Case report on severe febrile disease in pediatrics

A child (6 months of age) has been admitted in our hospital for restlessness, crying much, vomiting any time breastfeeding.

No signs of respiratory tract infection. No neck stiffness or other signs of meningitis.

There was fever and some dehydration. No Jaundice. Fever was very high and with a up-and-down pattern within the day.

M/S (malaria slide) taken on first day of admission was negative, but child had taken co-artesian (artemisin based combination) last week.

RBS (random blood sugar) =5.7 mmol/l HB (hemoglobin) = 11.5 g/l 

Otoscopy showed signs of acute otitis media

Stool test= WBCs seen. 

No signs of protozoal or helmint infection.

LP (lumbar puncture) was performed to rule out meningitis, because below 1 year of age the meningeal signs may be completely absent. It was negative.

Thinking of unresolved malaria we have put the child on intra venous quinine. We have covered the child with iv Rocephin either for the hypothesis of gastroenteritis secondary to salmonella or shigella, or for the treatment of otitis media. For otitis media (no perforation noticed) we have also added ciproxin ear drops.

Because the diarrhea has been relentless we have added also flagyl, even though the stool test did not see protozoa (high frequency of false negative results).

Rehydration was performed with iv Darrow’s (Ringer solution for pediatric patient).

Mother has requested discharge after 2 days’ admission alleging that there was no improvement.

We tried to convince her that the child was now less dehydrated and that we needed some time before deciding that drugs had failed. But we did not succeed to make the mother change her mind, and she went to a hospital of her choice.

LEARNING POINTS

1) Even when malaria slide is negative, malaria parasites can still be present at a low density, and this may be the cause of recrudescence within 2 weeks in case of falciparum infection.

2) Plasmodium falciparum has a very short time of parassitemia. Most of the times the parasites are found in the blood stream only when fever goes up (merozoites breaking up red blood cells in the life

cycle). The bulk of the parasites remain buried in the liver and in other connective tissues, making the malaria slide very unreliable when negative.

3) In the absence of IFAT (immunoflorescence antibody tests) looking for IgM against the plasmodium, a negative malaria slide doesn’t allow us to withdraw a malaria treatment if the clinical signs are suggestive of the disease. Therefore malaria slide is useful only when positive and in the follow up of a positive result.

4) Fever may be erratic in the case of falciparum malaria, and rarely follows the tertiary (ever 3rd day) pattern as described in the textbooks. We experience also many cases of “algid malaria”, where

there is no fever at all. Therefore we believe that the absence of fever doesn’t allow us to exclude malaria.

5) Severe vomiting and diarrhea can simply be symptoms of malaria (normally diarrhea without blood), but we normally try to cover our patients with antibiotics as well, considering the high prevalence of gastroenteritis secondary to salmonella typhi, campylobacter or shigella. The antibiotics become more important after weaning the child, because the chance of taking contaminated food or water is higher.

6) The stool test for ova and cysts is useful only when positive, because we have many false negative results, and because very rarely we have the possibility of collecting 3 stool samples before the diagnosis. The presence of WBCs in stool makes us think of bacterial dysentery, but we do not have possibility of culture and sensitivity test.

7) In children with fever it is mandatory to check the ears because the otitis media is one of the most common causes of unexplained fever in children who cannot yet talk.

8) Always consider and try to rule out meningitis in all the cases of severe febrile disease in pediatrics, because in small children the neurological signs of the above condition can be absent or very mild.

9) Even here in Chaaria, sometimes the relationship of trust between the doctor and the mother breaks down and we must accept that children are taken away from us even when we believe we were doing a good job.

Many times we are not able to follow up if the mother actually goes to other hospitals or she chooses a traditional healer.

Dr Bro Giuseppe Gaido,

Clinical Officers & Nursing Staff (Pediatric Department).

Cottolengo Mission Hospital Chaaria