Chapter 6 Fever Case I

1. Chapter 6FeverCase I

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

3. What are the stages in the management of Johnny?

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

5. What emergency or priority signs do you notice? Temperature: 39.7ºC, pulse: 185/min, RR: 48/min, SpO2 97%, capillary refill 4 seconds, cold hands and feet

6. 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

7. Does Johnny need emergency treatment?

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

9. Emergency treatment 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)

10. History Johnny is 6 months old, 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 said he felt very hot to touch.

11. Examination Johnny was lying with his eyes closed, not rousable to voice, but rousable on handling. Vital signs: temperature: 39.7ºC, pulse: 185/min, RR: 48/min, capillary refill: 4 seconds; cold hands and feet Weight: 6.9 kg Chest: no chest indrawing, normal air entry both sides Cardiovascular: tachycardia, soft systolic murmur, pulses normal, cold feet and hands Abdomen: soft, bowel sounds present; liver palpable 2 cm below the right costal margin Neurology: lethargic, no neck stiffness, fontanelle normal Mouth: dry, no oral thrush Ears: clear, no discharge Skin: fine red rash on chest, abdomen, arms and face

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

13. What investigations would you do to make a diagnosis?

14. Investigations • Blood glucose • Full blood examination • Blood culture • Urine microscopy (and culture if available) (Ref. p. 185) • “Clean catch” technique • Suprapubic aspirate (Ref. p. 350) • Malaria microscopy or rapid diagnostic test (RDT) • Lumbar puncture if signs suggest meningitis

15. Full Blood examination Haemoglobin: 8.9 g/dL (125 – 205) Platelets: 25 x 109/l (150 – 400) WCC: 19.6 x 109/l (5.0 – 19.5) Neutrophils: 18.0 x 109/l (1.0 – 9.0) Lymphocytes: 1.6 x 109/l (2.5 – 9.0) Blood sugar: 3.9 mmol/L (3.0 – 8.0) Malaria RDT: negative

16. Clean-catch technique

17. Suprapubic aspirate Why might it be dangerous in Johnny? Low platelets and risk of bleeding

18. Urine Protein / Glucose : nil Nitrate / Leucocyte esterase : 3+++ Blood: 2++ Microscopy: Red Blood Cells: 20 x 106/l (n<13) Leucocytes: 520 x 106/l Bacteria seen on microscopy

19. Diagnosis Summary of findings: • Urine examination abnormal • Blood examination shows mild anaemia, high neutrophils, thrombocytopenia (low platelets) • No other signs of focal infections • Urinary tract infection

20. How would you treat Johnny?

21. Treatment (Ref. p. 184) • Ampicillin and gentamicin IV initially, or ceftriaxone • Consider complications of UTI such as pyelonephritis or septicaemia • Give IV antibiotics until fever subsides for 1-2 days and the child improves, then switch to oral antibiotics such as cotrimoxazole

22. What supportive care and monitoring are required?

23. Supportive Care • Fever management (Ref. p. 305) • Fluid management (Ref. p. 304) • Avoid giving too much IV fluids, as high risk of oedema • Encourage regular breastfeeding

24. Monitoring • The infant should be checked by nurses frequently, at least every 2-3 hours at the start, and by doctors at least twice a day • Use a Paediatric monitoring and response chart (Ref. p. 320, 413)

26. Discharge planning Before discharge: • Fever resolved • Feeding well • Completed 3-5 days of IV antibiotics, then tolerating oral antibiotics to complete 7 days total • Investigate for kidney abnormality, which are more common if a child has a UTI • Renal ultrasound if possible • Recheck platelet count to see if thrombocytopenia resolves

27. Summary • Infant with systemic infection due to urinary tract infection • Symptoms and signs often non-specific • Follow the guidelines • Follow-up is important