Transcript Fever

GRAND ROUNDS
September 30, 2009
Bambico, Banzon, Barcarse, Barcenas, Barrera,Barrion
General Data
L.S, 5 months old
 Male
 Address: Baliuag, Bulacan
 Roman Catholic
 Birthdate: April 6, 2009
 Informant: mother
 Reliability: Good

FEVER
Chief complaint
History of Present Illness
19 days
PTC
• Fever (T 38oC)
• (-) cough, colds
• Paracetamol 100mg/mL 0.6mL q 4h
(9.2mg/kg/dose)
17 days
PTC
•Persistence of fever, (+) palpable cervical
lymph node, bilateral
•Consulted at health center
•Amoxicillin (unrecalled prep and dose)
•No relief
History of Present Illness
15 days
PTC
13 days
PTC
• Resolution of lymphadenopathy
• Consulted at private clinic
• Shifted Amoxicillin to Clarithromycin 10 mg/kg/day
• Persistence of fever
• (+) rashes on the back
• (+) dry cracked lips, non-exudative bilateral
conjunctival injection
• 2D Echo was done
History of Present Illness
12 days
PTC
10 days
PTC
•
•
•
•
Confined at a private hospital
CBC, CXR, UA
Dx: UTI and Atypical Kawasaki
Tx: Cefuroxime 750mg powder for injection (IV) (unrecalled
frequency)and Aspirin 100mg/tablet once a day (15 mg/kg/dose).
• Transferred to another hospital
• CBC
• Tx: Cefuroxime 750mg powder for injection (IV), Amikacin
50mg/mL IV, Aspirin 100 mg/tab 2 tabs, Nystatin (Mycotin) 100,000
U/mL TID
History of Present Illness
3 days
PTC
Admission
• Urine C/S
• Antibiotics shifted to
Piperacillin + Tazobactam 4g+
500 mg/IV
Review of Systems










General: (+) weight loss, (-) decrease in appetite, (+)
good activity level
Skin: (-) desquamation, (-) hair loss
Respiratory: (-) colds, (-)cough, (-) difficulty of breathing
CV: (-) cyanosis, (-) easy fatigability, (-) fainting spells
Gastrointestinal: (-) diarrhea, (-) constipation, (-)
vomiting, (-) jaundice
Genitourinary: (-)dysuria, (-) frequency, yellowish urine
Endocrine: (-)thyroid enlargement, (-) breast pain or
discharge
Hematologic: (+) pallor, (-) easy bruisability
Nervous: (-) seizures, (-) tremors, (-) sleep problems
Special senses: (-) lacrimation, (-) aural discharge, (-)
epistaxis, (-)salivation
Personal History

Gestational History:
 20
y/o (G1P0)
 Regular prenatal check-up since 4 months
AOG, and every month thereafter
 folic acid and ferrous sulfate
 Urinalysis and CBC: normal results
 (-) smoking, alcohol intake, intake of
teratogenic drugs
 (-) exposure to viral exanthem and radiation
 Hepatitis B and DM screening: not done.
Personal History

Birth History





Born live, term, singleton, male
NSD with spontaneous cry
Carpa Hospital in Baliwag, Bulacan
BW 2.8 kg
(-) complications
Personal History

Feeding

Eclusively breast-fed : 1 week
 Bona, 1:2 dilution
 5 bottles (4 ounces each) per day
 5 months: complementary food (Cerelac,
mashed potato)
 Vitamin C and ferrous sulfate
Development/ Behavioral History
Gross Motor: rolls over, chest up when
prone, good head control on sitting
position
 Fine Motor: reaches with either hand
 Cognitive: imitate speech sounds
 Social: laugh and play with his caretaker

At par for his age
Past Illnesses

Medical
 (-)
asthma,
 (-) allergies
 (-) URTI
 (-) UTI
 (-) viral exanthems
 (-) previous confinement
 (-) operations
 (-) blood transfusions
Immunization History

Health center

BCG
 Hepa B (3 doses)
 OPV (3 doses)
 DTP (3 doses)

Unrecalled dates
Family Profile
RELATIONSHIP NAME
A
G
E
Father
Alex
Mother
Laarni
e
EDUC.
ATTAIN
MENT
OCCUPATION
HEALTH
STATUS
21 College
Unknown
Healthy
21 College
Cellphone
vendor
Healthy
No sibling.
No relative or family member with the same signs and
symptoms as the of the patient.
Family History
(-) autoimmune disorders
 (-) hematologic disorders
 (-) DM, HPN, PTB, cancer, or thyroid
problems
 (-) asthma
 (-) allergies

Socio-Economic & Environmental History
Housing Condition: well-ventilated,well-lit
 No nearby factories, (-) pets
 Water source of the patient: distilled water
 Garbage collection: regular
 Garbage disposal: not segregated
 Primary caregiver: mother

Physical Examination







Awake, alert, in cardio-respiratory distress, wellnourished, well-hydrated
CR=168 bpm RR= 62 cpm T= 38.3oC
Wt: 6.5 kg (z= above -2) Ht 64 cm (z=0),
normal
Pale, warm moist skin, no active dermatoses, no
desquamation
No head deformity, patent anterior fontanel,
closed posterior fontanel
Pale palpebral conjunctivae, anicteric sclera,
pupils 2-3 mm ERTL
No naso-aural discharge, midline nasal septum,
turbinates not congested
Physical Examination







Moist buccal mucosa, non-hyperemic posterior
pharyngeal wall, tonsils not enlarged
(+) palpable cervical lymph nodes, bilateral, no
neck masses
Symmetrical chest expansion, no retractions,
clear & equal breath sounds
Adynamic precordium, apex beat at the 4th LICS
MCL, no murmurs
Globular abdomen, normoactive bowel sounds,
soft, (-) masses, liver span 2cm below right
subcostal margin MCL
No spinal deformities, no sacral dimpling
Pulses full and equal, no cyanosis, no edema
Neurological Examination






Alert, awake, good activity
(+) direct and consensual light reflex, isocoric
pupils 2-3 mm equally reactive to light, No facial
asymmetry
Good muscle tone on all extremities, no
spasticity or rigidity, no atrophy, no fasciculations
(-) abnormal lacrimation, (-) excessive salivation
(-) nuchal rigidity, (-) Brudzinski sign, (-) Kernig’s
sign
(+) Babinski, (-) Moro, sucking reflex
Salient Features








5 month old male
Prolonged Fever for 19 days
Bilateral cervical lymphadenopathy
Erythematous maculopapular lesions
Bilateral bulbar conjunctival injection, nonexudative
Dry cracked lips
Thrombocytosis, leukocytosis, and anemia
Previous admission with diagnosis of Atypical
Kawasaki
Signs, symptoms and laboratory findings
pathognomonic of a disease
KAWASAKI DISEASE
Patient
5 mos old
Rubeola
(Measles)
Infants or
older
children
Fever
Fever
Rash –
Rashmaculo
maculopapul
papular
ar,
Cervical
desquamates
Lymph
Adenopat Cough
Coryza
hy
Conjunctiv Conjunctivits
al
w/
injection
photophobia
Dry
Koplik’s spots
cracked
Scarlet Fever
Kawasaki
Disease
Infectious
Mononucleosis
School-aged
children
< 5 years
Any age
Fever
Rashblanches on
pressure,
diffuse, finely
papular
Pharyngitis
Cervical
lymphadeniti
s
Fever > 5
days
Rashtruncal
Extremity
changes
Cervical
lymph
adenopathy
Mucosal
changes
Fever
Pharyngitis
Lymph
adenopathy
Organomegal
y
Rash
Jaundice
Kawasaki
Disease
Infectious
Mononucleosis
Peaks at 4-5th Mild
day of illness,
defervescence
after 6th day
Fever
persisting at
least 5 days
Acute or
prolonged;
infants and
younger
children may
be clinically
silent
Maculopapula
r- begins at
forehead
(around
hairline),
behind ears,
upper neck
Various
Maculopapula
(Maculopapul r
ar, erythema
multiforme),
accentuated
at the groin
Patient’s
symptoms
Rubeola
(Measles)
Fever >2
weeks
Rasherythematous
maculopapula
r lesions on
back
Scarlet Fever
Beginning
diffuse, finely
papular
around neck,
spreading
over trunk
and
extremities
Patient
Rubeola
(Measles)
Scarlet Fever
Kawasaki
Disease
Infectious
Mononucleosis
Erythem
atous
lesions
after 5
days of
fever
Rash after 35 days of
fever,
conjuctivits,
coryza,
cough.
Rash
appears
after 24 hrs
onset of
fever, sore
throat
Febrile illness
w/ sore
throat
precedes
rash by 2-5
days
3-5 days
malaise,
fatigue
followed by
onset of
fever.
Lymphadeno
pathy, severe
sore throat.
Lymphade
nopathycervical,
unilateral
Generalized,
Cervical
Nonsuppurativ Generalized
more
lymphadenitis e,cervical,
prominent at
unilateral
cervical and
occipital nodes
Working Diagnosis
Kawasaki Disease
COURSE IN THE
WARD
1st HD
Impression: Sepsis vs. Kawasaki Disease
 IVF D5 IMB 500ml to run at 25 gtts/hr
 Medications:

 Ampicillin
250mg/SIVP q6 (38.5 mg/kg/dose)
 Gentamicin 24mg/SIVP OD (3.7 mg/kg/dose)
 Ampicillin was replaced with Meropenem 50mg/mL
2.4mL SIVP q8 (18.5mg/kg/dose)

CBC, Urinalysis, CRP, ESR
2nd HD




CBC, peripheral blood smear, PT, aPTT
2D Echo with Doppler
Hematology: Thrombocytosis secondary to
Kawasaki disease with coronary aneurysm
Medications:
 Antibiotics
were discontinued
 Paracetamol 100mg/mL 0.7mL q4 T>/= 38.5 (10. 76
mg/kg/dose)
 Aspirin 80 mg/tab 1 ½ tab q6 (18.5 mg/kg/dose)
 Warfarin 1.25 mg PO OD (0.19 mg/kg/dose)
3rd HD

IV Gammaglobulin infusion:
5 cc/hr - 1st 15 min
 + 5 cc/hr every 15 minutes until 20 cc/hr was
reached
 25 cc/hr until the completion of the infusion


Aspirin was continued
4th HD
IVF rate was adjusted to 27 ml/hour
 Medications:

 Aspirin
dosage was decreased to 80 mg/tab divided
into 3 pptabs, 1 pptab OD
DISCUSSION
Kawasaki Disease

also known as lymph node syndrome,
mucocutaneous node disease,
infantile polyarteritis and Kawasaki
syndrome

an inflammation (vasculitis) of the
middle-sized arteries affecting many
organs, including the skin, mucous
membranes, lymph nodes, blood vessel
walls
Epidemiology
predominantly a disease of young
children, with 80% of patients younger
than five years of age
 affects boys more than girls
 Among Asians, Japan(175 per 100,000)

Causes
 Unknown
 Theories

Infectious (probably viral)


KD associated Ag consistent with viral protein aggregates
may be present in cytoplasmic inclusion bodies, recovered
in bronchial epithelial cells in acute fatal cases.
Genetic
Affected individuals with parents who had the disease
 Genetic variation of CCR5 which encodes high affinity
receptor for the chemokines CCL3 and CCL3L1 suggest
influencial role in gene-gene interaction for susceptibility to
KD
 SNP in the ITPKC gene, which codes an enzyme that
negatively regulates T-cell activation
 HLA-B51: endemic instances among Japanese

Signs and symptoms
Signs and Symptoms
Signs and Symptoms
Signs and symptoms
Clinical Phases of Kawasaki

Acute febrile phase(1-2 wks)
 Fever
and other acute signs of illness
 Cardiac: myocarditis
 Macrophage activation syndrome

Subacute phase(until 4th wk)
 Desquamation
 Thrombocytosis
 Cardiac:

development of coronary aneurysm
Convalescent phase(6th to 8th wks)
 Clincal
signs disappeared until normal levels
of ESR and CRP
Diagnosis
Can only be diagnosed clinically
 No specific laboratory test
 Normally difficult to establish the
diagnosis

Weinstein, M. CMAJ 2006;174:459-460
Copyright ©2006 Canadian Medical Association or its licensors
Atypical Kawasaki Disease

Persistent fever but fewer than 4 other
clinical features of illness

Most frequent in infants,who have the
highest likelihood of developing coronary
artery disease
Laboratory findings in Kawasaki

Leukocyte count
 Normal
to elevated with predominance of
PMN and immature forms

ESR, CRP, and other acute phase
reactants
 Elevated

during acute phase upto 4-6th week
Platelet count
1st week
 Elevated to moroe than >1,000,000/mm3 2nd
to 3rd wk
 Normal-
Laboratory findings in Kawasaki

Urinalysis
 Sterile
pyuria
Liver enzymes: Elevated
 CSF: Pleocytosis

Ancillary test
2D-ECHO: done on day of diagnosis, 2-3rd
wk of illness,6-8th wk of illness
Copyright ©2004 American Heart Association
Newburger, J. W. et al. Circulation 2004;110:2747-2771
Treatment


Acute Kawasaki Disease:
 IVIG and high dose Aspirin as soon as possible after diagnosis
and, ideally within 10 days of disease onset
 Consideration should be given to:
 Patients diagnosed after the 10th illness day if fever has
persisted:because the anti-inflammatory effect may be
helpful, although the effect of such therapy on the risk of
developing aneurysms is unknown
On the 14th day of illness or after the patient has been afebrile
for 3-4 days:
 Decrease Aspirin dose to 3-5 mg/kg/day as single dose
Treatment

ACUTE STAGE:
 Intravenous
immunoglobulin (IVIG): 2 g/kg
(10-12 hour) +
 Aspirin: 80-100 mg/kg/day divided every 6 hr
orally (until 14th day of illness)

CONVALESCENT STAGE:
 Aspirin:
3-5 mg/kg once daily orally (until 6-8
wk after disease onset)
Failure of response
No response to initial IVIG infusion/
exhibits partial transient response
 Strong consideration to retreatment with
additional IVIG infusion (2g/kg)
 If no response to 2nd dose of IVIG infusion

 IV
Methylprednisolone (30 mg/kg/day x 3
days)
Patients with aneurysm

SMALL SOLITARY ANEURYSM:


continue Aspirin indefinitely
LARGER NUMEROUS ANEURYSM:

may require the addition of :
 Clopidogrel (1 mg/kg/day to max [adult dose] of 75 mg/day)
 Warfarin (0.1 mg/kg/day, given everyday; 0.05-0.34
mg/kg/day; adjust dose to achieve desired INR, usually 2.02.5) or
 Low Molecular Weight Heparin (Infants <12 mos; Tx: 3
mg/kg/day, divided 12 h; Prophylaxis 1.5 mg/kg, divided
every 12 h)
Treatment

LONG-TERM THERAPY FOR THOSE
WITH CORONARY ABNORMALITIES
 Aspirin:
3-5 mg/kg once daily orally +
 Clopidogrel: 1 mg/kg/day (Max 75 mg/day)
* most experts add Warfarin for those patients
at particularly high risk of thrombosis
Treatment

ACUTE CORONARY THROMBOSIS
 Prompt
thrombolytic therapy with TISSUE
PLASMINOGEN ACTIVATOR,
STREPTOKINASE, or UROKINASE under
supervision of pediatric cardiologist

LONG TERM FOLLOW-UP OF
PATIENT WITH CORONARY ARTERY
ANEURYSMS:
 Periodic
testing
echocardiography with Stress
Treatment
PATIENTS IN LONG TERM ASPIRIN
THERAPY :
 Annual
Influenza vaccination to reduce the
risk of Reye Syndrome

PATIENTS TREATED WITH IVIG:
 Delay
MMR and Varicella vaccination for 11
months

antiviral antibody in IVIG may interfere with the
immune response to live virus vaccine
Complications





Cardiac- coronary
artery aneurysm,
pericarditis,
myocarditis,
endocarditis
Aseptic meningitis
Arthritis
Urethritis
Hydrops of
gallbladder
LOOKing for pic pa -dj
Coronary Artery Aneurysm
Prognosis
Prognostic factors:
 male gender
 age <1 yr,
 Prolonged fever, recrudescence of fever
after an afebrile period, and the following
laboratory values at presentation: l
 low
hemoglobin or platelet levels,
 high neutrophil and band counts,
 Hyponatremia
 low albumin and age-adjusted serum IgG
levels
Prognosis

Without coronary disease
 Recovery
is complete and without long term
sequelae

With coronary disease
 50%

resolution of aneurysm after 1-2 yrs
Myointimal thickening with abnormal function of
vessels
 Giant
aneurysm is unlikely to resolve, more
likely to develop stenosis and thrombosis

Predisposition to develop atherosclerotic
heart disease
JOURNALS
Thank You!☺
Hgb
Reference
Range
120-170
RBC
4.0-6.0
Hct
0.37-0.54
unit
**9/12
**9/13
9/23
9/24
g/L
89
72
88
79
x1012/L
3.85
3.17
3.38
3.03
3.33
0.28
0.23
0.27
0.24
0.25
9/28
93
MCV
87±5
U3
74
74
78.20
77.40
76.00
MCH
29±2
pg
23.1
22.7
25.90
26.20
28.00
MCHC
34±2
gL
313
307
33.20
33.80
36.80
16.7
17.6
14.40
15.40
15.30
RDW
11.6-14.6
MPV
7.4-10.4
fL
6.9
6.5
6.00
5.40
5.70
Plt
150-450
x109/L
1081
810
1477
2045
1140
WBC
4.5-10.0
x109/L
26.2
27.1
27.60
12.10
16.80
Neutrophils
0.5-0.70
0.67
0.62
0.43
0.40
0.28
Bands
0.00-0.05
-
-
-
-
Segmented
0.50-0.70
0.62
0.43
0.40
0.26
Lymphocytes
0.20-0.40
0.26
0.30
0.55
0.58
0.65
Monocytes
0.00-0.07
0.07
0.08
0.01
-
-
Eosinophils
0.00-0.05
0.01
0.02
0.05
Basophils
0.00-0.01
0.01
-
-
URINALYSIS
Color
Transparency
pH
Specific gravity
Albumin
Sugar
Pus cell
Squamous cells
Yellow
Clear
7.0
1.010
negative
Negative
0-2/hpf
few
Peripheral Blood Smear
Microcytic hypochromic red cells with
anisopoikilocytosis; no abnormal WBC seen +
cytoplasmic vacuolation; increased platelets
with giant forms.
COAGULATION
ASSAY
PT
Normal Control
Prothrombin
Ratio
INR
aPTT
Normal Control
9/25
9/28
13.0
12.6
1.1
25.4
12.6
2.1
1.1
40.5
35.9
2.1
61.4
36.0
CRP
Result
273 (HIGH)
Unit
mg/L
Reference
0-5
ESR by Modified
Westergren
Result
140
Reference range
0-15MM after 1hr
2D ECHO
2D Echo done outside USTH
(09/08/09)
Normal 2D Echo Study
Normal Coronary Arteries
LCA: Proximal= 2.6 mm
LAD: 2.5 mm
LCx: 2.5 mm
RCA: Proximal= 2.4 mm
Distal= 2.4 mm
2D Echo done at USTH
(09/24/09)
No significant pericardial effusion
1-2 +mitral regurgitation
Trivial aortic regurgitation
RCA: 7.6-7.7 mm
LCA : Main= 3.37 mm ( near ostia) 4.7
mm ( mid)
LAD: Proximal=3.77 mm
Distal: 5.88 mm
LCX: 2.8 mm
No structural defecets
Impression was giant coronary
aneurysm
URINE C/S

No growth after 72 hours of incubation