Jeremy Root MD, Children’s National Medical Center

The Case:
A 2 year old presents with viral symptoms and an impressive leukocytosis.

Here’s How You Answered Our Questions:

Discussion:
The poll results for this case indicated relative agreement amongst respondents, with most opting for further workup of the leukocytosis, but ultimately discharge home if the results were reassuring. While it wasn’t explicitly listed as an option, giving a dose of ceftriaxone as empiric treatment for pneumococcus was a popular suggestion both in the comments and during our live discussion.

Our discussion had a few important take-home points. Jennifer Chapman reminded us that children with serious bacterial infections, including pneumococcal sepsis, can look surprisingly well. Regarding the blood smear, multiple participants reiterated that the ability to find atypical cells or blasts is only as good as your lab technicians. This made everyone more comfortable with the normal WBC differential here, as opposed to the reportedly normal smear at the outside hospital. For the history of prolonged fever, because so much hinges on an accurate fever history, Pavan Zaveri suggested pulling out a calendar and having parents mark the days that the patient had a fever. This can sometimes turn “fever for two weeks” into a “few days of fever over the past two weeks,” which can dramatically alter the workup.

Jennifer Chapman gave us an excellent overview of her rationale in working up this leukocytosis.

Denouement:
The patient was admitted to the hospitalist service and oncology was formally consulted. She was started on IVF due to history of decreased PO and insensible losses. Blood cultures and urine cultures were sent and the patient was watched off antibiotics. A respiratory viral panel was negative. WBC was repeated daily and was downtrending. The patient was ultimately discharged after two-day hospital stay with WBC count of 14.2. She was scheduled to follow-up with her PCP for repeat CBC.

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