The Febrile Child

Question 1

Differential diagnosis for high fever in children

Answer 1

V - collagen vascular disorders - SLE, JIA and other systemic vasculitis dosorders

I - infection bacterial, viral, fungal or parasitic

N - lymphoma, leukaemia

D - children with degenerative more prone to infections

Question 2

Exploring systems to find the source of a fever

Answer 2

CNS - bright lights, moving normally?, irritable/unsetled, high pitched cry?

ENT - pulling at ears?, difficulty swallowing?, nasal discharge? - ?URTI

Resp - cough, stridor, wheeze, struggling to breathe? - LRTI

Abdominal
Urinary
General - rash?
Joints/Bones - swelling, redness, pain or reduced movement?

Question 3

What is the glass test?

Answer 3

Assess if a rash disappears with pressure

Can be a sign of meningococcal septicaemia

Question 4

Type of rash seen in meningococcal septicaemia

Answer 4

Non-blanching petechial/purpuric rash (over 50%) - also seen in HSP, ITP and NAI

Can be blanching or no rash

Question 5

What are Koplik spots?

Answer 5

Tiny white spots seen early in measles inside the cheeks, often before the rash begins

Question 6

Type of rash seen in measles

Answer 6

Typically dark reddish/brown and starts 3-5 days after symptom onset
On the face at the hairline, before moving down neck to body and limbs

Question 7

Which Abx would be used if a serious bacterial infection was suspected?

Answer 7

First Line: IV Cephalosporin (Ceftriaxone or Cefotaxime if calcium containing infusions are used)

If <3 months use IV cefotaxime plus amoxicillin or ampicillin

Benzylpenicillin is given in the community if meningitis suspected with no evidence of non-blanching rash and transfer to hosp was likely to be delayed

Question 8

What is the normal age for the anterior fontanelle to close?

Answer 8

18-24 months

Question 9

What is Kernig’s sign?

Answer 9

Thigh is flexed at the hip and knee at 90 degree angles
Positive = subsequent extension in the knee is painful

May indicate SAH or meningitis

Question 10

Managing a child with suspected Meningitis

Answer 10

Call your registrar and request that they urgently review patient

Protect the airway and give high flow oxygen

Obtain intravenous /intraosseous access

Take blood

Prescribe antipyretic

Take urine culture
Perform LP if not contraindicated

Start Abx

Question 11

What bloods are needed in suspected meningitis?

Answer 11

FBC, CRP, Blood culture, lactate, whole blood real-time PCR testing for Meningococcus and Pneumococcus

Question 12

Expected CSF results for streptococcus pneumoniae meningitis (bacterial meningitis)

Answer 12

Gram positive cocci

High neutrophil count - 100-100,000)

High protein (>1, may be normal) 
Low glucose (<0.4, may be normal)

Question 13

Expected CSF results for viral meningitis

Answer 13

High Lymphocytes 10-1000 (can be normal)
Neutrophils <100

Protein - 0.4-1 (may be normal)
Glucose - normal

Question 14

Normal CSF results for child >1

Answer 14

Neutrophils - 0
Lymphocytes - <5

Protein < 0.4
Glucose ≥ 0.6 (2.5mmol/L)

Question 15

Normal CSF results for normal term neonate

Answer 15

Neutrophils <5
Lymphocytes <20

Protein <1
Glucose ≥0.6 (2.5mmol/L)

Question 16

Expected CSF results for TB meningitis

Answer 16

Neutrophils <100
Lymphocytes 50-1000 but may be normal

Protein 1-5 (may be normal)
Glucose <0.3 (may be normal)

Question 17

What is high red cell count in CSF usually caused by?

Answer 17

Traumatic tap

Also intercerebral haemorrhage

Question 18

What is the correction calculation?

Answer 18

Used to see if WCC is significant when RBC are present in CSF

1 white cell for every 500 red cells

Approximately reflects ratio of WBC to RBC in bloodstream

Question 19

Likely bacterial meningitis pathogens -

Neonates to 3 months

Answer 19

Group B streptococcus
E. coli
Listeria monocytogenes

Question 20

Likely bacterial meningitis pathogens -

3 months to 5 years

Answer 20

Nisseria Meningitides
Streptococcus
Haem influenza B

Question 21

Likely bacterial meningitis pathogens -

>5 years

Answer 21

Nisseria Menningitides

Streptococcus

Question 22

Common causes of viral meningitis

Answer 22

Enterovirus (85% coxsackie and echovirus)

adenovirus
mumps
EBV
CMV
VZV
HSV
HIV

Question 23

Risk factors for bacterial meningitis

Answer 23

Asplenia
Basal skull fracture
Children with facial cellulitis, periorbital cellulitis, sinusitis, and septic arthritis
Maternal infection and pyrexia at time of delivery

Low family income
Attendance at day care/crowding

Question 24

Give dexamethasone for suspected or confirmed bacterial meningitis if LP reveals what?

Answer 24

Frankly purulent CSF

CSF WBC count >1000

Raised WBC & protein >1

bacteria on gram stain

Never in children < 3 months, or >12 hours after first dose of abx

Question 25

Acute complications of meningitis

Answer 25

Seizures
Raised ICP
Metabolic disturbance
Coagulopathy
Anaemia
Coma
Death

Question 26

Long term complications of meningitis

Answer 26

Hearing impairment
Psychosocial problems
Epilepsy
Developmental / Learning difficulties
Neurological impairment

Question 27

Necessary measures on discharge for meningitis

Answer 27

Follow up with General Paediatrician

Audiology assessment within 4 weeks

Question 28

Treatment for Group B Strep meningitis

Answer 28

< 3 months

Min 14 days Cefotaxime

Question 29

Treatment for Listeria meningitis

Answer 29

< 3 months

Min 21 days amoxicillin plus gent for at least first 7 days

Question 30

Treatment for gram negative meningitis

Answer 30

< 3 months

Min. 21 days of Cefotaxime

Question 31

Treatment for unconfirmed suspected meningitis

Answer 31

< 3 months
Min. 14 days of Cefotaxime and ampicillin/amoxicillin

> 3 months
10 days Ceftriaxone

Question 32

Treatment for H. influenza B meningitis

Answer 32

> 3 months

10 days Ceftriaxone

Question 33

Treatment for Strep meningitis

Answer 33

> 3 months

14 days Ceftriaxone

Question 34

Treatment for meningococcal sepsis (confirmed or suspected)

Answer 34

> 3 months

7 days Ceftriaxone