A child with high fever and pain J C Mulder Rotary Doctors Nederland 8 januari 2014

WHO IMCI Assess and classify the sick child Treat the child - 2 months-5 years Aim: reduction morbidity and mortality

WHO triage systeem: ETAT (Emergency Triage and Treatment) 1 emergency 2 priority 3 nonurgent (compare APLS)

Children High fever and pain What to do in a setting with limited lab facilities, X-ray, CT and MRI access and no consultants/referral possibilities

Case 1 History: Peter 3 years of age, since 3 days a cold. Tonight suddenly more ill with high fever of 40º C. Grasping right ear. Refuses to drink. Examination: An ill looking child, tilted head, non- coöperative. Right ear stands away. You are not allowed to touch it. 1. What else do you want to know? 2. What do you examine? 3. What is your dd? 4. What is your action?

Mastoiditis Status after otitis media acuta Ear stands away/ pitting oedema behind ear Pain and high fever Admission! to hospital Lab.; OR? Depends on age and duration and facilities (Surgeon ENT experience) When full mastoidectomy is feared,make abscess incision antibiotics i.v. Start 1st dose orally! WHO:Chloramphenicol and benzylpenicillin 10 days Pain relief: paracetamol Complications: extradural abscess, meningitis, brain- abscess, facial nerve paralysis, sinus trombosis

OMA Otitis Media Acuta Pain!!! Paracetamol Paracentesis? Causes: Pneumococ, Haem. Infl. En Moraxella C. Meestal spontane perforatie< 48 uur Antibiotics (?) : Amoxicilline 7 days or cotrimoxazole Chronic ear infection/ cholesteatoom: attico- antrotomia (chronic mastoiditis)-ENT DD otitis externa

Tonsillitis (NTVG 4 januari) Volwassenen: complicaties moeilijk voorspelbaar: peritonsillair absces, otitis media, sinusitis, huidinfectie-(late Streptococ A complicaties: Scarlet fever, PSGNefritis, acuut rheuma.) Direct voorgeschreven AB verlagen kans daarop niet (Britse h.a. studie 600 pr.) Meer kans op Strept. A bij: koorts, purulente tonsillen, halsklieren, pijn Veelal virale oorzaak DD M. Pfeiffer Hoe te handelen bij kinderen in de tropen? Smal spectrum penicilline 3-6 dagen

Epiglottitis High temperature Haemophilus influenzae - vaccination Inspiratory stridor ++ Inspection throat on OR with pediatrician, ENT specialist and anaesthesiologist Often need for intubation and PICU - Alternative: tracheostomia Dd pseudocroup (laryngitis subglottica): less ill;lower temperature Antibiotics

Acute lymfadenitis colli Snel ontstaan Hoge koorts Cave abscedering: fluctuatie? Evt. echo - Evt. incisie en drainage Amoxicilline/clavulaanzuur ivm naast GAS ook SAureus

Ethmoiditis Upper respiratory tract infection Ill looking/in pain Red eye or chemosis Oedema of the orbita Always admission X ray and lab I.V. a.b.Start 1st dose orally! Sometimes OR Complication: sinus-trombosis

Case 2 Sabine, 9 years of age refuses to walk because of a painful right knee+ upper leg. T.: 39º5 C - 1 What do you want to know - 2 What do you examine - 3 What is your dd - 4 What is your action?

Artritis≠ artralgia Cave septic artritis: always admission for proper diagnosis and treatment Dd osteomyelitis in young children especially Acuut Rheumatic Fever PSRA JIA trauma

Septic artritis 1 ( pyogenic bacteria) Clinical Features: - Mostly knee or hip(80%): Why? - Unilateral - High fever and pain: Site/Age/Agent dependant - Poly-articular: neonates: Why? Examination:Hip: - Flexed leg/abduction/exorotation - Pain on passive movement/refusal to walk - Artritis hip can present with kneepain! Signs of inflammation: - red, hot, painful, swollen and loss of function

Septic artritis 2 Causative agents: - Staph.Aureus and strept.A - N.gon. (adolescents) - Strep.B and gram – bact. In neonates

Septic artritis 3 Management No delay ( hip catastrophic ) Always joint aspiration: synovial fluid: gram/WBC/culture Start iv antibiotics (tropics: chloramphenicol) X ray? Ultrasonography? Lab.: ESR,CRP,CBC c. diff.,Culture, ASO-titer Follow up temperature and CRP or ESR

Osteomyelitis Acute/subacute/chronic - Extremities: 70% tibia, femur, and humerus Hematogenous in children - Site of entry/local invasion Clinical features: - age related pain and immobility - the younger, the more signs on P/E: cellulitis Causes: 20-50% culture negative! - S.Aureus ( beware of MRSA)> 3years - Strep.B(infants) Strep.A /S. Pneum.and Hib(in toddlers) - Salmonella(sickle cell disease) Lab.: High WBC, ESR and CRP: follow up X-ray?

Osteomyelitis treatment Depending on age and causative agent: In general < 3 years chloramphenicol > 3years cloxacillin or flucloxacillin or clindamycine older children (or chloramphenicol) Africa: chloramphenicol <3 y or sickle cell Duration 3 weeks minimum Switch from I>V to oral depending on clinical course(pain and fever) and lab CRP Chronic o.: surgery Cave TB

Acute Rheumatic Fever w after strep.A tonsillo-pharyngitis Age 5-15 years preferrably Clinical diagnosis Jones criteria:2+1 or Major: 1.migratory artritis 2. pancarditis (leading to valvular damage and CHF) 3. cns involvement(Chorea) 4. erythema marginatum 5. s.c. nodules Minor:arthralgia, fever, elevated ESR and CRP, prolonged PR interval Lab.: ESR CRP ASO Recurrent disease not easy to establish Complications RHD f.e. Mitral regurgitation

ARF 2 DD: also PSRA - Shorter interval to throat infection - Mostly one joint - Less ill - No reaction to aspirin - No cardiac symptoms - Don’t meet Jones Criteria Management of ARF: - Eradicate streptococcal infection - Aspirin for 2 weeks - Prednisolone in case of carditis (then postpone aspirin) - ECG - Joint aspiration when fluid is present: sterile

Myocarditis High fever, acute onset Viral: many different viruses/part of ARF Tachypneua, increased respiratory efforts Tachycardia Dilated heart on chest Xray Congestive Heart Failure DD cardiomyopathy, sometimes very difficult to distinguish Treatment supportive

Case 3 Boy, 7 years, since 2d pain right lower abdomen,slight fever, nausea,vomiting. After 2d more abdominal pain, fever 39.5C. O/E sick boy, knees up. Defense musculaire right lower abdomen pain on palpation Laparoscopy: perforated appendix! Patient delay!

Peritonitis Primaire peritonitis: complicatie GAS - DD o.a. Typhus - Cave bij Nefrotisch Syndrome: Staph. Aureus Th./ breed spectrum antibiotica Secundair: Appendicitis- perforatie - Buikpijn, percussiepijn en défense Th./ chirurgie

Brucellosis Persistent or relapsing fever (Malaria -) Malaise Musculoskeletal pain Lower backache Splenomegaly Anaemia History of drinking unboiled milk Low wbc PCR Serology Elisa Culture R./ adults: doxycycline + 1 week gentamycine i.m. children: cotrimoxazole with gentamycine 1 w or rifampicine 6-8 weeks

Urgent illnesses with high fever in children Meningitis-Encephalitis-Mastoiditis-Ethmoiditis-URTI Sepsis - Meningococcal - Urosepsis after pyelonefritis - NTSS Pneumonia: pleural effusion Peritonitis NS Malaria! Septic Artritis - Rheumatic Fever Osteomyelitis sickle cell! Epiglottitis Typhoid Fever Myocarditis Pyomyositis Brucellosis