1. Chapter 6 Fever Case I

2. Case study: Johnny
Johnny is a 6 month old boy, brought to hospital with a two day history of fever, lethargy and decreased feeding

3. What are the stages in the management of Johnny?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. What emergency or priority signs do you notice?
Temperature: 39.7ºC, pulse: 185/min, RR: 48/min,
SpO2 97%, capillary refill 4 seconds, cold hands and feet

6. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable,
lethargic
Referral
Malnutrition
Oedema of both feet
Burns

7. Does Johnny need emergency treatment?

8. Emergency treatment □ Blood sugar Airway management? Oxygen?
Intravenous fluids?
Immediate investigations?
□ Blood sugar
(Ref. Chart 2 p. 5-6)

9. Emergency treatment
Because of tachycardia, poor perfusion and cold extremities insert intravenous drip and give 20 ml/kg
Ringer’s lactate or normal saline solution
(Ref. Chart 7, p. 13)

10. History
Johnny is 6 months old, was brought to the hospital with a two day history of fever, lethargy and decreased feeding. He had not been drinking well for about 2 days. He had vomited several times each day. His mother said he felt very hot to touch.

11. Examination
Johnny was lying with his eyes closed, not rousable to voice, but rousable on handling.
Vital signs: temperature: 39.7ºC, pulse: 185/min, RR: 48/min, capillary refill: 4 seconds; cold hands and feet
Weight: 6.9 kg
Chest: no chest indrawing, normal air entry both sides
Cardiovascular: tachycardia, soft systolic murmur, pulses normal, cold feet and hands
Abdomen: soft, bowel sounds present; liver palpable 2 cm below the right costal margin
Neurology: lethargic, no neck stiffness, fontanelle normal
Mouth: dry, no oral thrush
Ears: clear, no discharge
Skin: fine red rash on chest, abdomen, arms and face

12. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p. 151)

13. What investigations would you do to make a diagnosis?

14. Investigations Blood glucose Full blood examination Blood culture
Urine microscopy (and culture if available) (Ref. p. 185)
“Clean catch” technique
Suprapubic aspirate (Ref. p. 350)
Malaria microscopy or rapid diagnostic test (RDT)
Lumbar puncture if signs suggest meningitis

15. Full Blood examination
Haemoglobin: 8.9 g/dL (125 – 205)
Platelets: x 109/l (150 – 400)
WCC: x 109/l (5.0 – 19.5)
Neutrophils: x 109/l (1.0 – 9.0)
Lymphocytes: 1.6 x 109/l (2.5 – 9.0)
Blood sugar: 3.9 mmol/L (3.0 – 8.0)
Malaria RDT: negative

16. Clean-catch technique

17. Suprapubic aspirate Why might it be dangerous in Johnny?
Low platelets and risk of bleeding

18. Urine Protein / Glucose : nil Nitrate / Leucocyte esterase : 3+++
Blood:
Microscopy:
Red Blood Cells: 20 x 106/l (n<13)
Leucocytes: x 106/l
Bacteria seen on microscopy

19. Diagnosis Summary of findings: Urine examination abnormal
Blood examination shows mild anaemia, high neutrophils, thrombocytopenia (low platelets)
No other signs of focal infections
Urinary tract infection

20. How would you treat Johnny?

21. Treatment
(Ref. p. 184)
Ampicillin and gentamicin IV initially, or ceftriaxone
Consider complications of UTI such as pyelonephritis or septicaemia
Give IV antibiotics until fever subsides for 1-2 days and the child improves, then switch to oral antibiotics such as cotrimoxazole

22. What supportive care and monitoring are required?

23. Supportive Care Fever management (Ref. p. 305)
Fluid management (Ref. p. 304)
Avoid giving too much IV fluids, as high risk of oedema
Encourage regular breastfeeding

24. Monitoring
The infant should be checked by nurses frequently, at least every 2-3 hours at the start, and by doctors at least twice a day
Use a Paediatric monitoring and response chart (Ref. p. 320, 413)

26. Discharge planning Before discharge: Fever resolved Feeding well
Completed 3-5 days of IV antibiotics, then tolerating oral antibiotics to complete 7 days total
Investigate for kidney abnormality, which are more common if a child has a UTI
Renal ultrasound if possible
Recheck platelet count to see if thrombocytopenia resolves

27. Summary Infant with systemic infection due to urinary tract infection
Symptoms and signs often non-specific
Follow the guidelines
Follow-up is important