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?

4.

5.

6.

7.

1.

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage • Emergency treatment, if required 2.

History and examination • Laboratory investigations, if required 3.

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 • 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 39.7

0 C axillary. On arrival in the hospital he was lethargic.

Examination

Jone was lying with his eyes closed, but was rousable.

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

• 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: Platelets: WCC: Neutrophils: Lymphocytes: Monocytes: 119 gm/l (125 – 205) 45 x 10 9 /l (150 – 400) 23.4 x 10 9 /l (5.0 – 19.5) 12.78 x 10 9 /l (1.0 – 9.0) 6.06 x 10 9 /l (2.5 – 9.0) 4.81 x 10 9 /l (0.2 – 1.2) Blood sugar: 3.9 mmol/l (3.0 – 8.0) Malaria RDT: negative

Suprapubic aspirate

Urine Protein / Glucose : Nitrate / Leucocyte esterase : Blood: nil 3+ 1+ Microscopy: Red Blood Cells: Leucocytes: 20 x 10

6

/l n(<13) 500 x 10 6 /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