Sam Zhao, Children’s National Medical Center
with Alex Rucker, Children’s National Medical Center

The Case
7wo F with sickle cell disease presented with fever and URI symptoms after receiving vaccinations.

Here’s How You Answered Our Questions

Denouement:
The ED team did not want to administer ceftriaxone without performing an LP given the patient’s age. They also did not want to perform an LP on this otherwise well-appearing infant with low risk of SBI based on exam. Additionally, the thought process was that the patient’s young age actually meant that she had a significant level of fetal hemoglobin that was protective against infections more commonly associated with older sickle cell patients like pneumococcal bacteremia. Thus, the decision was made to discharge home without empiric antibiotics with PMD follow-up the next day and strict return precautions for poor PO intake, lethargy, or any other changes in behavior.

The patient was unable to be seen by her PMD the next day, so she re-presented to the ED for follow-up. She had no more fever in the interval, no change in PO intake, and no decrease in UOP. She continued to be well-appearing and was discharged home with hematology clinic follow-up appointment in two days.

Discussion:

Everyone rather rapidly decided that we could treat this kid like any other healthy 7 week old, given his fetal hemoglobin, and that he is not at risk of splenic sequestration/dysfunction this early, so should have a normal immune system.

There was robust discussion about serious bacterial infection in a neonate.  Dewesh reminded us of the literature that children under 1 month have a 1% chance of bacterial meningitis, under 2 months have a 0.4% chance of bacterial meningitis and under 3 months have a 0.2% chance of bacterial meningitis.  And, we should consider this when risk stratifying in the ED.

And, furthermore, that WBC has been shown to have no correlation with bacterial meningitis risk.  So, we should never be ‘reassured’ by normal CBC when considering whether or not to do an LP.

We all agreed that you could not start ceftriaxone on this patient without an LP, so if you had wanted to admit to Hematology and they wanted to start ceftriaxone, you would be obligated to tap the kid.  Luckily, that did not happen.

We also discussed the reliability of PCP followup.  Rob and Pavan mentioned that this kid is in the ED, so he is inherently at a different risk category as the family did not go the PCP for some reason (don’t have one, it’s a weekend, PCP couldn’t see them), which would make us have less faith in PCP followup in 24 hours.  However, Dewesh also brought up the PROSE study among community pediatricians, which shows that so many PCPs treat fever like this supportively, without invasive testing.  Christina also brought up the important point of family reliability, which we should take into account in this case as well when discussing disposition and followup.