Question 11#

A 10-month-old fully immunized child presents with a high fever of 40°C and no evidence of a focus. The child does not appear toxic but is miserable.

Which ONE of the following is the BEST answer?

A. If the child defervesces with paracetamol, it is predictive of a benign process

Answer: C: Defervescence after paracetamol administration has not been shown to reliably exclude bacteremia and therefore a response to paracetamol does not predict a benign course in these children. The use of antipyretics such as ibuprofen and paracetamol are useful in lowering the temperature of the child more rapidly (compared with the child’s natural sinusoidal temperature variance), allowing for two important management points: symptomatic relief, as the child may be less irritable, and assessment of the child in the afebrile state. Many children are labeled ‘toxic’ by inexperienced ED clinicians because they are assessed when febrile. Often with time or antipyretics, the fever settles and the child becomes animated and alert. If the child is not septic or toxic, antipyretics should be administered and the child observed in the ED. Urine screening with a clean catch urine or catheter specimen to exclude UTI should be performed. If the child is observed to remain well and alert in the ED, their risk of serious bacterial illness is extremely low (<1%) and WCC and BC are not indicated. Listeria affects the neonatal population.

References:

1. Baker MD, Avner JR The febrile infant: what’s new? Clin Ped Emerg Med 2008;9:213–20.
2. The Royal Children’s Hospital Melbourne. Clinical practice guidelines. Febrile child under 3 years. Online. Available: http://www.rch.org.au/clinicalguide/cpg. cfm?doc_id=5181.
3. Baker RC, Tiller T, Bausher JC, et al. Severity of disease correlated with fever reduction in febrile infants. Pediatrics 1989;83(6):1016–9.
4. Bonsu BK, Harper MB. Identifying febrile young infants with bacteremia: Is the peripheral white blood cell count an accurate screen? Ann Emerg Med 2003;42(2):216–25.

Question 12#

A 2-year-old child is referred with fever 39°C, cough and coryza, with tussive vomiting for 1 day. The child is noted to have petechiae. The child appears very well, and is active and alert.

Which ONE of the following is the BEST answer?

A. If the distribution of petechiae is restricted to above the nipple line, the cause of petechiae is likely to be benign

Answer: A: The most common cause of petechiae in children is due to mechanical causes. Petechiae from tourniquetting, retching or violent coughing and vomiting is typically confined to the skin above the nipple line in the distribution of the superior vena cava (SVC), whereas petechiae caused by serious bacterial illness can have any distribution. This is the only group of well-appearing children with an obvious mechanical cause who should not need immediate investigation.

The incidence of meningococcal infection is 7–11% in patients hospitalized with fever and petechiae. The rate of bacteremia of any cause was found to be much lower (1.9%) in an ED population; however, most studies have looked at this scenario during the pre-vaccination era. The differential diagnosis of fever and petechiae also includes disseminated intravascular coagulation, rickettsial disease, pneumococcal bacteremia, Streptococcus pyogenes infection, various viral infections, idiopathic thrombocytopenic purpura, Henoch-Schönlein purpura, and leukaemia. Due to the wide differential and potential for serious infection, most children will need investigation with WCC, BC and coagulation studies.

Empirical antibiotic therapy (ceftriaxone) should be considered in all children presenting with fever and petechiae, even if an outpatient disposition is anticipated.

Reference:

1. Mick NW. Pediatric Fever. In: Marx JA, Hockberger RS, Walls RM, editors. Rosen’s emergency medicine: concepts and clinical practice. 7th ed. Philadelphia: Elsevier; 2009. p. 2094–103.

Question 13#

A 2-year-old child presents with a fever of 39°C. Regarding the clinical approach to this patient, which ONE of the following is CORRECT?

A. Identifying a source for the fever is the first priority during assessment

Answer: B: The approach to a child with fever includes the following:

• Identify if there are signs of shock/septic shock. If shock is present, resuscitate first, followed by work-up. Evidence of shock should be aggressively treated with fluid resuscitation. An intravenous or intraosseous line should be placed and the initial resuscitative fluid should be 20 mL/ kg of isotonic crystalloid. This should be repeated to a total of 60–100 mL/kg if the signs of hypovolaemia persist, after which the use of a vasopressor should be considered. Every effort should be made to obtain appropriate specimens for culture (blood and urine), even in a critically ill child prior to antibiotic administration. LP may be deferred in a critically ill child until stabilization occurs. Empirical antibiotic therapy should be directed at the most likely causative organisms based on age.
• If no shock is present, carefully search for the source of the infection and, if found, manage it as per local protocols.
• If no source is found, assess if the child is ‘toxic’ versus ‘nontoxic’ using a systematic clinical score (such as the NICE guidelines traffic light scoring system) or discuss with a senior clinician.
• If toxic, perform a septic work-up and consider admission and empiric antibiotics.
• If nontoxic, perform urine screening and observe the child in the ED for signs of deterioration.
• If the child remains well, discharge them with follow-up arranged within 12–24 hours with a GP or within the ED.

References:

1. National Institute for Health and Clinical Excellence. NICE clinical guideline 47: Feverish illness in children. Assessment and initial management in children younger than 5 years. Issue date: May 2007. Developed by the National Collaborating Centre for Women’s and Children’s Health. Online. Available: http://www.nice.org. uk/CG047; 13 Jun 2011.
2. The Royal Children’s Hospital Melbourne. Clinical practice guidelines. Febrile child under 3 years. Online. Available: http://www.rch.org.au/clinical guide/cpg. cfm?doc_id=5181.
3. Mick NW. Pediatric Fever. In: Marx JA, Hockberger RS, Walls RM, editors. Rosen’s emergency medicine: concepts and clinical practice. 7th ed. Philadelphia: Elsevier; 2009. p. 2094–103.

Question 14#

A 12-month-old boy presents to the ED with a generalized rash and fever for 6 days. He has been treated for ‘tonsillitis’ by his general practitioner (GP) with amoxicillin syrup for 3 days with no improvement. Examination reveals a temperature of 39°C, dehydration, dry, fissured lips and injected pharynx. A pink morbilliform rash is present on the trunk. A mild conjunctivitis without exudate is present. Urine microscopy shows 100 leucocytes and no bacteria.

Which ONE of the following is the best answer?

A. Measles is the most likely diagnosis

Answer: D: Classic KD presents with a fever for >5 days (present from the start of the illness) and 4 out of 5 criteria (polymorphous rash, conjunctival injection, mucous membrane changes, peripheral extremity changes, cervical lymphadenopathy), whereas in atypical or incomplete KD the full criteria are not met. Other findings (not included in the criteria) include sterile pyuria, arthritis (10%), reactive thrombocytosis, normocytic normochromic anemia, transaminitis, hydrops of gallbladder, hyponatremia, aseptic meningitis (which may explain severe irritability) and erythema of the Bacillus Calmette-Guérin (BCG) vaccination site (50%).

This patient has signs satisfying the criteria for incomplete KD (fever as well as oral, conjunctival and rash features). Adenopathy and peripheral changes are absent. The child also has one supplemental criteria – sterile pyuria. The next step will be inflammatory markers. If raised, the rule is a low threshold to commence on intravenous immunoglobulin as well as high-dose aspirin to avoid the coronary complications of KD. The risk of coronary artery aneurysm formation is 15–25% if untreated.

Measles is unlikely in this case because the fever and rash usually settles by day 5. Other characteristics include a morbiliform rash that normally appears in the hairline and face first, generalised adenopathy, non-exudative conjunctivitis and Koplik spots in the mouth. Peripheral features are rare and usually appear after day 7. Desquamation only occurs in severe cases and not in the hands.

Scarlet fever is unlikely. Although pharyngitis and a strawberry tongue are characteristic, conjunctivitis is not a feature, and a good response is the rule with penicillin administration. For the same reason, titres to streptococcal antigen are unlikely to be elevated. The fever usually settles within 5 days and the rash starts from day 2 onwards, initially in the groin and axilla. Adenopathy is usually extensive and severe and desquamation may occur at day 7–10. 

Rubella, roseola infantum and systemic juvenile idiopathic arthritis may also mimic KD and should be included in the differential diagnosis.

Table below outlines the clinical profiles of the various conditions:

SYMPTOM PROFILE OF VARIOUS CONDITIONS:

References:

1. Maconochie IK. Kawasaki disease. Arch Dis Child Educ Pract Ed 2004;89:ep3–ep8.
2. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 2004;110:2747–71. 

Question 15#

A 2-year-old girl presents with fever, sore throat and coryzal illness for 5 days. She developed a maculopapular pink rash on day 2 of her illness as well as ‘pink eyes’. She appears miserable on examination with a temperature of 40°C, bilateral conjunctivitis with exudate, phayngeal injection and dry, fissured lips. She has painful cervical adenopathy and a profuse pink morbilliform rash on her trunk.

Which ONE of the following is INCORRECT?

A. Adenovirus is a potential infective aetiology for this presentation

Answer: D: This child has the typical IM-like syndrome associated with adenovirus infection. Adenoviruses cause prolonged fever and IM-like syndromes and should be included, along with cytomegalovirus, toxoplasmosis and HIV, as a cause of heterophile-negative IM, especially if peripheral blood counts reveal neutrophilia rather than atypical lymphocytosis. In addition, many of the features associated with KD, including high fever, pharyngitis, lymphadenitis, conjunctivitis and rash, as well as laboratory findings of acute inflammation, such as elevated sedimentation rate and C-reactive protein levels, have been described in children with virologically proven adenovirus disease.

Concurrent infections are common in patients with KD, found in up to 40% of patients. Concomitant viral infection is associated with a higher frequency of coronary artery dilatation. A diagnosis of an infectious condition does not preclude a concurrent diagnosis of KD.

References:

1. Demmler GJ. Adenoviruses. In: Long S, Pickering LK, Prober CG, editors. Long: principles and practice of pediatric infectious diseases. 3rd ed. Philadelphia: Churchill Livingstone; 2008. p. 1052–5.
2. Jordan-Villegas A, Chang ML, Ramilo O, et al. Concomitant respiratory viral infections in children with Kawasaki disease. Pediatr Infect Dis J 2010;29:770.