Hot Seat Case #94: 2 y/o F with fever & leukocytosis
Posted on: May 15, 2017, by : Jeremy Root
Jeremy Root MD, Children’s National Medical Center
with Karen O’Connell MD, Children’s National Medical Center
The Case:
2 year-old female referred from an outside hospital with tactile temps x 2 weeks and elevated white count. The patient began coughing yesterday and had five episodes of non-bloody, non-bilious, post-tussive emesis. She also had associated fevers with Tmax of 102.7F yesterday. At the outside hospital, she had a negative CXR and negative flu swab. A CBC was drawn with a WBC count of 53,000, with 85% bands. Due to the elevated WBC count she was transferred to your tertiary care center.
Mother says the patient started day care 2 months ago and had frequent viral illnesses over this time period. She was diagnosed with AOM 3 weeks ago and recently completed a course of antibiotics. Denies recent travel or TB contacts.
ROS: +night sweats, inc fatigue, no weight loss, decreased PO, chronic rhinorrhea, watery eyes, denies easy bruising/bleeding.
PMHx: born at 36 weeks, neonatal jaundice requiring a brief course of phototherapy
Immunizations: UTD
Medications: None
Exam:
VS T 38.5, HR 154, RR 20, BP 104/78, SpO2 98%
GEN: Well-appearing, active, smiling, cooperative
HEENT: PERRL, EOMI, normal conjunctiva, no discharge. OP clear. TMs clear. No meningismus.
CV: slight tachycardic, regular rate, no murmurs or gallops, < 2 sec cap refill
PULM: CTAB, intermittent cough, no inc WOB
ABD: soft, NT, no HSM
NEURO: CN II-XII intact, normal sensory, normal motor, normal speech, normal strength
MSK: No joint swelling or limited ROM
SKIN: No ecchymoses, petechiae, or erythema
LYMPH: No cervical, axillary, or inguinal lymphadenopathy
OSH Labs/Rad:
WBC count of 53,000, 85% PMN, 4%L, 5% M, no blasts or atypical cells noted
HgB 12, Hct 37.8, PLT 399
CMP unremarkable
You receive sign out from a senior attending. He/she says they are repeating the CBC and smear. He/she states if the CBC is stable compared to the OSH results, he/she plans to discharge home given well appearance with repeat CBC in 3-5 days.
Shortly after sign out, the repeat CBC shows 49,000 WBC with 89% neutrophils, 3% lymph, 5% mono, no blasts or atypical cells on smear. Patient is well appearing, playing in room, now afebrile, normal HR, BP.
Questions for you:
ID is consulted who recommends LDH and uric acid, which are normal. They also recommend an abdominal ultrasound, which shows heterogeneity of the liver but no organomegaly or masses. Repeat LFTs and coags are unremarkable.
What are your next steps?
One More Question:
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With a WBC that high despite the well appearance of the child, I’d also give the child empiric Ceftriaxone (50 mg/kg IV) therapy pending the results of the blood culture, given the concern for pneumococcal bacteremia. She is Ok for d/c home with close PCP follow-up (1 day) and repeat of CBC (1-3 weeks).
Significant leukocytosis has a shorter list of causes, and helps focus our thought process.
With the fever and cough, infection is the most likely explanation for the leukocytosis, specifically pneumococcal disease with this extreme leukocytosis. The illness script would have been complete with a round pneumonia on CXR. But this is not the case. Other infections that cause high white blood counts include pertussis (lymphocytosis) and tick-borne infections (monocytosis).
After infection, oncologic disease needs to be seriously considered. The exam is reassuring by having no clear signs of a large tumor burden (multiple LN enlargement, palpable HSM), which one might expect with such a high WBC count in a child with ALL. The other reassuring sign is that only one cell line is abnormal, with the red cell and platelet counts being in the normal range. On the other hand, if the oncologic process is a lymphoma, then there may be fewer abnormalities on the initial CBC. So the CXR needs to be reviewed carefully for any middle and anterior mediastinal mass that is compressing the airway and causing the cough.
Other causes include medication use, such as steroids and AEDs, that lead to demargination of the white blood cells, and therefore an elevated count on the CBC. Still other causes are not relevant to this child: being a newborn; being asplenic; genetic condition such as Trisomy 21.
Plan in ED:
– BCx, because pneumococcal infection is still the most likely explanation for this presentation;
– Ceftriaxone related to above;
– Review any medications the child is on;
– Review CXR with a Pediatric Radiologist;
– Disposition home only after conversation with PMD and agree follow-up exam in 24 hours to check on child and on BCx.