by Erin Augustine, Children’s National
with Emily Willner, Children’s National

The Case
This case deals with a  3 mo F with recent travel to Honduras who presents with fever and diarrhea.  The challenge of this case is how to address a febrile infant >60 days old with recent travel, recent immunizations, and a high fever.

Here’s How You Answered Our Questions

“Other”  for >3 yrs PEM = Stool culture, o&p, cbc, bcx

The poll was mixed on work-up.  Most providers would obtain a CBC and BCx in addition to UA/UCx.  The CBC could show neutropenia, thrombocytopenia, and/or anemia if thinking about dengue, chikungunya, or malaria.  Providers mentioned specifically looking for S. typhi in the BCx.  Others would obtain a malaria thick/thin smear, after obtaining a detailed travel history and looking at risk for malaria on the CDC website.  Several mentioned obtaining a stool culture and O&P.  No one felt strongly about obtaining dengue or chikungunya viral tests at this point.  Most would not perform an LP.  Several mentioned treating with ceftriaxone to cover S. typhi, S. pneumo, GBS, etc.  Others, felt that admission with observation due to persistent tachycardia/fever was sufficient.

Denouement
Repeat exam about 2 hours later significant for T 39.9, HR 200, RR 50, BP 115/51, Sat 100%, and capillary refill of 3 seconds. By this time, patient had been given a total of 5 fluid boluses, Ceftriaxone, and Vancomycin. CXR obtained and with possible retrocardiac atelectasis. No infiltrate or cardiomegaly. Patient admitted to PICU.
While in the PICU patient with continued fever and tachycardia. About 12 hours after presentation, patient developed bradypnea (RR 20) and was intubated. Shortly after intubation, patient became hypotensive (BP 61/32) and was required support with Dopamine and Milrinone.
Chikungunya titers eventually returned positive. Patient treated for culture negative sepsis for 10 days with Ceftriaxone and Vancomycin. Patient extubated after 6 days and discharged home after 10 days.

Teaching Points from Thursday Conference
Chikungunya (pronunciation: \chik-en-gun-ye) virus, transmitted by mosquitoes that causes fever (T>39), joint pain, headache, muscle pain, joint swelling, or rash. There are no vaccines or prophylactic medicines for chikungunya. Travelers should prevent mosquito bites.  It has a 3-7 day incubation period.  For more information on chikungunya look at the CDC website.

An excerpt from Dr. Willner’s comments:
“Dengue and chikungunya viruses are transmitted by the same mosquitoes and have similar clinical features. How to differentiate 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.”

As discussed in conference, don’t forget Salmonella typhi, which can cause both hypovolemic and septic shock and may progress rapidly.  Consider obtaining a BCx and giving CTX.  Vaccinate travelers >2yo for prophylaxis.