Monica Prieto, MD Children’s National Medical Center

Case: 80 day old fully vaccinated infant, ex 36-weeker, presented as a bounce-back for two days of fever and one day of fussiness. Workup the prior day revealed an unremarkable physical examination as well as a normal WBC count and UA. Blood and Urine cultures showed NGTD for the first 24 hours. ROS were significant for fussiness, fever, decreased po, and less wet diapers. Upon examination the infant was fussy, somewhat consolable, but intermittently preferred upper extremity flexion with normal tone.

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Discussion:

Bounce-backs often carry a negative connotation, however, in some cases they are great and warranted! We all give our patients and families return precautions and it’s always a sigh of relief when you realize your bounce-back is because they paid attention to those signs and symptoms. This is a classic case where the family did the right thing. Their infant remained febrile but was acting different than the day prior. Now fussy, not feeding well, and less urine output.

Given this change in mentation, we all agreed this patient needs a lumbar puncture to assess for meningitis, but, how much of the workup from the day prior needs to be repeated. Blood? Urine? Both? Most of the group (fellows and attendings) would do blood but only about half would re-catheterize for urine. 2 brave souls said they would do nothing (somewhat alarming and scary to me).

The main crux of this case was what to do with a bloody tap that would not clear in a fussy infant without any associated infectious symptoms. A classic game of chicken and the egg. Did the fever come from an infection or from an intracranial hemorrhage. There are literature out there that this occurs (see below), but no one knows to what extent are these children febrile. 38? 39? even 40? None of the studies looked at Tmax but all had different cutoffs for what they considered were a “fever”. The group was split on head imaging for this child. The ones that felt to defer stated that the patient is being admitted and can be watched for any further decompensation and or inadequate response to treatment pending lab results. Dr. Zaveri mentioned that with NAT it is never black and white and he argued that if it comes across your mind you should do what you need to do to close that chapter, as the inpatient team may not have NAT on their illness script for a febrile infant.

91% of patients in this study (adults) had a fever greater than 37.5. (non infectious)

http://n.neurology.org/content/54/2/354

32% of patients in this study (adults) had a central fever greater than 38.3 (non-infectious). Mean temperatures were 38.5 for survivors and 39 for deceased patients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324842/

Among 153 neonates with fever > 37.8 axillary or rectal, 11 babies (7.2%) had ICH, and this incidence was significantly higher than that in afebrile neonates (11/153 vs. 3/315; p < 0.001). 82% of these babies were non-infectious.

https://www.ncbi.nlm.nih.gov/pubmed/18947002

Denouement:

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