Chapter 6 Fever Case I

Case study: Baby Jone Baby Jone is a 6 month old boy, brought to hospital with a two day history of fever, lethargy and decreased feeding

What are the stages in the management of Jone?

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage Emergency treatment, if required History and examination Laboratory investigations, if required Differential diagnoses Main diagnosis Treatment Supportive care Monitoring Plan discharge Follow-up, if required

What emergency (danger) and priority (important) signs do you notice from the picture? Temperature: 39.7ºC, pulse: 170/min, RR: 30/min, capillary refill 4 seconds. Cold hands and feet

Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

What emergency treatment does Jone need?

Emergency treatment □ Blood sugar Airway management? Oxygen? Intravenous fluids? Anticonvulsants? Immediate investigations? □ Blood sugar (Ref. Chart 2 p. 5-6)

Emergency treatment (continued) Because of tachycardia, poor perfusion and cold extremities insert intravenous drip and give 20 ml/kg Ringer’s lactate or normal saline solution (Ref. Chart 7, p. 13)

Give emergency treatment until the patient is stable

History Baby Jone is a 6 month old boy, who was brought to the hospital with a two day history of fever, lethargy and decreased feeding. He had not been drinking well for about 2 days. He had vomited several times each day. His mother had taken his temperature and this registered 39.70C axillary. On arrival in the hospital he was lethargic.

Examination Jone was lying with his eyes closed, but was rousable. Vital signs: temperature: 39.7ºC, pulse: 170/min, RR: 30/min, capillary refill: 4 seconds; cold hands and feet Weight: 7.0 kg Chest: normal air entry both sides Cardiovascular: both heart sounds were audible and there was no murmur Abdominal examination: soft, bowel sounds were present; liver was palpable 1 cm below the right costal margin Neurology: lethargic, no neck stiffness, fontanelle normal Mouth: slightly dry, no oral thrush Ears: clear, no discharge Skin: fine rash on trunk, arms and face

Differential diagnoses List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 151)

Additional questions on history Duration of fever Feeding pattern / vomiting Conscious state – irritable / lethargic Immunization history Infectious contacts Malaria endemic area

Further examination based on differential diagnoses Look for signs of serious bacterial infection: Chest indrawing Rash / skin sepsis Stiff neck / fontanelle normal or bulging Ear-Nose-Throat examination

What investigations would you like to do to make your diagnosis ?

Investigations □ Discuss expected findings from investigations Blood glucose Urine microscopy (and culture if available) (Ref. p. 185) “Clean catch” technique Supra-Pubic Aspirate (Ref. p. 350) Malaria microscopy of rapid diagnostic test (RDT) Lumbar puncture if signs suggest meningitis Blood culture if possible □ Discuss expected findings from investigations

Full Blood examination Haemoglobin: 119 gm/l (125 – 205) Platelets: 45 x 109/l (150 – 400) WCC: 23.4 x 109/l (5.0 – 19.5) Neutrophils: 12.78 x 109/l (1.0 – 9.0) Lymphocytes: 6.06 x 109/l (2.5 – 9.0) Monocytes: 4.81 x 109/l (0.2 – 1.2) Blood sugar: 3.9 mmol/l (3.0 – 8.0) Malaria RDT: negative

Suprapubic aspirate

Urine Protein / Glucose : nil Nitrate / Leucocyte esterase : 3+ Blood: 1+ Microscopy: Red Blood Cells: 20 x 106/l n(<13) Leucocytes: 500 x 106/l

Diagnosis Summary of findings: Urine examination abnormal Blood examination shows mild anaemia, mild neutrophilia with significant left shift, thrombocytopenia No other signs of focal infections Urinary tract infection/Urosepsis

How would you treat Jone?

Treatment (Ref. p. 184) Ampicillin and gentamicin IV/ IM initially or a third generation cephalosporin, such as ceftriaxone. Consider complications such as pyelonephritis or septicaemia Give parenteral treatment until fever subsides and/or urine culture results improve; switch then to an appropriate oral antibiotic Depending on local sensitivity patterns different drug regime may be chosen

What supportive care and monitoring are required?

Supportive Care Fever management (Ref. p. 305) Nutritional management (Ref. 298-299) Fluid management (Ref. p. 304) Give initially IV fluids because of signs of shock, but then reduce the rate Encourage regular breastfeeding

Monitoring The infant should be checked by nurses frequently (at least every 3 hours) and by doctors at least twice a day Use a Monitoring chart (Ref. p. 320, 413)

Follow up Investigate for renal abnormality Renal ultrasound if possible Recheck platelet count to see if thrombocytopenia resolves Watch for progression or resolution of petechial rash

Summary Infant with systemic infection due to urinary tract infection Symptoms and signs often non-specific Importance of good history and examination, screening investigations Management of early shock, antibiotics, ongoing fluids Frequent monitoring Follow-up