A child with high fever and pain

J C MulderRotary Doctors Nederland

8 januari 2014

WHO IMCI

• Assess and classify the sick child• Treat the child

- 2 months-5 years

• Aim: reduction morbidity and mortality

WHO triage systeem:ETAT (Emergency Triage and

Treatment)• 1 emergency• 2 priority• 3 nonurgent

• (compare APLS)

Children High fever and pain

• What to do in a setting with limited lab facilities, X-ray, CT and MRI access and no consultants/referral possibilities

Case 1

• History: Peter 3 years of age, since 3 days a cold. Tonight suddenly more ill with high fever of 40º C . Grasping right ear. Refuses to drink.

• Examination: An ill looking child, tilted head, non- coöperative. Right ear stands away. You are not allowed to touch it.

1. What else do you want to know?2. What do you examine?3. What is your dd?4. What is your action?

Mastoiditis• Status after otitis media acuta• Ear stands away/ pitting oedema behind ear• Pain and high fever• Admission! to hospital Lab.; OR? Depends on age

and duration and facilities (Surgeon ENT experience)• When full mastoidectomy is feared,make abscess

incision• antibiotics i.v. Start 1st dose orally!

WHO:Chloramphenicol and benzylpenicillin 10 days• Pain relief: paracetamolComplications: extradural abscess, meningitis, brain-

abscess, facial nerve paralysis, sinus trombosis

OMA Otitis Media Acuta

• Pain!!! Paracetamol• Paracentesis?• Causes: Pneumococ, Haem. Infl. En Moraxella C.• Meestal spontane perforatie< 48 uur• Antibiotics (?) : Amoxicilline 7 days or

cotrimoxazole

Chronic ear infection/ cholesteatoom: attico-antrotomia (chronic mastoiditis)-ENT

DD otitis externa

Tonsillitis (NTVG 4 januari)• Volwassenen: complicaties moeilijk

voorspelbaar: peritonsillair absces, otitis media, sinusitis, huidinfectie-(late Streptococ A complicaties: Scarlet fever, PSGNefritis, acuut rheuma.)

• Direct voorgeschreven AB verlagen kans daarop niet (Britse h.a. studie 600 pr.)

Meer kans op Strept. A bij: koorts, purulente tonsillen, halsklieren, pijn

• Veelal virale oorzaak DD M. Pfeiffer• Hoe te handelen bij kinderen in de

tropen?• Smal spectrum penicilline 3-6 dagen

Epiglottitis

• High temperature• Haemophilus influenzae

- vaccination

• Inspiratory stridor ++• Inspection throat on OR with pediatrician, ENT

specialist and anaesthesiologist• Often need for intubation and PICU

- Alternative: tracheostomia

• Dd pseudocroup (laryngitis subglottica): less ill;lower temperature

• Antibiotics

Acute lymfadenitis colli• Snel ontstaan• Hoge koorts• Cave abscedering: fluctuatie? Evt. echo

- Evt. incisie en drainage

• Amoxicilline/clavulaanzuur ivm naast GAS ook SAureus

Ethmoiditis

• Upper respiratory tract infection• Ill looking/in pain• Red eye or chemosis• Oedema of the orbita

• Always admission• X ray and lab• I.V. a.b.Start 1st dose orally!• Sometimes OR• Complication: sinus-trombosis

Case 2• Sabine, 9 years of age refuses to walk because

of a painful right knee+ upper leg. T.: 39º5 C

- 1 What do you want to know- 2 What do you examine- 3 What is your dd- 4 What is your action?

Artritis≠artralgia

• Cave septic artritis: always admission for proper diagnosis and treatment

• Dd osteomyelitis in young children especially

• Acuut Rheumatic Fever• PSRA• JIA• trauma

Septic artritis 1(pyogenic bacteria)

• Clinical Features:- Mostly knee or hip(80%): Why?- Unilateral- High fever and pain: Site/Age/Agent dependant- Poly-articular: neonates: Why?

• Examination:Hip:- Flexed leg/abduction/exorotation- Pain on passive movement/refusal to walk- Artritis hip can present with kneepain!

• Signs of inflammation: - red, hot, painful, swollen and loss of function

Septic artritis 2

• Causative agents: - Staph.Aureus and strept.A- N.gon. (adolescents)- Strep.B and gram – bact. In neonates

Septic artritis 3 Management

No delay ( hip catastrophic )•Always joint aspiration: synovial fluid: gram/WBC/culture•Start iv antibiotics (tropics: chloramphenicol)•X ray?•Ultrasonography?•Lab.: ESR,CRP,CBC c. diff.,Culture, ASO-titer•Follow up temperature and CRP or ESR

Osteomyelitis• Acute/subacute/chronic

- Extremities: 70% tibia, femur, and humerus

Hematogenous in children- Site of entry/local invasion

• Clinical features: - age related pain and immobility- the younger, the more signs on P/E: cellulitis

Causes: 20-50% culture negative!- S.Aureus ( beware of MRSA)> 3years- Strep.B(infants) Strep.A /S. Pneum.and Hib(in

toddlers)- Salmonella(sickle cell disease)

Lab.: High WBC, ESR and CRP: follow upX-ray?

Osteomyelitis treatment

• Depending on age and causative agent:• In general < 3 years chloramphenicol• > 3years cloxacillin or flucloxacillin or

clindamycine older children (or chloramphenicol)

• Africa: chloramphenicol <3 y or sickle cell • Duration 3 weeks minimum• Switch from I>V to oral depending on clinical

course(pain and fever) and lab CRP• Chronic o.: surgery Cave TB

Acute Rheumatic Fever 1

• 2-4 w after strep.A tonsillo-pharyngitis• Age 5-15 years preferrably• Clinical diagnosis Jones criteria:2+1 or 1+2

- Major: 1.migratory artritis 2. pancarditis (leading to valvular damage and CHF) 3. cns involvement(Chorea)4. erythema marginatum 5. s.c. nodules

Minor:arthralgia, fever, elevated ESR and CRP, prolonged PR interval

• Lab.: ESR CRP ASO• Recurrent disease not easy to establish• Complications RHD f.e. Mitral regurgitation

ARF 2• DD: also PSRA

- Shorter interval to throat infection- Mostly one joint- Less ill- No reaction to aspirin- No cardiac symptoms- Don’t meet Jones Criteria

• Management of ARF:- Eradicate streptococcal infection- Aspirin for 2 weeks- Prednisolone in case of carditis (then postpone

aspirin)- ECG- Joint aspiration when fluid is present: sterile

Myocarditis

• High fever, acute onset• Viral: many different viruses/part of ARF• Tachypneua, increased respiratory efforts• Tachycardia• Dilated heart on chest Xray• Congestive Heart Failure• DD cardiomyopathy, sometimes very difficult

to distinguish• Treatment supportive

Case 3

• Boy, 7 years, since 2d pain right lower abdomen,slight fever, nausea,vomiting. After 2d more abdominal pain, fever 39.5C.

• O/E sick boy, knees up. Defense musculaire right lower abdomen pain on palpation Laparoscopy: perforated appendix!

• Patient delay!

Peritonitis

• Primaire peritonitis: complicatie GAS- DD o.a. Typhus- Cave bij Nefrotisch Syndrome: Staph. AureusTh./ breed spectrum antibiotica

• Secundair: Appendicitis- perforatie- Buikpijn, percussiepijn en défenseTh./ chirurgie

Brucellosis• Persistent or relapsing fever (Malaria -)• Malaise• Musculoskeletal pain • Lower backache• Splenomegaly• Anaemia• History of drinking unboiled milk• Low wbc PCR Serology Elisa Culture • R./ adults: doxycycline + 1 week gentamycine

i.m.• children: cotrimoxazole with gentamycine 1 w or

rifampicine 6-8 weeks

Urgent illnesses with high fever in children

• Meningitis-Encephalitis-Mastoiditis-Ethmoiditis-URTI• Sepsis

- Meningococcal- Urosepsis after pyelonefritis- NTSS

• Pneumonia: pleural effusion• Peritonitis NS• Malaria!• Septic Artritis

- Rheumatic Fever

• Osteomyelitis sickle cell!• Epiglottitis• Typhoid Fever• Myocarditis• Pyomyositis Brucellosis