Hot Seat #44: 3 yo F s/p appendectomy with fever
Posted on: October 2, 2014, by : Dave Mathison
by Mordechai Raskas, Children’s National
with Dave Mathison, Children’s National
The Case
3 year-old female, bounceback to the ED s/p appendectomy 3 days ago, now with fever, poor po intake, headache, and emesis. Tmax 104 F. 4 days prior had been seen in ED and found to have appendicitis by ultrasound. Appendix removed the following day. Since then the mother reports she has been fussy, had fever, refusing to take po, and today had 3 episodes NBNB emesis. On further questioning, mother reveals that the patient was with an aunt until 5 days ago. Today, the aunt told mother that the patient had a fall last week from 6ft and no medical attention sought at that time.
ROS: No rhin, no cough. No diarrhea, no rash. No sick contacts.
Exam: VS Temp 38.0, HR 130, RR 25, BP 113/82, 100% on RA
Gen: Awake, conversant, appears uncomfortable, at times stating she has a headache
HEENT: normocephalic, atraumatic, EOMI, neck with FROM and easily movable in all directions, oropharynx normal, TMs with normal landmarks
CV: RRR, CR<2s
Lungs: CTAB
Abd: Mild tenderness in RLQ, nl BS, not distended, laparoscopic surgical sites covered in dressings that are intact and dry
Neuro: Alert, interactive but uncomfortable appearing, No focal neurological deficits
Labs/Rad:
You review the US Appendix from 4 days earlier.:1.0cm tip, moderate mesenteric fat stranding.
Surgical Pathology: appendix 7 x 0.8 cm, no significant histopathologic abnormality
Surgery is consulted (given the recent surgery), and they are very concerned about the unreported fall and feel a NAT workup is indicated.
It is at this point that you receive sign-out on the patient…
Questions for you:
Interim Update:
Pain medications and antipyretics have been given, IV fluids are running and blood and urine testing are pending.
When you see the pt, she has defervesced but is still fussy and uncomfortable appearing, lying in mother’s arms and interacting appropriately. No emesis in ED. Continues to have minimal RLQ tenderness at sites of appendectomy only, abdomen otherwise nontender. She complains about her head as her main site of pain.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
The first thing to realize about this case is that you do not have the correct diagnosis from the first visit. It’s important to recognize that though the evidence pointed to appy at first, the pathology was negative, so you must go back to your differential (ie, this is prolonged unexplained fever in a child with mild belly pain who had a recent surgery rather than appendicitis post OR with complication)
What could be going on: infected hematoma from fall, viral illness, pneumonia (had a case v similar to this in residency where child bounced back after appendectomy and had no respiratory symptoms and a large pneumonia), UTI, less likely malignancy, though always on differential with unexplained fever.
So what would I do?
CBC, CMP, complete abdominal US, UA, IV fluids
Would I do NAT workup?
At this age, a NAT workup really is only a couple of additional labs, namely amylase, lipase and coags, so I think it would be reasonable to send them. By protocol this child does not get a head CT or skeletal survey.
I also think a skin exam is important if considering a dx of NAT.
I like Katie’s response. You have some info that we rarely have in the ED – a prior exam and data points – ie a prior BP, HR, fever curve, US read and possibly lab work (if blood was sent with the prior appendectomy). These are all helpful to review the case from another vantage point – since she did not have appendicitis on that prior visit.
SO what’s concerning here?
Well, she has fever with symptoms that seem mostly GI – poor po intake, vomiting, abd pain. It makes the most sense to send CBC, CMP, lipase with abd US to start. It is reasonable to focus on an infectious cause for these symptoms but, like Katie, I had a prior case that was actually intussusception after an original misdiagnosis. SO, I would broaden the differential beyond infectious causes.
I would add a U tox to the work up and possibly AXR as ingestion such as iron pills or other strange things kids can put in their mouth can cause abd pain, malaise, vomiting etc. (Plus, that AXR is always great at looking at the lower lung fields as a bonus).
(PS I generally find U tox screens very unhelpful until I had a 2yo with malaise, vomiting and abd pain etc who had + THC on U tox – history revealed they had been eating “special” brownies)
You bring up NAT – agreed that this could be an issue especially with the history that this child was with another care taker who did not report a pretty significant incident. As Katie mentioned, a NAT work up at this age would be labs mainly. A call to the PMD would be helpful and involving our child protection clinic if labs/history are concerning. Our social workers are great at getting some history from mom about prior care experiences with the aunt and following that up with an investigation by child protection services is important if any red flags.
Interesting case. I like to think about the pertintent questions and decision points.
1) Is this a post-operative infection?
Classically, we think wind/pneumonia (1-2 days), water/urine (3-5 days), walking/dvt (4-6 days), wound (5-7 days). Our surgeons tell me they haven’t done an open appendectomy in years, they are all laproscopic now even when filled with pus. They often send kids home the day of surgery now from PACU so the rate of infection from uncomplicated appy is incredibly low. But sure, how bout an XR and a urine.
2) Was it appendicitis?
So I’m part of a Children’s Hospital Association consortium on appendicitis looking at quality measures and INTERESTINGLY the outcome of “was it appendicitis” is not on their list. The reason for this is that the pathology is not very accurate. They really do it to rule out carcinoid and other malignancy and not to diagnose. Just like the tonsils. So Quereshi tells me that the path reports “always say inflammatory findings suggestive of appendicitis” perhaps just from mucking around in there causes some local inflammation even in the absence of true raging appendicitis. In the US report listed above, the appendix diameter is only 0.49. Generally, radiologists talk about MOD (maximum outer diameter) and MMT (maximal mural thickening). In children, MOD >0.6 is abnormal and MMT > 0.3 is abnormal, but there may be age-appropriate measurements to consider here. Although from the looks of the US, i would say this was a mis-diagnosis.
3) What if it wasn’t appendicitis?
The biggest error in these kids are those with Crohns/IBD because taking out the appendix when not warranted leads to fistula formation in that already diseased area. It’s for this reason that the most important question in any kid with suspected appendicitis is duration of symptoms (also to exclude possible perforation). So in the absence of wound infection, pneumonia, and UTI…….I would send some screening labs. The most important might be an ALBUMIN as a sign of chronic disease and perhaps an ESR that may not necessarily be elevated like a CRP in the setting of acute appendicitis. Ok Hb is important too.
4) What about NAT?
I think this part is stupid and i would call the fellow and say “you can call CPS if you think it’s prudent”. He’s 3yo, not 1yo. He should be able to localize symptoms after an injury. Classically we do think about osteomyelitis as an inflammatory disease 5+days after a local trauma, but he should have some localizable pain on exam over a metaphysis. If they are worried about an infected intra-abdominal injury, well, i’m not sure what exactly that means.
5) Do we need another Ultrasound?
I don’t know if it adds much value here other than saying definitively there isn’t an intra-abdominal abscess from the appendicitis he never had…..but it’s a reasonable test to exclude other intra-abdominal masses or abscess. So yes-do it, but do a COMPLETE abdominal ultrasound to evaluate for psoas abscess, hepatic abscess, and post-operative complications.
6) Is this something or nothing??
I guess he could’ve had a viral blahblahblah and an unnecessary appendectomy but it sounds like the child is ill and in the absence of other abdominal pathology or abnormal findings on CXR/urine/blood…….i think the child would require a medical admission with surgical consult (and perhaps GI as well). I would like to get more information on the symptoms leading up to the surgery to screen for other possibilities. If there’s cronicity especially in the setting of weight loss or small weight/height or anemia or hypoalbuminemia, my money would be on Crohns disease.