Chapter 6

Fever Case II

Case study: Asha

Asha, a 4 year old girl brought to hospital after 2 weeks of fever, not eating or drinking. On the day of referral she could not be woken up and had a seizure.

What are the stages in the management for any sick child?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

Have you noticed any emergency or priority signs?

Temperature: 39.50C, pulse: 140/min, RR: 50/min; breathing noisy but regular, no cyanosis, intermittently shaking left arm and leg, unresponsive to voice, withdraws to pain

Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable Referral Malnutrition Oedema of both feet Burns

What emergency treatment will Asha need?

Emergency treatment
Airway management? Oxygen? Intravenous fluids? Anticonvulsants?

Immediate investigations?

Blood sugar

Emergency treatment - how do you position the unconscious child?

(Ref. Chart 6, p. 17)

How to give oxygen

Place the prongs just inside the nostrils and secure with tape. (Ref. Chart 5, p. 11 p. 312-315)

Use an 8 F size tube Measure the distance from the side of the nostril to the inner eyebrow margin with the catheter Insert the catheter to this depth and secure it with tape

Start oxygen flow at 1-2 litres/minute, in young infants at 0.5 litre/minute

Emergency treatment (continued)

How do you treat acute convulsions? Give diazepam (or paraldehyde) rectally (Ref. Chart 9, p. 15) Loading with phenobarbitone if convulsions continue How do you treat hypoglycaemia (Blood glucose <1mmol/l)?

Give IV glucose urgently (Ref. Chart 10, p. 16)

Give emergency treatment until the patient is stable

History
Asha was well until two weeks ago when she developed high fever and was eating and drinking poorly. She was taken to the health centre, where she was given benzyl penicillin for three days, but the fever persisted and she became more lethargic. On the day of referral she could not be woken up and had a seizure.

Family history: Asha's aunt has tuberculosis, which was diagnosed recently.
Social history: she lives with an extended family including her parents, grandparents and her uncle's family in a three-room house.

Examination
Asha was thin, pale looking, unconscious but withdrew to pain. She was intermittently shaking her left arm and leg.
Vital signs: temperature: 39.50C, pulse: 140/min, RR: 50/min Weight: 14 kg Height: 100cm

Use (Ref. p. 391-392) for weight-for-length

Neck: enlarged non-tender right-sided lymph nodes Chest: gurgling upper airway sounds. On chest auscultation only transmitted upper airway sounds

Cardiovascular/Abdomen: normal
Neurology: Asha was unconscious and withdrew only to pain (squeezing her earlobe) and only on the right side. Her neck was stiff and she grimaced when it was moved. Her pupils were unequal. Apart from the intermittent jerking of her left arm and leg, she did not move her left side.

Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 24-25, p. 151)

Differential diagnoses (continued)

Bacterial meningitis TB meningitis Cerebral malaria Viral encephalitis Trauma / head injury

Poisoning / drug overdose

Brain haemorrhage Hypoglycaemia

Shock (secondary to severe sepsis) Use references to suggest which are most likely

Ref. Table 3 p. 24-25 Ref. p. 151

Additional questions on history

Head injury? Prior convulsions? Stiff neck or neck pain? Headache or vomiting?
(Ref. Table 3, p. 24-25)

Prior illnesses? Tuberculosis in family? Malarious area? Traditional medicine?

Drug or toxin ingestion? Immunization history

Further examination based on differential diagnoses

Assess first the depth of coma
AVPU (Ref. p. 18) A alert V responds to voice

P Responds to pain
U unconscious Pupil size and light reaction

Unequal pupils
Abnormal posturing (Ref. p. 167-168) Tense or bulging fontanelle (only in infants)

Raised intracranial pressure

(Ref. p. 168, p. 56)

Neck Stiffness

(Ref. p. 168)

Further examination based on differential diagnoses (continued)

Look for signs of the cause of coma and fever:

Neck stiffness (suggesting meningitis)

Other signs of tuberculosis (Ref. p. 115-118, p. 171) Splenomegaly and pallor (suggesting malaria) Signs of trauma Rash (e.g. purpuric rash of sepsis) (Ref. p. 168, p. 153) Assess nutrition Weight-for-age, weight-for length (Ref. 379-402) Look for wasting and oedema

What investigations would you like to do to make your diagnosis?

Investigations

Full Blood Examination Blood glucose Film or RDT for malarial parasites Chest x-ray

Would you do Lumbar Puncture in this child

(Ref. p. 346-347) ?

Investigations (continued)
Full blood examination:
Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: Monocytes: 89g/l (115-140) 758x109/l (150 400) 30.6x109/l (5.5 15.5) 21.4x109/l (1.5 8.5) 8.0x109/l 1.2x109/l (2.0 8.0) (0.1 1.0)

Investigations (continued)
Blood sugar: <1mmol/l initially, then 4.5 mmol/l after emergency treatment Chest x-ray: enlarged perihilar lymph nodes, some calcified Blood film: malaria parasites were not seen in both samples, and RDT negative Other tests that could be done:
Mantoux test (Tuberculin skin test: TST)
Gastric aspirate (ZN stain, TB culture)

Lumbar puncture was not done because Asha had unequal pupils and focal seizures (Ref. p. 346-347)

Diagnosis
Summary of findings: Examination: comatose state and focal seizures, cervical lymphadenopathy, positive contact history for tuberculosis; failure to improve after 3 days of antibiotic treatment Chest x-ray: enlarged perihilar lymph nodes, some calcified Blood examination shows moderate anaemia, moderate neutrophilia with significant left shift and thrombocytosis

Diagnosis (continued)
Suspected Meningitis Tuberculosis

How would you treat Asha ?

Treatment
Clinical meningitis, possibly bacterial, possibly TB

meningitis

Ceftriaxone for 10 days (Ref. p. 169)

TB treatment (Ref. p. 116-117)

First 2 months (initial phase): isoniazid and rifampicin and pyrazinamid and ethambutol (or streptomycin) daily, Followed by next 8 months (continuation phase): izoniazid and rifampicin daily Dexamethasone for tuberculous meningitis (Ref. p. 152)

What supportive care and monitoring are required?

Supportive Care
Maintain a clear airway Positioning and turning

(Ref. p. 172-174)

Fluid and nutritional management: Early attention to nutrition is crucial to outcome Nasogastric feeding early Continue to monitor the blood sugar level Fever control

Anticonvulsants
Oxygen if convulsions, respiratory distress or apnoea Physiotherapy

Monitoring
Nurses should monitor frequently the child's state of (Ref. p. 174): Level of consciousness Adequacy of breathing (airway, RR, oximetry)

Pupil size
Record and treat seizures Use a Monitoring chart (Ref. p. 320, 413)

Medical review at least twice daily

Consider the complications

What acute complications might occur?

Aspiration Convulsions (Ref. p.15, Chart 9) Hypoglycaemia (Ref. p.16, Chart 10) Fluid overload (Ref. p.173) Skin pressure areas Progressive malnutrition Constipation Urinary retention Limb contractures Nosocomial infection

What long term complications might occur?

Hearing loss (Ref. p.174) Motor, visual and intellectual complications Nutritional

Progress and Discharge planning

Within 3 days Asha started to regain consciousness. She still had a left-sided residual hemiparesis and her weight had decreased to 12.6 kg She was fed more frequently (6 times a day) with nutritious foods (Ref. p. 298, 209) once she was conscious enough to swallow. The nasogastric milk was continued for several weeks to provide some additional supplementation. Physiotherapy was commenced for Ashas hemiparesis and her mother was also taught some passive exercises After three months her clinical condition has improved: she was alert, eating and sleeping normally, although she had a mild left sided hemiparesis and walked with a limp On discharge, Asha still had a residual left-sided hemiparesis but she had gained over 1.5 kg

Follow-up
On follow-up visit:

Assess neurological complications

Assess nutritional state Screen for hearing loss (Ref. p. 173) Continue physiotherapy
- and give simple suggestions to the mother for passive exercises

Follow-up family screening & TB contact tracing Monitor frequently if antituberculous treatment is taken at home

Summary
A case of probable tuberculous meningitis Think of tuberculous meningitis if the illness is prolonged there are other signs of TB (e.g. lymphadenopathy, malnutrition, family history) Children in coma are at risk of many complications that need to be anticipated: aspiration, hypoxia, hypoglycaemia, malnutrition, constipation, urinary retention, pressure sores, joint contractures Early attention to nutrition is very important