by Mordechai Raskas, Children's National
with Jennifer Anders, Johns Hopkins
The Case
6 month-old male was seen yesterday and diagnosed with a URI, discharged with instructions for supportive care and return precautions, and now presents again with his grandmother who is concerned for 2-3 days persistent fever and cough. Per report he had a temperature of 106.2 two days ago, 102.5 yesterday, and 102.8 today. In addition to cough, grandmother also notes 1 day of runny nose, bilateral eye discharge, non-pruritic rash on his arms and legs. Today PO intake has dropped sharply, 1 episode of emesis of milk only, and only 2 wet diapers in the past 18 hours with an orange coloring noted on the diaper with the urine.
PMH: eczema
PSH: circumcision
Immunizations up to date, including 6 month
No meds
No allergies
PE:
T 38.7 HR 180 RR 36 O2 Sat on RA 99% Wt 7.3kg
Gen: lying quietly in grandmother's arms
Skin: rough erythematous patches on face (grandmother states baseline) and scattered erythematous macular/ papular lesions on arms and legs throughout (new)
Head: anterior fontanelle soft and flat
Neck: no lymphadenopathy
Eyes: EOMI. injected conjunctiva bilaterally. no discharge noted.
ENT: lips dry, no oral lesions, TMs mildly injected, not bulging
Cardiac: tachycardia, no murmur, cap refill less than 2 sec, extremity pulses 2+ and equal
Lungs: CTAB, non labored respiratoins
Abd: soft, NT, ND, no organomegaly
GU: circumcised, no visible lesions
MSK: moves all extremities
Neuro: no focal deficits
You assess that the patient is at least mildly dehydrated and decide on an initial plan for rehydration.
Questions for you
In this immunized, circumcised 6 mo boy, do you order any initial studies?
Clock ticks, time passes
The patient fails a PO challenge and is given a NS bolus. He remains tachycardic between 190-210, and a second bolus is given. Urine and blood work are obtained. Urine sediment is visible and it is orange in color, UA demonstrates protein 3+, bilirubin 2+, trace ketones, nitrite negative, leuk esterase 3+, RBC 0, WBC 82.
CBC shows WBC 7, HGB 11.1, PLT 317.
Chem Na 135, K 4.2, Cl 101, CO2 19, BUN 18, Cr 0.4, Glu 142
How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.
Come back later for the denouement of this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
I'm going to try and summarize.........sounds like the kid has baseline facial eczema and now a viral exanthem with high fever, eye discharge, rhinorrhea, cough, emesis x 1, and a rash on trunk...and failed a PO challenge.
ReplyDeleteI like to play devil's advocate to convince myself why this child is anything other than "fine". So here are some of the questions i would ask myself:
1) Does this patient have routine superinfection (AOM, pnuemonia)? Pneumonia becomes higher on the list when patient has cough and emesis in addition to the very high fever. This is not roseola. Do a thorough physical exam and consider a CXR.
2) Should I get a cath urine? well, a circumcised 6 mo male no GU hx that has URI sx and rash.........BORDERLINE. if i were a PCP seeing this kid i probably wouldn't unless there was another red flag such as persistent symptoms, more vomiting, ill-appearance, etc. With the discolored urine, i guess that would push me over the top.
3) Should I give zofran to a 6mo old? I do it sometimes, but not routinely and this doesn't sound like a case of uncomplicated gastro
4) Does this child have real tachycardia? Persistent tachycardia is of course a big red flag, but a HR of 190-210 needs to be correlated with fever and level of hydration and level of fussiness. The easy answer is that you raise the bar and place a line, draw a blood cx (hold it), give a bolus, and re-evaluate. A second bolus in this clinical context is highly questionable unless you think the infant is septic or something else is going on.
5) If I hadn't drawn a blood culture and then got that urine result....do I need one? PROBABLY NOT. the incidence of bacteremia in the context of urosepsis is really low at 6mo, especially in a circumcised boy. so i would only do this if the tachycardia persisted, but at that point you're in a different illness severity category.
6) what should i do with the urine result? SEND A URINE GRAM STAIN AND TREAT. give ceftriaxone through your IV, wait for improvement in tachycardia.
7) does this patient have incomplete kawasaki because of high fever, red eyes, rash, and pyuria? NO. gram stain helps here, as does the presence of rhinorrhea, purulent conjunctivitis, cough and lack of adenopathy. But if urine culture is negative in 2 days and fever persists, i would think about this in the back of my mind.
8) what should i do if the patient has persistent tachycardia despite rehydration and defervescence? DO MORE. get a BP. do an ECG. re-evaluate. admit. If the urine culture showed gram negatives and i was concerned for GN bacteremia, i would probably double cover with my antibiotic selection. add gent or meropenem.
9) what do i think the kid has? ADENOVIRUS (or similar) with culture-negative cystitis. but i would send a blood cx, follow my HR and perfusion, and admit only if the tachycardia persists or if child looks unwell.
Nice sum-up, Dave!
ReplyDeleteSo, my one thought was that seeing that the baby was most likely viral and URI-y (and I;d suspect that the fevers were false - a bad thermometer), I probably would not have cath'd a circumcised male over 6 mon who had somewhat of a source for the fever (URI). Upon first reading the case, I was thinking of newborn brick dust - the pink dust often seen in those early diapers - and I briefly pondered whether significant dehydration in a baby could cause the same crystals... thus, I would have bagged the baby, just to see what the urine looked like... but if (when, in this case), the results came back ambiguous, i would have done a cath and started antibiotics... My diagnosis (and excellent teaching point to the resident on this kid) would be: he is the 3-5% of children with fever and URI symptoms who will still have a culture positive UTI. NOW, combining the cath UA evidence and the history of high fevers, I would now call this pyelonephrtitis.
But wait.
I'm curious about the HR after the second bolus. If it hasn't fallen to a totally acceptable level for an infant, I'm jumping to EKG and CXR. Even in the face of the UTI and viral URI. Myocarditis scares the living daylights out of me. And I always remember what Dewesh once taught me - that the cases we see and recognize of myocarditis are just the tip of the iceberg - that there are a lot of kids with sub-clinical myocarditis who are out there ,walking around, doing their thing, unrecognized.
Or, this kid has urosepsis - what's his temp now? what's his BP? should we call the picu?
My initial impression is that the infant described is somewhat ill and has fairly nonspecific complaints. He has a total of 3 days of fever, with an impressive maximum temperature of 106. He has upper respiratory symptoms of cough, runny nose, eye discharge and some sort of rash. He is described as having poor intake and relatively little urine output with an interesting description of orange colored urine. The physical exam description adds little, with the exception of tachycardia. He is very tachycardic for a child described as “lying quietly in grandmothers arms”.
ReplyDeleteThis is the kind child that I want to lay eyes on myself after presented by a trainee. The differential diagnosis ranges from fairly benign (e.g. viral syndrome with sinus tachycardia in the presence of fever) to life threatening conditions including sepsis or myocarditis. I may strongly believe in oral rehydration, and would try to encourage this baby to take a bottle. However, given the degree of tachycardia and his listlessness I would proceed with an IV bolus.Given that the summary assessment is "you assess that the patient is at least mildly dehydrated", I will presume that the child does not appear toxic. At this point I would not do additional studies but would reassess after hydration.
After the clock ticks and time passes, we have a child who is even more tachycardic with a heart rate around 200. I am now more concerned and would proceed with workup to screen for both septic shock and myocarditis. Assuming the child has not developed respiratory distress or hypoxia I would provide another 20 cc/kg fluid bolus. At a minimum I would send a CBC, chemistry panel, blood culture and urinalysis and culture. I would also ask for an electrocardiogram and chest x-ray.
Reviewing the results provided, there is pyuria, proteinuria and bilirubinuria. I would begin empiric antibiotic for UTI while awaiting culture, but this doesn't feel like pyelonephritis. White blood cell count is normal from the blood. Kidney function appears normal on the metabolic profile. The pyuria could potentially be sterile pyuria of Kawasaki disease - but this would be a strikingly incomplete case with only 3 days fever and only rash of the 5 criteria, in addition normal white blood cell count is not consistent with acute Kawasaki disease.
The infant may have hyperbilirubinemia secondary to a liver disease or biliary obstruction, and I would like to see transaminase and alkaline phosphatase levels from a chemistry profile. Liver dysfunction could also be secondary to myocarditis and poor cardiac output. Myocarditis can be extremely difficult to catch, especially in infants. A nice discussion of emergency department presentations of acute myocarditis was published by Freedman et al. in 2007. In that patient population, AST was elevated a majority of patients. In addition to EKG and chest x-ray, I generally draw transaminases when I am screening for myocarditis. Of course, echocardiography is the gold standard test and a bedside ultrasound may be another potential screening tool before calling in the specialists.
I expect to admit this child to the hospital however am not yet convinced whether he needs ICU or floor care. If all my studies come back normal, I will admit him to the floor for fluids and antibiotics while awaiting culture results. If his tachycardia does not resolve with fluids, I think he needs an echocardiogram.
Everyone has really gone through the whole differential nicely.
ReplyDeleteI just can't shake the feeling that this is Kawasaki. In this age group (i think <1yo), we don't need to wait for the 5 days of fever, plus he has conjunctivitis and rash. Typically I've been told though that these kids are fussy. This child appears calm.
Either way, while I'm putting the IV in, I would send the CBC, Kawasaki panel (ESR, CRP, LFTs), and I would send a blood culture.
Tachycardia is a big red flag in this child. He's definitely not going home, and not going to the floor unless I see that better after my NS boluses otherwise I concur: myocarditis w/u (CXR, EKG) and PICU for potential sepsis if still no improvement in HR, and no diagnosis other than UTI.