Hot Seat #214: Frustrating Flummoxing Fevers
Posted on: September 10, 2023, by : Brandon Ho
Case by Jasmine Thomas MD, CNMC PEM Fellow
A previously healthy 4-year-old female presents with 7 days of fever. The patient was seen at an urgent care a few days prior where a rapid strep test was positive, and she was started on a 7-day course of amoxicillin. Since then, she has developed new loose stools, abdominal pain, decreased urine output, and decreased appetite. She continues to have fevers. No sick contacts or recent travel.
Vitals: T 38.8, HR 140, RR 28, BP 125/58, SpO2 97%
General: Alert, fussy but consolable
Skin: Warm, dry
ENT: Tympanic membranes clear, no pharyngeal edema or exudate
Neck: no lymphadenopathy
GI: Soft, normal bowel sounds. Periumbilical tenderness. Negative rebound or guarding. No organomegaly
Results notable for WBC of 12, normal CMP, UA negative. RVP positive for COVID 19. Ultrasound negative for appendicitis, however, demonstrates hepatosplenomegaly with numerous hypodense splenic lesions/cysts.
CT demonstrated hepatomegaly with less defined splenic focal lesions that were previously demonstrated on ultrasound. EBV IgG elevated, IgM normal. LDH and Uric Acid are normal. The patient is tolerating PO and is discharged home with close PCP follow-up.
Seven days later the patient returned to the ED for persistent fevers and new onset neck pain. Now on day 14 of fever. ROS is positive for decreased PO and decreased urine output. Denies abdominal pain, rash, or vomiting. On exam, the patient complains her head hurts and is unwilling to move the right side of her neck and screams with light palpation. No visible swelling. No drooling, trismus. PERRL. She appears ill.
Expanded history reveals that a tick was removed from the scalp a few months ago, and the patient has had recent mosquito bites. No recent travel. No TB contacts, but an aunt is visiting from the Philippines and staying with them. The patient has two cats at home.
You consider admission and infectious disease consult. You order Lyme, bartonella, quant gold parvovirus, CMV and toxoplasma testing.
It was interesting that a 4 year-old with FUO and hepatosplenic lesions was discharged home with PCP f/u after 7 days of fever. Now, with 2 weeks of fever, cervical lymphadenopathy, hepatosplenic lesions and 2 cats at home, this is bartonella henselae until proven otherwise. TB/atypical mycobacteria are in the differential and lower down is lymphoma, but cat scratch is #1 in my mind.
100% agree w Dewesh. This is a great story for Bartonella. I have seen Bartonella cause cervical osteomyelitis with a similar presentation, and the hepatic/spleen lesions further raise concern. I would have consulted ID on the first ED visit w 7 days fever and liver/spleen lesions (even if not as prominent on CT as US) to discus workup / additional labs we need to send. Liver/spleen are tricky on imaging and I’d call the body attending to discuss these findings; it’s weird to have a “false positive” for lesions on US. Before calling ID, this kids needs the ED team to do a good, ID-style travel and exposure history. In addition to TB and non-TB mycobacterial infections, brucellosis and histoplasma are also in the ddx as can cause systemic illness w hypoattenuating liver/spleen lesions with disseminated infection. Need to know if they have visited central US (histoplasmosis) or eating unpasteurized dairy or been in contact w farm animals/even petting zoos (brucella).
Agree with above! It doesn’t seem like we ever had a good explanation for the hepatosplenomegaly/splenic cysts after the first visit? But interesting it doesn’t seem like she had elevated AST/ALT either. Given her throat looked fine- it seems like the positive strep was just a red herring. I definitely agree that an ID consult would be helpful in thinking about a differential. Without true nuchal rigidity (seems like more focal neck pain), and given the duration of symptoms at the second visit I don’t think an LP would be indicated emergently.