Hot Seat #44 Denouement: 3 yo F s/p appendectomy with fever

Posted on: October 9, 2014, by :

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. Also with concerns for an unreported significant fall.

Here’s How You Answered Our Questions

Overall, attendings seemed to be more concerned about ruling out NAT as compared to fellows.  Most found the missed history of a significant fall concerning, and many people suggested that they would at least  get NAT screening labs.  “Other” was “tie between looking uncomfortable and recent surgery.”

Denouement
CT head obtained and normal. An LP was performed: CSF had 450 WBCs, 4 RBCs, 45% neutrophils, 45% lymphocytes, glu 43, pro 60. Concern for meningitis. Immediately after the LP the patient became comfortable and went to sleep. The patient was given ceftriaxone and admitted and later diagnosed with enterovirus meningitis. It was not clear if the appendicitis was an additional true diagnosis or an earlier presentation of the viral meningitis (especially considering the negative histopathology). The patient was also fully evaluated for non-accidental trauma (given the fall from 6ft while being cared for by the aunt) and no other injuries/ concerns were identified.

Debrief Teaching Points – from Thursday Conference
1. Consider PNA: may be worthwhile to obtain a CXR (if considering appey) to rule-out PNA.

2. DDx FUO: ID, Rheum, Malignancies.  Click on this UpToDate link for a great DDX table.

3. NAT work-up:
Labs- <6yo ALT, AST, amylase/lipase, UA, CBC.  Consider additional tests if multiple bruises, suspected poisoning, sexual abuse, etc.
Imaging- <2yo skeletal survey, <1yo head CT

4. Head CT (contrast vs no contrast):
A non-contrast CT looks for fresh blood and calcifications.
A contrast CT is recommended to look for vascular malformation, infarction, neoplasm, abscess, or empyema.

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