out of 5 findings: cervical lymphadenopathy, bilateral non-purulent conjunctival injection, mucosal changes e.g. strawberry tongue/red cracked lips, red rash, and peripheral skin changes such as redness or oedema of the hands/feet. 2-3 weeks later the skin on the hands and feet may peel.

Children with this condition are often very miserable. Other causes of similar rash and symptoms should be excluded eg Toxic Shock Syndrome, Staph scalded skin, Scarlet fever, measles and Juvenile Idiopathic Arthritis. Kawasaki’s should always be considered in a child with a fever lasting more than 5 days but can be diagnosed before that time if clinical features are strongly suggestive. 

·          Meningitis

.Correct answer.

He sounds very unwell. He has a high fever, looks pale and may have an altered conscious level. You would be worried that he has a serious infection. His altered conscious level could be due to CNS infection and increased intracranial pressure or organ (brain) dysfunction due to possible sepsis or metabolic disturbance e.g. hypoglycaemia.

·          Septicaemia

.Correct answer.

He sounds very unwell. He has a high fever, looks pale and may have an altered conscious level. You would be worried that he has a serious infection. His altered conscious level could be due to CNS infection and increased intracranial pressure or organ (brain) dysfunction due to possible sepsis or metabolic disturbance e.g. hypoglycaemia.

You need to look for clues to the source of the fever.

CNS – do bright lights seem to distress him? Is he moving normally? Is he irritable/unsettled? Do you think he has pain anywhere? Is his cry normal for him or high pitched?

Often signs of meningitis are very non-specific in babies and young children as well as early in the disease – as the disease progresses more specific features may start to appear. In Henry’s case he is starting to become less responsive and doesn’t want to be handled even by mum.

ENT – has he been pulling at his ears or having difficulty or pain on swallowing? Has he still got nasal discharge? These may give a clue to an Upper respiratory tract infection eg Otitis media, Tonsillitis.

Respiratory – does he have a cough or any noisy breathing eg stridor or wheeze? Is he struggling to breathe? These may give a clue to a lower respiratory tract infection.

Abdominal – has he had any abdominal pains, distension, diarrhoea, blood/mucus in the stool? These may suggest an intra-abdominal/GI cause such as appendicitis/abscess (pain, vomiting, fever) or intussusception (pain, vomiting, blood/mucus in stool), Pyelonephritis (pain, vomiting

Urinary – is he passing urine? Is it smelly or discoloured? Does he seem to have pain on passing urine.

General – has mum noticed a rash? Is he his normal complexion? How much fluid/diet has he managed to tolerate in the last 12-24 hours?

Joints/Bone – has mum noticed any joint swelling, redness, pain or reduced movement. Could this be sepsis associated with osteomyelitis/septic arthritis ? Some children with sepsis have limb pain

This list in non-exhaustive. It is important when seeing an unwell child to take a focused history and to ensure that it does not delay any necessary investigations and treatment. In a seriously unwell child, an ABCDE approach will be performed and urgent interventions performed whilst at the same time taking a history and examining the child.

Probably not. You would monitor the rash and continue to review him regularly, noting any change.

You would want to know more about Henry and in particular any risk factors that may make a particular diagnosis more likely and also any information that may affect how you manage him. For example, it is essential to know if he has any drug allergies before prescribing any medications. At this stage your history needs to be focused –you may go back later to explore more detail when you have decided he is clinically stable.

Past medical history:

Has Henry had any other significant illnesses or infections? Previous atypical infections or frequent severe infections might raise the suspicion of an immune disorder. Is he known to have a condition that would increase his risk of infection eg sickle cell disease?

Mum tells you that other than the usual coughs and colds he has been a very well little boy.

This is his first time in hospital and he rarely sees his GP.

Medication history:

Does he take any regular medication? It is important to ensure there are no contraindications or potential interaction with a medicine you may prescribe. When were his last doses of Paracetamol and Ibuprofen given? And how many in the past 24 hours? Does he have any allergies? Remember some medications can cause immunocompromise eg high dose steroids.

Henry is taking no regular medications and has no known drug allergies. He last had Paracetamol 5 hours ago (he has had 3 doses in the last 24 hours) and Ibuprofen was given 2 hours ago (he has had 3 doses in the last 24 hours).

Immunisations: 

Are his immunisations up to date? Immunisations will help to protect him against several of the pathogens involved in serious infections and knowing what he is immunized against may help you to narrow the source. However, no vaccination is 100% effective.

Mum tells you that Henry is up to date with his immunisations except for his 12 months immunisations as he was unwell with a fever and cold and mum hasn’t rearranged them yet. She was also a little worried about the side-effects of the MMR and has kept putting it off.

You can remind yourself of the UK immunisation schedule here:

The complete routine immunisation schedule - Public Health England 

·          Group B haemolytic Streptococcus

.Correct answer.

Vaccination against Group B Streptococcus is not part of the routine immunisation schedule in the UK.

·          E. Coli

.Correct answer.

Vaccination against E. Coli is not part of the routine immunisation schedule in the UK.

Respiratory rate: 44 = 1

Oxygen requirement: 97% in air = 0

Pulse rate: 166 = 1

Blood pressure: 84/56 = 0

Capillary refill time: 2 seconds = 0

Conscious level: Responds to voice = 2

TOTAL SCORE = 4

Henry is scoring RED and he needs an urgent review and management plan.

·          Consider prescribing Paracetamol to make him more comfortable and ease his pain.

.Correct answer.

·          Inform a senior colleague

.Correct answer.

·          Give him Paracetamol and Ibuprofen to reduce his fever

·          Perform a rapid ABCDE assessment and examine Henry

.Correct answer.

·          Give him intramuscular Benzylpenicillin immediately

A child who looks unwell to a parent or health care professional, who has altered conscious level and who is pale would raise red flags for possible sepsis/serious illness.

He is sitting very still, perhaps suggesting he doesn’t like to be moved. This may represent pain on movement and the site of this should be sought. Children with meningitis may have neck stiffness. This sign may be absent in younger children and babies or only seen in the later stages of the illness. Henry has reduced responsiveness and when he does respond it is with altered response of a whimper. Both of these signs may suggest meningitis as the cause of Henry’s illness.

In any child with fever, serious bacterial infection should always be considered. In a young child with fever, lethargy, poor feeding +/- vomiting and altered alertness meningitis should always be considered.

·          18-24 months

.Correct answer.

The anterior fontanelle usually closes at around 18-24 months.

·          24-30 months

Probably not. Henry is breathing a little faster than normal for his age. He has no other signs of increased effort of breathing and his efficacy seems good. There were no focal chest signs to suggest a chest infection but these can sometimes be absent in young children. If a source of infection is not clear after examination you may consider performing a Chest X-ray as part of a Septic Screen His tachypnoea may be due to his fever but other causes might include metabolic disturbance e..g lactic acidosis, respiratory compromise due to sepsis, toxins.

1.    Tachycardia

2.    Pallor

3.    Cool Peripheries

4.    Possible reduced urine output

The signs need to be reviewed in combination and considered as part of the whole picture. Prolonged CRT taken on its own is not a sensitive marker of serious illness but when taken alongside other concerning features raises this suspicion.

·          Yes

.Correct answer.

 Meningitis

.Correct answer.

Henry’s constellation of symptoms and signs would raise suspicion for serious illness and you would be particularly concerned about Meningitis +/- septicaemia being the cause. He does not at present have the classical features of  septicaemia but you would closely monitor him with at least hourly observations.

B, C, D, I, E, F/A, H

You should call for senior help and give high flow Oxygen if tolerated as he is triggering red for sepsis. In sepsis there is a relative hypovolaemia. Therefore the amount of oxygen that is delivered to the tissues is less than the normal. Oxygen demand may also be higher. By providing supplementary oxygen (even if saturations are normal), oxygen delivery in improved.

You should then obtain intravenous access and take bloods for FBC, blood gas with lactate, biochemistry profile, CRP and Blood culture. A lactate >4mmol/l would heighten your concern of sepsis. You would also want to check bloods for renal profile, liver function, glucose and clotting if adequate blood is obtained. In sepsis these may be deranged. In severe sepsis you should not delay antibiotics for blood cultures, LP and urine culture. However in Henry’s case, he is currently stable for further investigations. He should be closely monitored and if he deteriorates antibiotics should be given immediately.

LP should be performed unless clinically contraindicated. LP should not delay the administration of antibiotics. It can be delayed if necessary and CSF taken up to 72h can still yield useful clinical information.

You may want to prescribe an antipyretic as mum feels that Henry is uncomfortable.

You may want to obtain a urine sample if the source of infection is unclear in a febrile child. Bag specimens should not be used as have a high false-positive yield. Either a clean catch sample or an in-out catheter sample or even a suprapubic aspiration sample in a severely unwell child.

If bacterial meningitis is suspected you should start empirical antibiotics. This will be discussed later. 

·          All of the above

.Correct answer.

Please note: A blood glucose or BM should be obtained prior to the LP to allow CSF:blood glucose ratio

·          Commence intravenous antibiotics immediately

.Correct answer.

You strongly suspect that Henry has meningitis and should not delay in commencing appropriate intravenous antibiotics. If performing the Lumbar puncture were to cause a delay in starting treatment the lumbar puncture should be deferred. Useful results can be obtained up to 72-96h after starting antibiotics.

·          Intravenous Cefotaxime and Amoxicillin

·          Intravenous Ceftriaxone and Ampicillin

·          Intravenous Erythromycin

.Intravenous Erythromycin may be given in cases of penicillin allergy.

·          Intramuscular Benzylpenicillin

.Intramuscular or intravenous Benzylpenicillin may be given pre-hospital for suspected bacterial meningitis if urgent transfer to hospital is not possible. It should be given pre-hospital, at the earliest opportunity, if a child has suspected meningococcal septicaemia.

·          Intravenous Ceftriaxone

.Correct answer.

A child over 3 months with suspected Meningitis should be treated with Intravenous Ceftriaxone at a dose of 80mg/kg once daily.

Remember it is important that Ceftriaxone is not administered at the same time as Calcium containing infusions. In this situation, Cefotaxime should be used instead.

An infant under 3 months with suspected meningitis should be treated with intravenous Cefotaxime with either Amoxicillin or Ampicillin (Listeria cover).

 Streptococcus pneumoniae meningitis is the most likely diagnosis

.Correct answer.

High polymorph (neutrophil count) and low glucose are in keeping with bacterial meningitis. Streptococcus Pneumoniae is a gram positive coccus.

·          Children with facial cellulitis, periorbital cellulitis, sinusitis, and septic arthritis.

.Correct answer.

·          Attendance at day care/crowding

.Correct answer.

·          Having pets at home

.Pets are not known to increase the risk of meningitis.

·          Maternal infection and pyrexia at the time of delivery

.Correct answer.

·          Asplenia

.Correct answer.

·          Basal skull fracture

.Correct answer.

·          Low family income

.Correct answer.

·          Age group 5-10 years

.Two spikes of incidence are seen in childhood. One in infancy/neonatal period (peak incidence 3-8 months) and the other in adolescence.

·          Do not give Dexamethasone if under 3 months of age

·          Give Dexamethasone if CSF white cell count is >1000

·          Do not start Dexamethsone, even if indicated, if it is more than 12hours after the first dose of antibiotics.

·          Ideally give Dexamethasone after the second dose of antibiotics

.Correct answer.

Dexamethasone, given as an adjunct to antibiotics, is thought to reduce the incidence of neurological and audiological complications in bacterial meningitis. If indicated, it should ideally be given before or with the first dose of antibiotics. If more than 12 hours has lapsed from first antibiotic dose, Dexamethasone should not be started. When indicated, and after discussion with a senior clinician, it is usually given 4 times daily for 2-4 days.

Indications for Dexamethasone in suspected/confirmed Meningitis include:

- Frankly purulent pus

- CSF wcc > 1000/microlitre

- Raised CSF wcc with CSF Protein > 1g/l

- Bacteria on Gram stain

·          If indicated, give Dexamethsone 0.15mg/kg four times daily for 4 days

·          Give Dexamethasone immediately if frankly purulent CSF on LP and within 12 hours of antibiotics commencing

·          Give Dexamethasone if Gram stam is positive, or white cells raised with a Protein of >1g/l

Yes as early as possible– invasive Pneumococcal infection is a notifiable disease.

Have a quick look at Public Health England’s policy for notifiable disease in children via this link and see how to make sure the referral is made.

· Notifiable disease in children information - Public Health England

·          Chronic steroid dependency

.Correct answer.

Any cause of immunosuppression, including iatrogenic from steroids, increases the risk of infection to a child.

·          Congenital heart disease

.Correct answer.

Children with congenital heart disease have an increased risk of respiratory infections.

·          Coeliac disease

·          Sickle cell disease

.Correct answer.

Those with sickle cell disease have a functional asplenia due to sequestration of sickle cells within the spleen and subsequent fibrosis. This leads to increased susceptibility to capsulated organisms, in particular Haemophilus influenza and Pneumococcus amongst others.

·          Burns patient

.Correct answer.

Significant burns injuries induce a state of immunosuppression and therefore increased risk of infection, not only of the wound but commonly also respiratory and sepsis.

·          Neonate

.Correct answer.

Neonates have an immature immune system and hence are more susceptible to infection.

Identify the anterior superior iliac crests and draw an imaginary line between them. In the midline of this line is the L5 vertebrae. The space is just above.

· Child is too unstable

·   Signs of shock or

·   Respiratory insufficiency

· Symptoms or signs suggestive of raised intracranial pressure:

·   reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)

·   relative bradycardia and hypertension

·   focal neurological signs

·   abnormal posture or posturing

·   unequal, dilated or poorly responsive pupils

·   papilloedema

·   abnormal ‘doll’s eye’ movements

· Suspected intracranial mass e.g. brain tumour

· After convulsions until stabilised

· Extensive or spreading purpuric rash

· Bleeding disorder

·   Low platelets (<100x109/L)

·   On anticoagulants

·   Known clotting abnormality

· Local infection at site of LP

·          It has a wide differential diagnosis and can be diagnostically challenging.

·          It is one of the most common reasons for children to present acutely to a health care practitioner.

·          Requires appropriate and timely assessment in order to recognise the seriously unwell febrile child.

·          The fever itself is part of the immune response to infection and does not need to be treated unless thought to be causing discomfort to the child.

·          It is most commonly associated with a serious bacterial infection.

·          Appears unwell to parent or to healthcare professional

.Correct answer.

·          For every hour delay in giving antibiotics in severe sepsis mortality rises by 15%.

.Correct answer.

·          Living in crowded accommodation is a risk factor for meningitis.

.Correct answer.

·          Dexamethasone should be given to all children with suspected Meningitis with or soon after the first dose of antibiotics.

.Correct answer.