INFECTIOUS DISEASES CASES

CASE 1: A PERSISTENT FEVER

History
 Ben is a 2-year-old boy who presents to the rapid referral paediatric
clinic with a 10-day history of fever, blood shot eyes, a sore throat and a
rash.
 He also has an occasional cough.
 His mum describes him as being miserable with a poor appetite.
 There is no history of travel or contact with infections.
 Ben has already had a 6-day course of amoxicillin from his general
practitioner (GP) that made no difference.
 He had an inguinal hernia operated on at 2 weeks of age.
 There is no other medical history of note.
 CASE 1: A PERSISTENT FEVER

Examination

 Ben’s temperature is 39.8°C.

 He has bilateral conjunctivitis, erythematous, cracked lips and an
erythematous pharynx.
 There is a non-specific maculopapular rash over the trunk.
 There is cervical lymphadenopathy with the largest node being 2 cm in
diameter, but no lymphade-nopathy elsewhere.
 His chest is clear and there are no other abnormalities.
 CASE 1: A PERSISTENT FEVER

Questions
• What is the likely diagnosis?
• What is the treatment?
 CASE 1: A PERSISTENT FEVER
ANSWER 1
 
 Fever and rash are very common in paediatrics.
 Most rashes are non-specific viral rashes, but some illnesses are
accompanied by typical rashes.
 For instance, chickenpox is characterized by a vesicular rash and
meningococcal septicaemia by a petechial non-blanching rash.
 Ben’s most likely diagnosis is Kawasaki disease, which is a vasculitis.
 This disorder occurs mainly in young children (80 per cent <5 years).
 It is diagnosed clinically.
 CASE 1: A PERSISTENT FEVER

Criteria for diagnosis are as follows:

• The presence of a fever for 5 or more days and four of the

following five features:
• Non-purulent conjunctivitis
• Cervical lymphadenopathy
• Skin rash
• Erythema of the oral and pharyngeal mucosa
• Erythema and swelling of the hands and feet (followed a week
later by skin desquamation)
 CASE 1: A PERSISTENT FEVER

 Accompanying features are a raised WCC, CRP and ESR.

 In the second week of the illness, a thrombocytosis usually develops.
 When assessing a child with a prolonged fever (>7 days), the following
conditions should be considered:
!!!! Causes of a prolonged fever
• Infections, e.g. tuberculosis, HIV
• Malignant diseases, e.g. lymphoma, leukaemia
• Autoimmune diseases, e.g. juvenile idiopathic arthritis
• Miscellaneous, e.g. drugs, inflammatory bowel disease
 CASE 1: A PERSISTENT FEVER

 Treatment consists of an infusion of immunoglobulins on the day of

diagnosis, initially high-dose aspirin at anti-inflammatory doses followed
by low-dose aspirin at anti-thrombotic doses.The main complication of
this disorder is coronary artery aneurysms that can, in some cases, lead to
myocardial infarction and sudden death. A prolonged fever (>16 days),
male sex, age<1 year, cardiomegaly, raised inflammatory markers and
raised platelets areall risk factors.An echocardiogram at diagnosis and
follow-up echocardiograms are required to rule out this complication. The
prognosis is related to the cardiac complications.The risk of cardiac com-
plications if treatment with immunoglobulins was commenced within
10 days of diagnosis is <10 per cent.
Key Points
• Kawasaki disease should be considered in all children with a
prolonged fever.
• Treatment consists of immunoglobulins and aspirin.
• The main long-term complication is coronary artery aneurysms.
CASE 1: A PERSISTENT FEVER
CASE 1: A PERSISTENT FEVER
 CASE 2: RECURRENT INFECTIONS
History
 Michelle is a 7-year-old girl who presents to the emergency department
(ED) with a 2-day history of fever, progressively worsening headache,
vomiting and neck stiffness.
 She was born in Zimbabwe and moved to the United Kingdom at
2 years of age to live with her aunt after her mother died from
tuberculosis.
 She was admitted to hospital last year with pneumonia and developed
an empyema, which required drainage.
 Streptococcus pneumoniae was isolated from blood cultures at that
time.
 Since then, she has had several episodes of otitis media treated by her
general practitioner (GP), and has been off school quite frequently.
 Her aunt is not very sure about which immunizations she has received.
 There has not been any recent travel.
 CASE 2: RECURRENT INFECTIONS
Examination
 Michelle has a temperature of 38.8°C,heart rate 120 beats/min, her blood
pressure is 100/65 mmHg, respiratory rate is 20 breaths/min and her
oxygen saturation is 96 per cent in air.
 Her weight is 17 kg (second centile) and her height is 114 cm (ninth
centile).
 She has multiple enlarged cervical lymph nodes, oral candidiasis,
extensive dental caries and suppurative left otitis media.
 There is no rash, and cardiovascular, respiratory and abdominal
examinations are normal.
 She is alert but uncomfortable, has marked neck rigidity and prefers the
lights to be dimmed.
 There are no other abnormalities found on neurological examination.
 CASE 2: RECURRENT INFECTIONS

Questions
• What is the diagnosis for the acute illness and what is the management?
• What other problems should be considered?
• What other investigations might be appropriate?
 CASE 2: RECURRENT INFECTIONS
ANSWER 2

 Michelle has acute bacterial meningitis, which is most likely to be due to S.

pneumoniae.
 This diagnosis is strongly suspected from the acute history and the blood
results, and confirmed by the CSF findings (see Case 62).
 It may have developed secondary to the otitis media.
 She should be commenced on an appropriate antibiotic (most commonly
an intravenous third generation cephalosporin) and on intravenous
dexamethasone.
 Michelle has a history of recurrent infections with two of these being
severe.
 Any child with unusual, severe, recurrent or persistent infections must be
evaluated for the possibility of an underlying immunodeficiency.
 CASE 2: RECURRENT INFECTIONS
 In Michelle’s case, recurrent S. pneumoniae infections raise concerns
about hyposplenism, complement deficiency, antibody deficiency and
HIV infection.
 The findings of severe dental caries, oral candidiasis and cervical
lymphadenopathy, together with the history of immigration from
Zimbabwe and her mother dying from TB, strongly suggest HIV.
 Testing for HIV is done with informed consent of the
person with parental responsibility for the child.
 If the test is positive, the child will gradually be given information and
prepared for disclosure of the diagnosis when they are able to
comprehend the implications of having HIV.
 CASE 2: RECURRENT INFECTIONS

Key Points
• Consider immunodeficiency in all children with unusual,
severe, persistent and recurrent infections.
• HIV testing should be part of the assessment of a child with recurrent
infections.
 CASE 3: UNEXPLAINED WEIGHT LOSS

History
 Ehsan is seen in the paediatric clinic with his mother, who speaks little
English. He is 12 years old, was born in Afghanistan and moved to the
United Kingdom as a refugee 3 months ago. He was diagnosed with
asthma when he was seen in the emergency department (ED) 4 weeks ago,
on the basis of a chronic nocturnal cough. Today, his mother is more
worried about the fact that he has been losing weight and has had a poor
appetite since coming to the United Kingdom.Ehsan is using salbutamol
and beclometasone inhalers, which have not improved his cough. He has
not yet been to school in the United Kingdom. He lives with his mother
and three younger siblings in a damp two-bedroom flat and his mother
has also been coughing a lot over the last month. His father died last year.
They are uncertain which immunizations he has received, but he was
healthy before coming to the United Kingdom. He has been feeling too
tired to play games with his siblings for the last 4 weeks and he finds that
his clothes are all much looser than when he arrived in the United
Kingdom. His mother says that he sometimes feels hot, but she has not
measured his temperature.
 CASE 3: UNEXPLAINED WEIGHT LOSS
Examination
 Ehsan is very thin, his height is 153 cm (75th centile) and his weight is
27 kg (2nd centile).
 His heart rate is 80 beats/min, his respiratory rate is 26 breaths/min,
and oxygen saturation is 97 per cent in air.
 There is no wheeze but there are bronchial breath sounds in the right
upper zone of his chest.
 There is no lymphadenopathy and his cardiovascular and abdominal
examinations are unremarkable
 CASE 3: UNEXPLAINED WEIGHT LOSS

Questions

• What further history is required?

• What does the chest radiograph
show?
• What is the most likely
diagnosis?
• What further tests are needed?
• What is the treatment?

Figure 3.1 Ehsan’s chest radiograph.

 CASE 3: UNEXPLAINED WEIGHT LOSS
ANSWER 3

 Ehsan’s history of weight loss with a chronic cough needs to be fully

investigated. It is important to ask about the past medical history,
family history and contact history with direct questions about
tuberculosis. What happened to Ehsan’s father? (In fact, he died in
Afghanistan after suddenly coughing up a large amount of blood). Even
if the immunization history is unknown, they may know if Ehsan has
received the Bacillus Calmette–Guérin (BCG) vaccine (as this leaves a
distinctive scar) and whether he has ever been treated for tuberculosis.
Ask about the onset of the cough, whether it is productive, whether
there is blood-stained sputum and if there is any chest pain or
dyspnoea. Ask about exacerbating and relieving factors. Ask when
the weight loss started and whether it is associated with abdominal
pain,diarrhoea, malabsorptive (bulky, offensive) stools, nausea or
vomiting. Also ask about night sweats.
 CASE 3: UNEXPLAINED WEIGHT LOSS
!!!! Causes of weight loss

• Inadequate nutrition/neglect
• Gastro-oesophageal reflux
• Coeliac disease
• Inflammatory bowel disease
• Cystic fibrosis
• Anorexia nervosa
• Cardiac failure
• Chronic renal failure
• Diabetes mellitus
• Malignancy
• Infections, e.g. tuberculosis, HIV
 CASE 3: UNEXPLAINED WEIGHT LOSS

 The chest radiograph shows dense consolidation and cavitation in the

right upper lobe.The most likely diagnosis is pulmonary tuberculosis.
Ehsan’s father probably died from pulmonary tuberculosis and Ehsan’s
mother probably also has pulmonary tuberculosis. Ehsan will require
admission for investigation and treatment, with isolation whilst he may
have mycobacteria in his sputum. The possibility of multidrug-resistant
tuberculosis should be considered in view of his recent immigration from
Afghanistan. Although new molecular techniques (e.g. PCR) are
increasingly used to diagnose tuberculosis, the gold standard for diagnosis
remains culture of the mycobacteria from clinical specimens.
Unfortunately, this is much more difficult to achieve in children than in
adults, and only possible in <50 per cent of cases. More often the diagnosis
is based on suggestive clinical and radiological features, history of exposure
to tuberculosis, and results of tuberculin skin test (TST). Interpretation of
the TST is affected by prior BCG vaccination, and newer tests based on the
release of interferon gamma from blood mononuclear cells in response to
antigens present in tuberculosis but not in BCG may aid diagnosis further.
 CASE 3: UNEXPLAINED WEIGHT LOSS
Ehsan will require a TST, sputum to be collected for microscopy and culture,
erythrocyte sedimentation rate, C-reactive protein, full blood count and liver
function tests. It is likely that his sputum will show acid-fast bacilli on
microscopy, because he has cavitating pulmonary disease. Cavities are often
teeming with mycobacteria. This presentation would be much rarer in
younger children, who rarely have cavitating disease. If he is unable to
expectorate sputum by himself, techniques to induce sputum production
may be attempted, and gastric aspirates may besent for mycobacterial
culture (but their positive yield is low). Drug sensitivity testing will be
needed on cultured specimens. Ehsan and his mother should be counselled
for an HIV test, because HIV is an important risk factor for development of
tuberculosis. Standard treatment for pulmonary tuberculosis should
commence with four drugs, such as isoniazid, rifampicin, ethambutol and
pyrazinamide. Pyridoxine should be given to reduce the risk of isoniazid
causing peripheral neuropathy. The rest of the family will need to be
screened for evidence of active or latent tuberculosis. Latent tuberculosis
occurs when a person has been infected with tuberculosis, but, rather than
causing disease, the mycobacteria become dormant.
 CASE 3: UNEXPLAINED WEIGHT LOSS
 Individuals with latent tuberculosis are generally not infectious to
others but are at risk of developing active tuberculosis in the future.
Chemoprophylaxis (a course of one or two anti-tuberculous drugs) is
advised for latent infection. Tuberculosis is a notifiable disease in the
United Kingdom.

Key Points

• Suspicion of tuberculosis should be high in children from high-

incidence countries with a compatible clinical history.
• The likelihood of obtaining a positive sputum smear or culture in
children with pulmonary tuberculosis is much lower than in adults.
• Diagnosis of tuberculosis is often made on the basis of likelihood of
exposure, clinical and radiological findings and tuberculin skin test.
 CASE 4: HOT BUT COLD

History
 Edwin is a 12-month-old boy. He is brought by ambulance to the
resuscitation room in the emergency department (ED). He has had a
very high fever and slight runny nose for 2 days, but for the last 6 hours
has been sleepier than normal and his parents noted a rash on his legs
which did not fade when pressed with a glass. Edwin has no other past
medical history of note, but has not received any vaccinations because
his parents are worried about side eects.
Examination
 Edwin looks very unwell. He is pale, cyanosed peripherally and his
limbs feel very cold even though his tympanic membrane temperature
is 39.9°C. He is drowsy with a Glasgow Coma Scale (GCS) of 11. His
respiratory rate is 70 breaths/min, but his lung elds sound clear. His
oxygen saturation is 94 per cent in air. Edwin’s capillary rell time is 4 s,
his heart rate is 170 beats/min and his blood pressure is 60/30 mmHg.
His heart sounds are normal. Edwin has a non-blanching rash on his
legs and feet.
 CASE 4: HOT BUT COLD

Questions
• What is the interpretation of the blood gas result?
• What is the most likely cause of Edwin’s illness?
• What are the most important steps in the initial management of Edwin?
 CASE 4: HOT BUT COLD

 ANSWER 4
 Edwin’s pH is 7.05, which is severe acidosis. e low Pco2 and bicarbonate
together with the large negative base excess demonstrate this as a
metabolic acidosis for which Edwin is trying to compensate (by rapidly
exhaling CO2 ). The severe metabolic acidosis has developed due to
circulatory failure (shock) and tissue
hypoperfusion.Edwin has signs of sepsis, and the most likely cause
is meningococcal infection. Edwin has a high fever and purpuric
rash, characteristic of meningococcal septicaemia. Infants with
meningococcal disease oen also have a history of signs and symptoms
of upper respiratory tract infections which can lead to a delay in the
diagnosis. Edwin’s tachycardia, delayed capillary rell time, low blood
pressure, cold limbs, reduced GCS and severe metabolic acidosis
indicate he has developed septic shock.
 CASE 4: HOT BUT COLD

!!! Definition of sepsis and septic shock

Sepsis is defined as a child with suspected or proven

infection AND at least 2  of the following:
• Altered mental state/reduced GCS
• Fever or hypothermia
• Inappropriate tachycardia
• Inappropriate tachypnoea
• Prolonged capillary refill time
• Abnormal white cell count
 CASE 4: HOT BUT COLD
Septic shock is sepsis with hypoperfusion despite appropriate (e.g. ≥30
mL/kg)fluid therapy. In a septic child, the Paediatric Sepsis 6 resuscitation
bundle should be adopted immediately- it is an adaptation of the standard
Airway-Breathing-Circulation (ABC) approach for septic children.
1. Maintain the airway and administer high-ow oxygen.
2.Obtain intravenous (IV) or intraosseous (IO) access and take blood
tests (blood culture, full blood count, lactate, C-reactive protein, blood
glucose and clotting prole).
3. Give empiric IV/IO antibiotics (usually a broad spectrum agent such
as a third generation cephalosporin).
4. Fluid resuscitation while avoiding uid overload (and treat
hypoglycaemia with IV/IO glucose).
5. Early involvement of senior paediatricians, an anaesthetic
team and paediatric intensive care unit will help guide appropriate
management.
6. Consider cardiovascular inotropic support early if signs of shock
remain despite adequate fluid resuscitation.
 
 CASE 4: HOT BUT COLD

The routine infant immunization programme in the United Kingdom

now includes vaccines against meningococcal capsular groups B and C.
Meningococcal sepsis is expected to become less common but it is
unlikely to be totally eliminated.

Key Points
• Sepsis is a medical emergency.
• Meningococcal disease must be ruled out in children with fever and
non- blanching rash.
• Respiratory support, fluid resuscitation and antibiotics are key in the
management of septic shock.