Fever in infancy and childhood

Chapter 6 Fever in infancy and childhood

Case 6.1

1. What does this information tell you about the cause of her problem?

Nasal flaring and indrawing of the intercostal and supraclavicular spaces suggest that there is airway obstruction. Stridor localises this obstruction to the upper respiratory tract. Fever suggests the presence of an infective process. Thus, the diagnosis is likely to be an infection in the upper airways, severe enough to cause obstruction.

2. What is the most likely diagnosis? Why?

• fever suggests an infection rather than inhalation of a foreign body

• croup would usually present with a cough as a predominant symptom.

3. Does this patient require referral to a medical practitioner or a hospital? How urgent is the situation?

She should be immediately sent to hospital in an ambulance, as this can be a life-threatening condition.

4. List the possible causes of fever in an infant or child.

Fever is usually associated with the presence of an infection. It is possible, however, for a fever to occasionally be the result of another type of pathological process. This includes:

• neoplastic processes, for example, leukaemia and lymphoma (not due to an infection that may occur during the course of the illness as a result of the altered immune status of the child)

• drugs (they can act as external pyrogens)

• metabolic or inherited diseases

• connective tissue disorders

• overheating

• infarctions (rare in children).

Note: it is very common for parents to state that their child will have a fever when he/she is teething. This is a very common observation, but the reason for it is unclear. A study of attitudes to the connection between teething and fever was reported in 2005, when 55 paediatricians, 130 nurses and 277 parents were surveyed. Their results revealed that nearly all parents, the majority of the nurses and a large number of the paediatricians believed that a mild fever and other symptoms occurred with teething.^[1]

However, high fever is not believed to be the result of teething. Assuming otherwise may endanger the life of an infant or toddler. High fever must be investigated promptly.

Case 6.2

1. Do you think that the doctor’s initial assessment was reasonable?

The doctor was probably correct about her having ‘an infection of some kind’. Without the localisation of pain, his assessment was reasonable. However, it was his responsibility to suggest re-assessment if her symptoms persisted or altered.

2. If she went back to her doctor now, do you think that the differential diagnosis may alter? What are the possibilities?

Yes, the localisation of pain to the right side narrows the differential diagnosis. The recent overseas travel, in combination with her clinical features, suggest the possibility of infectious hepatitis or a parasitic liver disorder. The information given does not specify whether the pain is in the upper or lower abdomen. If in the lower abdomen, acute appendicitis or mesenteric adenitis are possibilities.

3. For each disorder you named in question 2, state the other clinical features that may be present, or likely to occur, that would support your diagnosis.

Disorder	Symptoms	Signs
Infectious hepatitis	• Right upper quadrant discomfort • Development of jaundice • Anorexia, nausea	• Fever • Right upper quadrant tenderness
Parasitic liver disorder (eg: amoebic liver abscess)	• Right upper quadrant discomfort • Anorexia, nausea • History of diarrhoea may or may not be present • Jaundice not common	• Fever • Right upper quadrant tenderness
Acute appendicitis	• Right lower quadrant pain with tenderness • Anorexia and nausea	• Rebound tenderness and guarding over area of pain is common • Fever
Mesenteric adenitis	• Right lower quadrant pain with tenderness • Anorexia and nausea • May have a recent history of a respiratory tract infection	• May possibly have some rebound tenderness and/or fever

Case 6.3

1. What is meant by the terms ‘papular’ and ‘vesicular’ lesions?

A papular lesion refers to a small, elevated, firm skin lesion, generally less than 1cm in diameter. A vesicular lesion refers to a small, elevated, fluid filled skin lesion, generally less than 1cm in diameter. They are also known commonly as ‘blisters’.

2. What is your differential diagnosis?

a Gingivostomatitis, possibly herpetic in origin. This disorder is characterised by significant swelling of the affected tissues.

b Hand, foot and mouth disease.

4. Assuming that Jade’s mother has recently had a ‘blister-like’ lesion on her lip, what is the most likely diagnosis?

Herpetic gingivostomatitis.

5. What is the causative agent?

A virus: herpes simplex 1.

6. Approximately how long will Jade’s symptoms last, assuming no complications or secondary infection?

7. Can Jade expect further episodes of this problem?

She is unlikely to have any severe recurrences, but may have ‘cold sores’ during times of stress to the body.

Case 6.4

2. What do you tell your friend to do? Why?

She needs to take the infant immediately to hospital, as the indrawing of the intercostal spaces indicates significant breathing difficulties.

3. Two days later your friend informs you that Jane is now stable, but was hospitalised requiring oxygen and hydration. She had been informed that her condition was due to a viral infection. What is the most likely diagnosis?

4. What type of virus causes this disorder?

Most commonly due to Respiratory Syncytial virus.

5. What is the common age distribution of this disorder? How common is it?

It occurs in infancy and early childhood. Peak incidence is 2–8 months, and most patients are under the age of 2 years.^[2]

Case 6.6

1. Is your friend correct about the diagnosis of herpes?

2. Name the most likely causative agent of this disorder.

It is a viral infection. The most common aetiological agents are enterovirus 71, and coxsackie viruses.

3. Describe the typical clinical presentation of this condition.

Many are asymptomatic. The classic clinical presentation includes the following.

Symptoms	Signs
• Fever • Malaise • Sore throat and pain with swallowing • Occasional headache, abdominal pain and vomiting, plus a skin rash	• Lesions predominantly involving oropharynx, tonsilar region and soft palate (start as macules, then develop into papules and vesicles, and ulcerate centrally to form what appears to be a red ‘halo’) • Cervical lymphadenopathy

4. How does it differ clinically from ‘hand, foot and mouth disease’?

Hand, foot and mouth disease is generally associated with lesions in the anterior part of the oral cavity (eg: tongue and buccal mucosa), whereas herpangina affects predominantly the posterior part of the pharynx.

Tags: Cases in Differential Diagnosis for the Physical and Manipulativ

Dec 26, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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