Hot Seat #35 Denouement: 6 mo with fever

by Mordechai Raskas, Children's National
with Jennifer Anders, Johns Hopkins on the Hot Seat

The Case
This is a case of a 6 month-old boy with 2-3 days of persistent high fevers and dehydration. The challenge in this case is how to approach this moderately ill-appearing patient with an abnormal UA. For a complete case presentation, please click here.
 
Here's How You Answered Our Questions
What's your plan for initial rehydration?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=14
 
More than 3 years PEM experience (PEM attendings, pediatricians) n=11
 
The hydration plan breakdown is fairly similar between the less than 3 years PEM experience and greater than 3 years PEM experience. Most people would go straight to IV fluid bolus in this patient. Dave discusses in his comments his hesitation with giving zofran to a 6 month-old, limiting it's use to those with straight-forward acute gastroenteritis. Jennifer, the Hot Seat attending, says that while she is a proponent of PO hydration, the clinical scenario here warrants IV hydration.

If you order initial studies, what is the highest priority study?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=15
 
More than 3 years PEM experience (PEM attendings, pediatricians) n=11
 
There is a difference in what the less than 3 years PEM experience would prioritize compared to the greater than 3 years PEM experience. A larger proportion of the less than 3 years group would get a CBC and blood culture while a larger proportion of the greater than 3 years group would do no studies initially. The proportion of catheterized urine and chest x-ray are similar. One person in the less than 3 years experience group said, ">Cef for the UA, sure, but the VS must be addressed." It brings up the question of if you're going to give ceftriaxone to this child, do you first need a blood culture in the case that it's urosepsis? Do you rely on the white blood cell count to guide your management?

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 14

What is your next step?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=13
 
More than 3 years PEM experience (PEM attendings, pediatricians) n=8
   
The groups again diverge here, more so than usual. A larger proportion of the greater than 3 years experience group would most next like to give ceftriaxone for pyeloneprhitis and admit. In contrast, the less than 3 years group had about a third that wanted to get LFTs next. Jennifer, our Hot Seat attending, provides us with a reference for the utility of LFTs in myocarditis in her discussion.

Clinical Reasoning
This case spurred an excellent discussion on fever in a 6 month-old. It touched on the common, likely, and worrisome. As a whole, the four respondents--including our Hot Seat attending--gave us an excellent analysis that will likely come in handy the next time we are faced with such a patient (which is probably tomorrow). For their complete comments, click here.

How to Piece It Together
"I 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 a routine superinfection?
2) Should I get a cath urine?
3) Should I give zofran to a 6 month-old?
4) Does this child have real tachycardia?
5) If I hadn't drawn a blood culture and then got that urine result...do I need one?
6) What should I do with the urine result?
7) Does this patient have incomplete Kawasaki because of high fever, red eyes, rash, and pyuria?
8) What should I do if the patient has persistent tachycardia despite rehydration and defervescence?"
-Dave Mathison, Children's National

"I 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." -Rasha Sawaya, Children's National

Urine and URI
"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 mo who had somewhat of a source for the fever (URI)... he is the 3-5% of children with fever and URI symptoms who will still have a culture positive UTI. " -Sabah Iqbal, Children's National

About that Tachycardia
"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." -Sabah Iqbal, Children's National

"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." -Rasha Sawaya, Children's National

From the Hot Seat
by Jennifer Anders, Johns Hopkins

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”.

This 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.

The Denouement
by Mordechai Raskas, Children's National

Due to bili in the urine, LFTs ordered and showed T. Bili 3.7, conjugated bili 3.0, ALT 194, AST 78. Additionally, CRP 9.1, ESR 60. CXR was normal. EKG shows sinus tachycardia. Blood and urine cultures were obtained, ceftriaxone is given. Pt admitted to PICU for closer monitoring in setting of unclear diagnosis and significant tachycardia despite 40cc/kg NS IVFs and defervescing. Cardiology consulted and initially wanted to hold off treating for Incomplete Kawasaki given only day 3 of fever. However, PICU requested treatment and Echo when tachycardia persisted despite normal EKGs and appropriate fluid replacement. Echo showed prominence and ectasia of left main coronary artery. Pt given aspirin, IVIG, had a repeat fever, and given a second dose of IVIG. During this time pt developed mucosal changes, swelling of the feet bilaterally, and HgB dropped to 9.8. Fever resolved and pt was discharged 5 days after presenting to the ED. 2 and 6-week follow ups with cardiology showed no abnormalities on Echo; ectasias had resolved and no aneurysm formation.

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The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.