Hot Seat #173: 5yo with fever and rashPosted on: June 16, 2021, by : Mary Beth Howard
Malek Mazzawi, MD, Children’s National Medical Center
Outside hospital calls requesting transfer of a 5-year-old previously healthy girl with fever and rash for 7 days. She was diagnosed with roseola 5 days prior at urgent care then started having worsening headache, somnolence and decreased PO. She developed a diffuse, non-pruritic, erythematous rash on her trunk that spread to her extremities. Fevers have been daily but unsure Tmax. She complains of photophobia and some pain with neck movement. Has had a few episodes of NBNB emesis, one episode of diarrhea, no dysuria. No recent travel, no bug bites, no known COVID contacts.
Review of Systems:
Constitutional symptoms: +Fever, +Fatigue, +Somnolence
Skin symptoms: +Non-pruritic rash on trunk and limbs
ENMT symptoms: No sore throat
Respiratory symptoms: No shortness of breath, +Cough, +Congestion
Cardiovascular symptoms: No chest pain
Gastrointestinal symptoms: +Vomiting, +Diarrhea, +Mild abdominal pain
Musculoskeletal symptoms: +Neck pain
Neuro symptoms: +Photophobia, +Irritability, No seizures
- Previously healthy, has had several dental surgeries for poor dental hygiene
- Fully immunized
- No meds or allergies
HR 130-150, RR 26, temp pending but feels very warm, O2 sat 95-96, unable to get BP.
She is in no respiratory distress, she is flushed, brisk cap refill. Has flat, erythematous rash. Irritable but consolable. Looks sick.
Labs and imaging at OSH were:
WBC 19K (28% bands), Hgb/Hct of 9.6/28, Plt 355
Chem normal, BUN/Cr of 19/0.49, Albumin 2.4
ALT 22, AST 40, Tbil 0.4. Ca 8.2
PTT 26.5, INR 1.36.
Lactate 2.3, Procal 25.36 , CK 34
COVID, Rapid Strep, Flu and RSV all negative
There is no PICU bed available so the patient must come to the ED. Transport team is available, round trip time 20 min by air.
While awaiting transport the OSH attempted LP and failed. No CT was done. They gave Ceftriaxone and fluid resuscitated. You get Med Control from transport team who reports ill-appearing child with BP that has dropped from 112/59–>78/37. She is started on Norepi drip. Patient is protecting airway and is not intubated.
Physical Exam upon Arrival:
Initial vitals: T 40.5C, HR 145, RR 32, SpO2 99% on RA, unable to obtain BP
Wt 19.5 kg
General: Moderate distress, responds to commands, irritable but consolable
Skin: Erythematous non-raised rash on the back and trunk and bilateral extremities.
HEENT: NCAT. Conjunctiva clear. Nares patent. Moist oral mucosa. PERRL. + conjunctival injection.
Neck: Mild nuchal rigidity
ENT: Tympanic membranes clear. Oral mucosa moist. 2-3 cm area of swelling posterior and inferior to the left angle of the mandible, mobile, without overlying erythema, nontender to palpation. Both tonsils appear enlarged, mildly erythematous, without exudate. Left tonsil > right.
Cardiovascular: RRR, normal S1/S2, no murmur. Distal pulses 2+ and cap refill < 2 sec
Respiratory: Lungs CTAB. No wheezes, rales or rhonchi.
Musculoskeletal: No deformity. Full ROM of extremities. Normal back.
Gastrointestinal: Soft, diffusely tender to palpation. No hepatosplenomegaly
Neurological: Responds to commands however no verbal interaction with examiner or parents, unable to assess orientation, moving all 4 extremities equally.
CT scan was performed. Radiologist read was “Findings indicate cerebral leptomeningeal enhancement, suggestive of meningitis. Recommend clinical correlation with lumbar puncture for further evaluation of etiology. No evidence of extra-axial fluid collections.”
CSF RBCs 0
CSF Nucleated Cells 3 Cell count 31
Further workup included MIS-C labs which resulted as following:
COVID IgG Positive
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