The Febrile Child Flashcards
Differential diagnosis for high fever in children
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
Exploring systems to find the source of a fever
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?
What is the glass test?
Assess if a rash disappears with pressure
Can be a sign of meningococcal septicaemia
Type of rash seen in meningococcal septicaemia
Non-blanching petechial/purpuric rash (over 50%) - also seen in HSP, ITP and NAI
Can be blanching or no rash
What are Koplik spots?
Tiny white spots seen early in measles inside the cheeks, often before the rash begins
Type of rash seen in measles
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
Which Abx would be used if a serious bacterial infection was suspected?
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
What is the normal age for the anterior fontanelle to close?
18-24 months
What is Kernig’s sign?
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
Managing a child with suspected Meningitis
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
What bloods are needed in suspected meningitis?
FBC, CRP, Blood culture, lactate, whole blood real-time PCR testing for Meningococcus and Pneumococcus
Expected CSF results for streptococcus pneumoniae meningitis (bacterial meningitis)
Gram positive cocci
High neutrophil count - 100-100,000)
High protein (>1, may be normal) Low glucose (<0.4, may be normal)
Expected CSF results for viral meningitis
High Lymphocytes 10-1000 (can be normal)
Neutrophils <100
Protein - 0.4-1 (may be normal)
Glucose - normal
Normal CSF results for child >1
Neutrophils - 0
Lymphocytes - <5
Protein < 0.4
Glucose ≥ 0.6 (2.5mmol/L)
Normal CSF results for normal term neonate
Neutrophils <5
Lymphocytes <20
Protein <1
Glucose ≥0.6 (2.5mmol/L)
Expected CSF results for TB meningitis
Neutrophils <100
Lymphocytes 50-1000 but may be normal
Protein 1-5 (may be normal)
Glucose <0.3 (may be normal)
What is high red cell count in CSF usually caused by?
Traumatic tap
Also intercerebral haemorrhage
What is the correction calculation?
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
Likely bacterial meningitis pathogens -
Neonates to 3 months
Group B streptococcus
E. coli
Listeria monocytogenes
Likely bacterial meningitis pathogens -
3 months to 5 years
Nisseria Meningitides
Streptococcus
Haem influenza B
Likely bacterial meningitis pathogens -
>5 years
Nisseria Menningitides
Streptococcus
Common causes of viral meningitis
Enterovirus (85% coxsackie and echovirus)
adenovirus mumps EBV CMV VZV HSV HIV
Risk factors for bacterial meningitis
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
Give dexamethasone for suspected or confirmed bacterial meningitis if LP reveals what?
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
Acute complications of meningitis
Seizures Raised ICP Metabolic disturbance Coagulopathy Anaemia Coma Death
Long term complications of meningitis
Hearing impairment Psychosocial problems Epilepsy Developmental / Learning difficulties Neurological impairment
Necessary measures on discharge for meningitis
Follow up with General Paediatrician
Audiology assessment within 4 weeks
Treatment for Group B Strep meningitis
< 3 months
Min 14 days Cefotaxime
Treatment for Listeria meningitis
< 3 months
Min 21 days amoxicillin plus gent for at least first 7 days
Treatment for gram negative meningitis
< 3 months
Min. 21 days of Cefotaxime
Treatment for unconfirmed suspected meningitis
< 3 months
Min. 14 days of Cefotaxime and ampicillin/amoxicillin
> 3 months
10 days Ceftriaxone
Treatment for H. influenza B meningitis
> 3 months
10 days Ceftriaxone
Treatment for Strep meningitis
> 3 months
14 days Ceftriaxone
Treatment for meningococcal sepsis (confirmed or suspected)
> 3 months
7 days Ceftriaxone
