Hot Seat #158: 6 week old transferred for second opinion.
Posted on: October 5, 2020, by : Brian Lee
HPI:
6-week-old, ex-full-term girl with history of VP shunt for congenital hydrocephalus, g-tube dependence presents as a transfer from outside hospital for evaluation of fever. Unfortunately, she arrives with her grandfather (patients parents preferred to drive vs fly and are about 60 minutes away). Grandfather only knows that she has had fevers and was recently discharged from another hospital. He thinks she is well appearing and denies any recent changes that he is aware of. Grandfather is not sure of any other medical issues and does not know when the shunt was placed.
Call ahead information from outside hospital states that she was recently discharged from another children’s hospital (where VP shunt placed) 3 days prior, where she underwent an extensive evaluation for fever, all of which was reportedly negative. Today she presented to a local community ED for another fever (Tm- 102 at home) and diarrhea. CXR reportedly negative, but her parents refused any blood draws and requested transfer for second opinion.
Exam: Vitals 36.2, HR- 140, RR- 32, BP- 99/48, SaO2- 99% on RA
Gen: No distress, awake and alert
HEENT: Macrocephalic with large fontanelle, but not tense; PERRL, EOMI, Shunt site is c/d/i without any erythema, discharge, or TTP
CV: RRR, no murmurs
Pulm: Ctab
Ab: Soft, NTND. VP surgical incision is well healing
Extrem: 2+ pulses, <2 sec capillary refill
Neuro: CN2-12 intact, moving all extremities equally, palmar and plantar grip intact, +suck reflex
You attempt to contact parents regarding workup, but phone repeatedly goes to voicemail.
While waiting for parents to arrive, which is likely 60+ minutes, what workup (if any) would you pursue?
Her Grandfather agrees to blood and urine studies, which are obtained. Labs are significant for:
CBC: 9.85>9.2//29.5<428 with: 25%segs, 19% bands, 35% lymphs, and 15% monocytes
CMP: unremarkable
CRP: 11.88
UA: negative
Repeat Vitals: T- 37.1, HR- 132, RR- 28, 99/48, SaO2- 99% on RA
Exam is otherwise unchanged and her parents still have not arrived.
Before having to decide on next course of action, family arrives. They inform you that they are frustrated that no one has been able to tell them why their daughter is having a fever. She has been having intermittent fevers for the last 3 weeks. She was hospitalized last week at the institution where shunt was placed and had “an extensive workup.” They report that her bloodwork was negative, and imaging of the shunt was normal. She was discharged 3 days ago, but fever has continued. Today she had diarrhea, which is a new symptom, so they brought her back to be evaluated. They report that she has also been less active than usual but has had no intolerance of feeds. Reviewing her PMHx, they report that she has no other medical problems, takes no medications, and had the shunt placed within the first week of life and it has had no issues. With this new information neurosurgery is consulted, who requests head CT and shunt series.
Shunt series is normal, and CT shows no definite evidence of shunt failure but “failure cannot be fully excluded without comparison of prior imagining.” Neurosurgery evaluates patient and agrees that they see no sign of shunt failure, and do not feel that fever is related to shunt. They do not feel that tapping the shunt for CSF is indicated and that the fevers are from another source.
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If neurosurgery does not think that there is a true shunt failure, they almost never want to tap a shunt for infection (at least at our institution). Their worry is that each time you tap the shunt you take the risk of introducing bacterial into the shunt, leading to infection and eventually removal or externalization of the shunt. They would much prefer that you just perform an LP. So then you have to ask if you think this child has meningitis or a shunt infection. She’s definitely in the right time course for a shunt infection this soon after placement but the overall time course of her illness and otherwise well appearance suggests otherwise. And the bandemia on labs makes me nervous. The documents from the OSH could be helpful but not sure if you have the time to get them.
The child has high fever without source and bandemia. The shunt has been recently placed. It could be infected, and the child seems far more likely to have an infected shunt (staph aureus, GAS) than to have meningitis of hematogenous origin (very late GBS, GNRs, strep pneumo, Hib, mening). I therefore find it to be unreasonable that NS will not tap shunt. If they stick to that position, I would perform a LP and initiate antibiotics. Getting outside CT images is important too to assess for failure.
Would anyone get a procalcitonin to guide their decision to LP or not?
In this case, I would definitely try to get some CSF to help guide this case, especially. because the bandemia makes me (and Katie) nervous. From what I could find on PubMed, there’s a wide variation of rates of shunt infection (some reporting .3% to a terrifying 40% in non-US countries). But in the early 2000s, the rate was about 11% from what I can gather. Risk factors included premature birth, previous infection and neuroedoscopic tools being used. In this case, I would probably ask the NSGY resident why they were so confident and if they spoke to their attending versus speaking to the NSGY attending myself. Then, if really getting push back, would perform an LP if necessary. To Dewesh’s point, not sure where the pro cal would fit in my decision making, considering there is a bandemia and that initial temp was 36.2, which is a little low.
Also, for admission, I might call the NICU first, before the hospitalist team.
I was about to type what Stephen says above — I would do the LP myself for all the reasons listed by all – bandemia, timing since shunt placement, age of patient etc. How helpful or possible is it to get OSH records — at least to document or trend this extensive work up the parents refer to. What abx has this child already been exposed to? The risks are too great to miss an infection in this case . Agree with Lecuyer –this is a good discussion for NICU admit.