Hot Seat #147: Denouement

Posted on: March 15, 2020, by :

The case: 10 week old, ex-36 week boy presenting as a repeat for 4 days of fever, who had received ceftriaxone 2 days ago as part of a fever work up

Here how you answered:

Discussion: This case prompted a very lively discussion and highlighted the spectrum of practice patterns across the group. Almost all agreed that at baseline, this child’s risk for meningitis is very low. A recent article that studied a younger cohort (1188 infants aged 29-56 days), found only 1 case of bacterial meningitis (0.08%). Some argued that the challenge in this case was the “pre-treatment” with antibiotics 2 days prior. Nearly all participants stated that if this child had no received antibiotics, they would have likely sent home without further workup, but felt that the antibiotics “muddied the waters” and would be the reason to obtain a lumbar puncture. Finally, most participants agreed that WBC count is only marginally helpful in the evaluation of these infants (and really any otherwise healthy child). Looking into the literature, a study looking at children with “extreme leukocytosis” found no difference in rates of serious bacterial infection, as compared to those with mild leukocytosis, with an AUC of 0.57 for proven infections.

Denouement: Given how well the patient looked, and with the parents able to verbalize signs to look out for, the patient was sent home without antibiotics. The patient followed up with his PCP the next day and continued to look well. He had a fever that morning, but defervesced later that day. Blood cultures and urine cultures remained negative; no source for the fever was identified.

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.

Brian Lee
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