Hot Seat Case # 118: 80 day infant febrile and fussy
Posted on: October 2, 2018, by : Monica Prieto MD
Monica Prieto, MD Children’s National Medical Center
with Christina Lindgren, MD Children’s National Medical Center
80 day old vaccinated infant female born at 36 weeks gestation presents as a bounce-back for fever and fussiness for 2 days. The patient was seen the day prior for fever and sleepiness. The parents report that she had blood and urine testing performed, and she was discharged home with a diagnosis of a viral illness. The patient has been persistently febrile, with temperatures at home as high as 39.7F measured axillary, and she has become fussier since discharge. She is no longer taking her bottle and has had fewer wet diapers. The parents believe that she is uncomfortable when her back is touched. They report no nasal congestion or cough. No new rashes.
ROS:
Constitutional symptoms: Fever, decreased appetite, decreased urine output.
Skin symptoms: No rashes or bruising.
Eyes: No redness or discharge.
ENMT: No nasal congestion or oral lesions.
Respiratory: No coughing or difficulty breathing.
Gastrointestinal: No vomiting, no diarrhea, no blood in stool.
Genitourinary: No hematuria.
Neurologic: Fussy and sleepy, but no abnormal movements.
Hematologic: No petechiae or bruising.
PMH: Spontaneous labor at 36 weeks, born by NSVD. Perinatal course complicated by hypothermia and hypoglycemia treated with glucose and passive warming. Maternal serologies negative. Infectious work-up at birth negative.
FH: No known family members with history genital or muco-cutaneous HSV.
SH: Lives with parents and 3 siblings. Is in daycare.
PE:
VS: Wt: 6.8kg, T 39.4, HR 197, RR 64, BP 94/55, O2 Sat 100% on Room Air
General: Well-nourished, irritable infant, intermittently consolable while drinking from bottle
Skin: Warm, dry, pink. No rashes, petechiae, or bruising.
Head: Normocephalic, atraumatic. Anterior fontanelle open and flat.
EENT: Keeps eyes closed. Normal conjunctiva and PEERL upon forcibly opening eyes. Moist mucus membranes, no mucus in nares
Cardiovascular: Tachycardic regular rhythm. No murmur or gallop. Femoral and distal pulses present and equal bilaterally. Capillary refill of 3 seconds.
Respiratory: Tachypneic with mild subcostal retractions. Lungs clear to auscultation without wheezes, crackles or rhonchi.
Gastrointestinal: Abdomen soft, non-tender, and non-distended. No palpable masses or organomegaly.
Back: No appreciable tenderness. Normal alignment, no step-offs.
Musculoskeletal: No swelling or deformities noted in all four extremities.
Neurological: Cries with minimal stimuli. Holding upper extremities flexed but with normal tone on passive range of motion. Noted to move all extremities spontaneously. Symmetric Moro reflex. Intact suck reflex. Upward-going Babinski reflex bilaterally.
You review the patient’s chart from her visit the day before and confirm that blood and urine testing was completed with the following results:
CBC: WBC 8.1, PMNs 57%, Lymphocyte 29%, Monocytes 12%. H/H 10.5/31.7, Plts 405
Urinalysis: Clear appearance, spec grav 1.011, negative leukocyte esterase and nitrites, no white or red blood cells. Blood culture and urine culture are both no growth to date at 24 hours.
You order a normal saline bolus and antipyretics for the patient.
You perform a lumbar puncture that is traumatic, but CSF is obtained on the second attempt. The CSF color is bright red in tube one, and clears over time, but it remains blood-tinged through tube 4.
On re-evaluation, the patient is noted to be fussy but less irritable overall.
VS: T38.5, HR 170’s, RR 45, BP 92/49, O2 sat 100% on RA.
CBC: WBC 8.0, PMNs 49.1%, Lymphocytes 40.9%, Monocytes 10.1%
BMP + LFTs: Normal electrolytes, mild elevation in BUN, normal liver enzymes.
Urinalysis: Clear appearance, spec grav 1.020, negative leukocyte esterase and nitrites, no white or red blood cells
CSF: Protein 46, glucose 75. RBCs >4,000, WBC 6. Gram Stain with moderate erythrocytes and few white cells. Meningitis/encephalitis panel pending.
CXR: Normal
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
The patient is at 80dol therefore 60-90 days of age so it really depends on if you follow Boston v. Rochester/Philadelphia criteria. For me, given that a partial sepsis work up was done already I would start by doing a repeat CBC without a BCx (given it was done in 24 hours previously) that way the WBC can be trended. I would not repeat the urine. RVPCR is not one of the first things I would consider in this child. Maybe an RSV/Flu if there were respiratory symptoms. Cxr for an occult PNA would be on my list but not initially.
Given the poor po and urination with associated high grade fever (103F) I would still have a high suspicion for doing an LP. However I would give IVF and antipyretics and see how the patient responded in the time that the cbc came back. If the patient still looked lethargic after this I would not hesitate to do an LP or if the CBC was more concerning than prior.
I think I would go with the majority of providers in giving ceftriaxone/cefotaxime. Good broad coverage especially against S.Pneumo/E.coli respectively. Given patient above 4weeks, no herpetic skin lesions or eye involvement, normal platelets, I would hold acyclovir at this time, pending LFTs, and CxR.
I would have an extremely hard time sending this child home. Especially given the fact the child is not yet back at baseline (fussy), the tap was >2000RBC (even though only 6wbcs), tachycardic, febrile. I would not do a Head CT at this time. No bulging fontanelle, CSF looks like it may be reassuring (no frank pus and cleared after blood, not cloudy) and patient is improving.
This is a great case with multiple great points for discussion. I recognize that we are not good as providers at predicting who is ill appearing, however the fact that both the parents and the provider express concern regarding her degree of irritability this would raise my concern. With that being said, I would likely start from scratch in this patient and do a CBC, blood culture, UA, urine culture and I would add an LP given her irritability. While this is likely the same process as the day prior, it is possible that she could have something new. I think it is okay to hold off on a CXR given the absence of cough but I would do the RVPCR to determine if there is a viral source of her fever.
I think that regardless of the outcome of the above studies, this patient warrants inpatient admission for observation. Pending the above results, I would also empirically cover with antibiotics. I think that ceftriaxone and vancomycin would be sufficient to start. We do not need ampicillin given that she is 80 days and is at decreased risk for GBS, Enterococcus or Listeria. Given that her LFTs are not elevated, no vesicles and there are no known exposures to HSV, I would defer acyclovir at this time pending the result of the CSF meningitis/encephalitis panel. The CSF is difficult to interpret for HSV infection. Also, this patient is no longer a neonate and therefore I would think of an HSV infection in this patient differently than a neonate with HSV.
Regarding neuroimaging, I would defer at this time given that her irritability is improving and I would plan for admission. However, I think that in a child with irritability it is always important to consider NAT on the differential.