Hot Seat #50: 3 mos F w/ fever and recent travel
Posted on: January 26, 2015, by : Erin Augustine MD
by Erin Augustine, Children’s National
with Emily Willner, Children’s National
The Case
Term, healthy 3 mo F who presents with fever (Tmax 38.8 at home) for < 24 hours. No congestion, cough, vomiting, or rash. Loose, nonbloody stools x 4 during this time. Decreased oral intake with urine diapers x 1 in last 15 hours. Patient received 2 month immunizations one day prior to presentation.
Of note, patient was born in United States but recently traveled to Honduras (returned to United States 4 days prior to presentation).
Physical Exam: VS: T 40.1°C, HR 178, BP 125/58, RR 48, O2 Sat 99%.
General: Alert, appropriate for age.
Head: Anterior fontanelle open, soft, and flat.
Skin: Warm, dry, pink. No rash.
Eyes: PERRL. Extraocular movements intact. Conjunctiva normal.
Mouth: MMM. Normal posterior pharynx.
Neck: Non-tender. Complete range of motion.
Heart: RRR. Grade I/VI SEM loudest at left sternal border. Pulses 2+.
Lungs: Clear to auscultation bilaterally. No wheeze or crackles.
Abdomen: Soft, non-tender, and non-distended. No organomegaly.
Neurologic: Age appropriate. Normal tone and strength.
Musculoskeletal: Moves all extremities.
Acetaminophen is given in triage. You order a UA and culture, and start a PO trial.
Questions for you:
“Other” for >3 yrs PEM = Stool culture, o&p, cbc, bcx
Re-examination 2 hours later . . .
T 39, HR 188, RR 50, BP 112/70, Sat 100%. Age appropriate behavior. RRR. No murmur. Lungs clear. No hepatomegaly. Pulses 2+. CR 2 seconds.
Given continued fever and persistent tachycardia, a total of 3 fluid boluses have now been given. Labs were sent and return with WBC 7, otherwise unremarkable CBC, UA negative, CMP normal, and malaria thin/thick negative.
Assuming that an LP has not been performed and antibiotics have not been given…
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
Persistent tachycardia (although here with persistent fever) should give room for pause. Recent travel would imply possible exposure to all kinds of tropical illness, the other usual suspects for which, ah yes, she was vaccinated only a day prior (including rotashield?)
So if she wasn’t persistently tachycardic or febrile, I might send her home with great followup and good parenting. But that isn’t probable, so let’s admit, repeat bloodwork (including CRP) and stool studies, give continued antipyresis. LP to consider enterovirus, I suppose. Proper belly exam to make sure there is no appendicitis…:)
We have just finished reviewing Lactates and other markers. Would you get one? I might.
I think the real question here is “how young can infants get travel diseases….particularly malaria and typhoid?” not sure if there is Dengue there. It’s always good to find out exactly where folks have traveled and look at the CDC website for outbreaks and other diseases endemic to the area.
My impression has always been that YOUNG infant travel disease risk is a real question mark. Mom’s can get malaria and pass along disease to the fetus, but usually the first few months of life the infant is protected from mom’s antibodies if born healthy. The graphs usually show 6 months as the breaking point for infant Ab > mom Ab, but infants CAN get malaria before that as maternal Ab diminish. I think the magic number is around 3 months to realistically consider these diseases.
When my daughter was 6 weeks old i took her to a travel/ID doctor preparing for a trip to the Dominican Republic at a tender 2 mo of age amidst a cholera outbreak. me=superdad. I asked if she needed malaria prophylaxis or a typhoid shot and his reply was, “huh…not sure. use DEET and bottled water.”
So for this infant, the temp of 40.1 is pretty hot and would make me at least get a malaria prep, blood cx, and consider treating empirically for typhoid (if its endemic there).
So then there’s the HR going UP with defervescence from 40->39. Maybe giving 3 boluses for a kid with normal perfusion was too many 🙂 I would put the infant on cardiac monitors, make sure there aren’t PVCs or runs of v-tach that might indicate acute myocarditis. 188 isn’t a crazy heart rate for that age but an increasing HR in the setting of an acute febrile illness is not reassuring. yes to CXR and repeat lung exam.
Now with a negative malaria prep and normal WBC and normal mental status…..i would make my admit/discharge decision based on the HR trend and ability to tolerate PO. i would NOT LP this infant unless fussy, not feeding, lethargic, has a seizure, leukopenia, etc. maybe there is value to the rapid flu test ?
Just as an interesting note, the CDC website states that these are the febrile illnesses currently found in Honduras.
1. Malaria
2. Dengue Fever
3. Typhoid
and that hot newcomer to Central America, Chikungunya
They are recommending Yellow Fever vaccination for anyone traveling to Central America as well, though it looks like it is not typically found in Honduras.
Just thought it was an interesting collection of things we don’t typically think about!
Agree, always good to check the CDC website: http://wwwnc.cdc.gov/travel/destinations/traveler/none/honduras
From the Hot Seat attending…
A bunch of my main points for this case have already been covered – thanks, guys. Here we have a common scenario: a febrile infant over 60 days old, with one set of vaccines. This case has several twists: recent travel, recent immunizations, and a quite high fever.
Clinically, this patient is described as highly febrile, and tachycardic but without other focal findings. I am concerned for possible dehydration by history with decreased UOP and diarrhea, but the stated exam does not suggest significant dehydration. She has a murmur on exam: I would explore with the family whether this has been noted earlier, worked up etc. I’d be sure to listen again when she defervesces to see if it is just related to increased flow in a hyperdynamic state. If never noted before and does not go away with defervesence, it would raise my concern for myocarditis, anemia (malaria??), or an undiagnosed structural heart lesion.
The specific details of the travel history are important (but not provided). I would ask how long they had been in Honduras, where exactly they stayed (region, as well as urban vs rural), did they stay in a home without screens/nets vs a hotel with AC, how the baby was fed while there (formula vs breastmilk, any other foods). Then I’d consult the CDC website, which has already been listed above. There are a few different areas I’d look at: first, the location-specific listing for clinicians [link below]. From there, there you can link to the detailed yellow fever risk chart, as well as the region-specific malaria risk. http://wwwnc.cdc.gov/travel/destinations/clinician/children/honduras
What I learned is that typhoid, dengue, and chikungunya are fairly prevalent in Honduras. Malaria transmission risk is moderate and present in most (but NOT all) parts of the country. Typhoid is also a consideration. Yellow fever is not active in Honduras, and vaccine is not required to travel there from non-endemic areas.
As a brief reminder about the above, courtesy of CDC:
Dengue: Viral. NO vaccine or prophylaxis. Leading cause of febrile illness among travelers returning from the Caribbean, South America, and South and Southeast Asia. 4-7 day incubation period. Febrile illness, associated sx are N/V, severe HA, retroorbital pain, body aches, rash, and minor hemorrhagic manifestations (petechiae, gum bleeding, +tourniquet test). 5% of patients develop dengue shock syndrome, with severe capillary leak leading to hypovolemic shock, ascites, pleural effusions.
Chikngunya: Viral. NO vaccine or prophylaxis. Increasingly common in Central America and Carribean. Febrile illness (T>39) with 3-7 day incubation period. Associated sx- severe polyarthralgia, also headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, or maculopapular rash. Mortality is rare, and more common in elderly, chronically ill, and in utero transmission to neonate.
Dengue and chikungunya viruses are transmitted by the same mosquitoes and have similar clinical features. How to differntitate clinically?
Chikungunya- more likely to cause high fever, severe arthralgia, arthritis, rash, and lymphopenia.
Dengue – more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock, and death.
Typhoid – S. typhi, vaccine available (over age 2). Fecal-oral transmission. Low grade progressing to high grade fevers over 3-4 days. Headache, malaise, anorexia, transient macular rash. Late complication is intestinal perforation. Fever may be prolonged. Not typically a diarrheal illness (unlike S. enteritidis).
Malaria- Parasitic. In Honduras, P. vivax >>> P falciparum. Fever, often cyclical, assoc w chills, headache, myalgias, and malaise. Incubation 7 days to months. Severe disease: seizures, confusion, kidney failure, acute respiratory distress syndrome, coma, and death.
SO- what to do with the baby? In highly febrile (>39) young infants without 2 doses of vaccines, I tend to order CBC and blood culture, even if I’m not checking the CDC website first.
With the recent history of travel, I’d definitely do a CBC (specifically looking for cytopenias suggestive of dengue or chikungunya, or anemia from malaria), blood culture (for typical pathogens as well as S. typhi), and a CMP (looking for transaminitis, lytes w diarrhea). I wouldn’t do any initial testing for dengue or chikungunya. If there was any concern for malaria- i.e. stayed in an area with transmission risk – I would send malaria thick and thin smear. I’d get a stool culture too (for S typhi, as well as common bacterial stool pathogens).
I would likely defer an LP unless the baby had neuro symptoms or seemed irritable or lethargic. I WOULD wait for a platelet count before LP, if indicated, due to bleeding risk/low plts w dengue.
I’ve got to admit, the normal labs in part 2 of this case would make me breathe a sigh of relief: it’s less likely dengue shock syndrome, even with persistent tachycardia. That said, I would definitely admit and would cover with ceftriaxone (covers S. typhi, S. pneumo, S. enteritidis, GBS, most E. coli) given age, travel, clinical course with persistent fever and tachycardia. I’d do a careful cardiac re-eval if she was really still that tachycardic (when calm, even with a fever) after 60 ml/kg NS to convince myself that she doesn’t need more eval for myocarditis.