A child with high fever
and pain
J C Mulder
Rotary 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
•
•
1.
2.
3.
4.
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, noncoöperative. Right ear stands away. You are not allowed
to touch it.
What
What
What
What
else do you want to know?
do you examine?
is your dd?
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: paracetamol
Complications: extradural abscess, meningitis, brainabscess, 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: atticoantrotomia (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 up
X-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. Aureus
Th./ breed spectrum antibiotica
• Secundair: Appendicitis- perforatie
- Buikpijn, percussiepijn en défense
Th./ 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