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Just a fever- when to act
- 1. From Textbooks toReal Life Scenario A child with just a fever DR SHAILESH MEHTA SENIOR PEDIATRICS CONSULTANT CHANDIGARH
- 2. Story of Golu,6 yrs old healthy boy Chirpy little boy who lives in Hoshiarpur. Gets fever . No other symptoms. Managed at home on sos Paracetamol Fever was high grade but not measured. Fever was coming back after 4 hours Parents take the child to doctor on Day3
- 3. Day 3 feverGolu goes to a GP Since there are no associated complaints , the GP examines the child and with No Definite Diagnosis, prescribes- Paracetamol and Comoxyclav Advised parents to follow up in case of any deterioration. No investigations were done at this point.
- 4. Golu is lethargicand refuses to eat Fever 5 days , intermittant high grade, Max 103 F No rash, no GI or respiratory complaints Clinical examination- No focus of fever found Hemodynamically stable Given symptomatic treatment – Paracetamol HB 10.2 TLC 2100 N46, L43, M6,E5, MCV 70 ESR 80, MP negative PLATELET COUNT 61000/ CUMM CRP 60 mg/lt Other investigations awaited
- 5. Golu is admitteddue to lethargy, persisting fever Day6 ,refusal to eat Developed vomitings and loose stools Was put on IVF, Ceftriaxone Latest Hemogram report HB 8.6 HCT 25.8 TLC 9100 N30, L62, M5, E3 PLATELET 26000/ CUMM Dengue IgM and IgG Negative, NS 1 Negative Widal negative IgM Scrub typhus Negative Urine routine normal, Stool routine normal.
- 6. LFT report ofGolu on Day 6 of fever • TSB 0.75 mg% • SGOT 93 U/L • SGPT 66 U/L • Alkaline phosphatase 241U/L • Total Proteins 5.83 gm% • Albumin 2.9 • Globulin 2.9 Child shifted from Hoshiarpur to Chandigarh with D/D of Dengue vs Scrub Typhus even though tests were negative, in v/o fever, lethargy, low platelets
- 7. On Day 7and Day 8 of fever Parents of the child took double opinion from various doctors. Investigations re-sent RTPCR COVID 19, Antibody levels COVID 19 Repeat Hemogram, PBF, MP , Dengue and Scrub serology sent along with Cultures • Oral intake remained poor , Golu was lethargic • Physical examination findings were non contributary • Patient was hemodynamically stable
- 8. Golu met meon Day 9 fever • Cannula in situ • Lethargic, carried in lap by grandfather • Obeying commands but unable to maintain posture, dehydrated • HR 86/min, RR 26/min, BP 100/60 Temp 103F, CFT =3sec, PPWF • Cheilitis, stomatitis • Abdomen tense tender over right subcostal region with liver 2 cm BCM • No rash , no lymphadenopathy Eschar noted in the perineal region. Referred to tertiary hospital.
- 9. Day 10 offever – Scrub Typhus clinically ( Eschar +History of travel to Himachal 3 weeks back- Revealed later) Golu admitted in a tertiary hospital Goes in shock with MODS. On ionotropic support and IV Ceftriaxone &Doxycycline Sensorium deteriorates over 12 hours and put on manual IPPR Subsequently ventillated with features of ARDS
- 10. Day 11 offever Golu is lost. Parents did not reveal further diagnostic details or the death summary of the child, as they were too heartbroken. What did we miss? What are the recommendations? What more could have been done? In a child with Fever without localising signs , how long should we wait till we investigate? (In a seemingly stable child) Should we start empiric Azithromycin on Day 5 onwards in fevers without localizing signs with low platelets?
- 11. Nothing can replacea good clinical examination and a good history taking
- 12. Facts about ScrubTyphus • Serology tests positive after 7 days of illness • Serology IFA- Reference standard for diagnosis • ELISA IgM done most commonly • Sensitivity of Serology 26%- 96% • Specificity of Serology 96% • PCR fastest and most specific method • Cultures rarely done – time consuming • Eschars and rash seen in about 50 % cases • CDC recommends initiation of Doxycycline without waiting for reports as mortality is as high as 24% in severe disease.