Management Stages for Fever and Joint Pains in Children: Case Study Analysis

1. Chapter 6Fever and joint pains

2. Case study: Mere Mere is an 11 year old girl brought to hospital after 4 days of fever. She has pain in her right knee that is preventing her from walking. Temperature: 38.9°C, pulse: 110/min, RR: 20/min; no cyanosis, capillary refill 1 second, SpO2 93

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

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. 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 • Referral • Malnutrition • Oedema of both feet • Burns

6. History and examination in a child with fever and joint pains • What are key questions to ask on history? (Ref. p. 150) • What are key things to look for on examination? (Ref. p. 150)

7. History • Mere was apparently well until 4 days ago when she developed a fever. She also had a painful left ankle for 2 days. Yesterday, she developed right knee pain with swelling and is now unable to walk. • 2 weeks prior she had a sore throat that was treated by her aunty with a herbal remedy. She has had no rashes, no neck stiffness, no abdominal pain. She is not eating, but drinking OK. • Past history: Mere had a similar episode of sore joints 1 year ago. • Family history / social history: lives in a rural village with her large extended family.

8. Examination • Vital signs • Temp: 38.9ºC Pulse: 145/min RR: 22/min BP 115/65 mmHg, SpO2 95% • Chest and heart • Chest clear, systolic murmur loudest at the apex and radiating to the axilla. No thrill. Apex beat normally placed. • Abdomen • Soft to palpation, normal bowel sounds, no organomegaly • Neurology • AVPU = A (alert), no neck stiffness, pupils equal and reactive • Skin • No rashes • Nutrition • Height: 135 cm Weight: 34 kg → BMI = 34/1.352 = 18.7 • Limbs • Hot and swollen right knee that is very tender to touch • (Ref. p.150, p.154)

9. History and examination in a child with fever • What category of fever is Mere presenting with? • (Ref. p.152) • Fever with no localising signs (no rash) • Fever with localising signs (no rash) • Fever with rash • (Fever lasting longer than 7 days) • Fever plus arthritis

10. Differential diagnoses • Differential diagnoses: Septic arthritis Rheumatic fever Dengue Viral arthritis (reactive, e.g. Chikungunya) Chronic juvenile arthritis (onset) Others… (Tables 16, 17, 19 may be helpful)

11. What investigations would you like to do?

12. Joint aspiration? If septic arthritis is suspected then x-ray and joint aspirate should be done What are the features of septic arthritis? ( Ref p. 186-187)

13. Investigations for acute rheumatic fever FBE ESR – 88 mm/hour ASOT ECG Chest x-ray Joint x-ray Throat swab Echocardiogram

14. Investigations Full blood examination: Haemoglobin: 10.2g/dl (11.5-14.0) Platelets: 450x109/l (150 – 400) WCC: 16.2x109/l (5.5 – 15.5) Neutrophils: 7.9x109/l (1.5 – 8.5) Lymphocytes: 7.0x109/l (2.0 – 8.0) Monocytes: 1.2x109/l (0.1 – 1.0) ESR: 88 mm/hour

15. Diagnosis Summary of findings: • History: 11 year old girl with fever and pains and inflammation in 2 joints (left ankle, resolved and now right knee) • Exam: fever but non-toxic, with right knee swelling, tenderness. A new heart murmur. • Investigations: mild anaemia, mild leukocytosis, elevated ESR • Likely acute rheumatic fever

16. Treatment  Suspected acute rheumatic fever  Aspirin (Ref p. 357) • Benzyl-penicillin G to treat acute Streptococcus infection • Oral penicillin V daily or Benzathine penicillin IM every 28 days as prevention (prophylaxis) (Ref p. 367)

17. Supportive Care • Fever control • Pain control • Bed rest • Nutrition

18. Monitoring • Using a monitoring chart (Ref. p. 320, 413) • Assess response to treatment (Ref .Chart 1 p.xxii; p. 319) • Follow-up results • ASOT 1600 • BC negative • ESR 88 mm/h

20. Discharge planning • Mere responds quickly to the aspirin and her joint pain and fever resolves by 2 days • She is able to walk adequately • She is eating well after 2 days • She has no problems taking her medication • Mere and her parents are educated about rheumatic fever and rheumatic heart disease and given printed information • Mere prefers to receive an IM dose of Benzathine penicillin every 28 days, as she thinks she will forget to take daily penicillin • A clear plan is made for follow-up visit

21. Follow-up • Benzathine penicillin G every 28 days (or daily oral) • Register the patient on the PNG RHD Register • Echocardiogram and paediatric review • Education, advise Mere and her mother when to come back if she has a fever, sore joints, breathlessness or chest pain • Tell Mere when she can return to school and normal activity

22. Diagnosis of acute rheumatic fever WHO Guidelines (Ref 6.11, page 193) Major manifestations • Polyarthritis • Carditis • Chorea • Erythema marginatum • Subcutaneous nodules Minor manifestations • Polyarthralgia • Fever, • Elevated inflammatory markers • Prolonged PR interval on ECG Evidence of Group A Streptococcus infection in the last 45 days • Elevated or rising streptococcal antibody titre (ASOT) • Positive throat swab Two major and one minor Or One major and 2 minor, PLUS Streptococcal infection