This week's case

This week’s case scenario is based on a paediatric patient and you will find the pathophysiology section as well as the principles of management very useful regardless of whether you are a paediatrician or not. If you are in primary health care, this case will be invaluable to your work and knowledge.

Please note that it has been adapted from ‘ Lessons from research for doctors in training’ by Dr Nelly Ninis, Imperial College London and Linda Glennie, Menningitis Research Foundation. May I emphasize that this is an educational resource. It is not an evidence- based guideline and only educational use of the material is permitted.

I have merely presented the material in a format that makes it easy to use on the internet. Enjoy

 

Case History

10 month old boy. Taken to GP with h/o sudden onset of fever, vomiting and lethargy for 4 hours. Mother very anxious about child. GP referred child to walk-in clinic at hospital.

History on admission: Feverish and drowsy – sudden onset. 2 episodes of vomiting, 1 soft stool, no rash.

Assessment on admission:

Drowsy and pale, dark rings around eyes.

Temp 37.7

CVS: P 181, BP 120/52. CRT ( capillary refill time) 4 secs. Child peripherally shutdown.

RS: RR 32 breathing laboured and child cyanosed.

SaO2 100% in oxygen.

NS: GCS10 then 9, no neck stiffness. Fine blanching rash on abdo/chest. 1 petechial spot on abdo.

 

Questions

What might sudden onset of illness in an otherwise well child suggest?

What do you think of this assessment?

What do these signs tell you? How would you interpret the normal blood pressure in the context of other observations?

When conscious level is depressed and/or falling, is severity of disease likely to be worse when signs of meningitis are present, or when they are absent? 

Is the very scanty rash a reassuring sign?

Answers

 

Action taken :

1. Immediately given antibiotics and 40 ml/kg albumin.

2. “Crash call” put out for PICU team.

3. Full set bloods taken.

Results:

WCC 2.4, Hb 10.5, pl 70.

Na 149, K 3.4, urea 10.9, Creat 121.

HCO3 15, BE -7.

PT 30, APPT 75, INR 2.5.

Taken to PICU. Still shocked after 40ml/kg. Electively intubated and ventilated.

Commenced adrenaline, bicarbonate and K corrections.

Extensive purpuric rash developed.

PICU consultant called in to supervise care.

 

Questions

What do you think of this course of action? Answer

What do you think of these results?  Answer (Under 'Clinical features of severe disease' highligted in red )

 

Outcome

Subsequent PICU care (summary): Severe respiratory failure with pleural effusion - ventilated for total of 3 weeks. High dose inotropes required for several days. Severe coagulopathy - treated with fresh frozen plasma and cryoprecipitate. Renal replacement therapy needed. Peritoneal dialysis later that evening for fluid overload and renal failure - progressed to haemofiltration after several days. 3 weeks PICU, in hospital 2 months.

Discussion

Sudden onset of illness in otherwise well child.

Assessment:

Very thorough and entirely appropriate. Evidence of shock. Tachycardia, cool peripheries. Note normal blood pressure which in association with signs of shock indicates cardiac compensation.

Child had evidence of respiratory decompensation secondary to acidosis, hypoxia and capillary leak syndrome.

Depressed or falling conscious level must always be taken seriously, but it may occur quite early in meningitis. Depressed or falling conscious level in a patient with septicaemia, in the absence of signs of meningitis, indicates very advanced shock.

The rash was not dramatic on admission. There was only one non-blanching spot. This shows how the typical haemorrhagic rash may only appear once the child is very ill. Do not be reassured if a child has only a scanty rash: you must try to determine how advanced is the underlying septicaemia.

The results show a low white cell count, falling platelets, coagulopathy and rising urea and creatinine. These are all features of severe disease.

Action:

The severity of the child’s illness was appreciated immediately and aggressive resuscitation commenced. Senior help was called for and the child was admitted an appropriate intensive care unit.

Once on PICU the aggressive management was continued following the early management protocol. Senior PICU help was sought to ensure this child had one one medical attention whilst being stabilised. The typical rash of meningococcal septicaemia was by then apparent. Multi-organ failure was managed in PICU.

Learning points

Febrile illness of sudden onset = classic picture of meningococcal disease, mainly affecting well children. However, respiratory illnesses, particularly flu, may predispose to meningococcal disease. The less typical picture is of initially trivial symptoms suddenly becoming more serious with a high fever and other symptoms.  Always take a parent’s anxiety very seriously.

 Meningococcal septicaemia is a medical emergency.

 Falling conscious level in a shocked child is a poor prognostic sign. Isolated pinprick spots may appear where the rash is mainly blanching so it is important to search the whole body for small petechiae.  Underlying disease may be very advanced by the time a rash appears. The rapidly evolving haemorrhagic ‘text book’ rash may be a very late sign. It may be too late to save the child’s life by the time this rash is seen. Once shock is advanced, it can only be reversed by aggressive

Conclusion

Children with severe septicaemia and multi-organ failure have a high risk of mortality especially if they are under 1 year of age. In this case all the signs of severe illness were recognised immediately and acted on appropriately. It is likely that without such rapid medical attention this child would have died.

Pathophysiology and Principals of Management