From: Ed Oakley ([log in to unmask])
> Obviously there was a reason for posting this case.
--> He, he... Not obvious to all on the list, unfortuntely... Hence the loud accusation of time-wasting...
What does a foot taste like, I wonder...
Enough of that...
How well you did to present your case in "bits" - probably the best way to remind us all how far "knowing enough" to practice medicine, which is what we need to be, is NOT the same as "knowing everything", which is what we think we think we are just before we ruin someone's life... Of course, I write with a collection of episode of "knowing everything" scattered all along my career!
> ... still very well and had no focus (now 10 days into the illness). At no time was there any sign for kawasaki's disease other than the fever. At this visit the antibiotic were ceased, she was observed for 12 hours and sent home.
--> Why was she observed for 12 hours? If she's well for 10 days, what benefit of observing for half a day? Why not let parents "observe"? If it is because you are stopping the Ceclor, I would not expect you to "pick up" anything related to that in the first 12 hours...
> Obviously I would ask what you would do at this point. In the interest of not causing further chest pain to those reading I will finish the story.
--> Thanks. Running low on my nitrates here...
> She returned a further 3 days later with ongoing fever (now off a/b for 4 days). she was occasionally complaining of not feeling well but looked well and was eating junk food in the ED FBE - WCC 15, CRP>250 other bloods ok, bl cult -ve.
--> That's 2 weeks with fever and no documented focus... Sounds like a good "round figure" for a time to start looking for mysterious stuff before officially stating it's of "unknown origin"...
> Admitted for observation
--> I would NOT have done that. I say this realising that it was during that time she actually decompensated for what must have been the first time from your description. I would have spent quite some time explaining why it would not make sense to me to "observe" at this late a stage. My options at that stage would have been either "go home" or "come in and let us scan every organ & sample every fluid you have until we find either something or definitely nothing!"...
I honestly think that, had I seen her for the first time at that stage, I would have arranged LP, repeat cultures of blood & urine, serum rhubarb levels and everything else, without observing.
"Observing" is what I do when:
1. I think I know what is going on
2. I think I have provided the correct treatment for it
3. I want to "observe" it working just to make sure
Don't have 1 & 2 here!
> LP done 12 hours later (as she had deteriorated on the ward) confirmed pneumococcal meningitis.
--> Curious as to what its sensitivities were...
> Child became very unwell - ICU stay needed - but eventually got home. This has raised for us the question of when to investigate for partially treated meningitis, when to investigate persistent fever in kids on antibiotics. Of the 24 replies - to the list and directly to me - only one would have tapped her at the first visit. I agree this is a common presentation but should we have tapped on the second visit?
--> I would NOT have arranged LP at that first ED visit, as you described it. I would not wish to do it for a similar case tomorrow. If, on such a first visit in the future, a patient's mother actually asked me whether this could be undiagnosed, partially-treated meningitis, then I would probably want to say something like:
1. Chances are very minimal that it is
2. Just as likely (without stats to back it up) to have any "weird" infection we are not thinking about, e.g. TB... Or some radiation poisoning from something burried in the garden... Or some other systemic condition and bad news...
3. More likely to suffer harm from an LP than obtain benefit...
When WOULD I have done it? Any other changes? Well, I'll scan back again through your description:
> Her fever persisted and she returned to her family doctor 2 days later
--> I would have liked to have instructed the patient to continue her follow-up in the ED for this, rather than the FP. But I cannot honestly claim I would have done that for certain, only probably... I just tend to say it whenever I am not sure what the diagnosis is - I consider that we have the better resources.
> and was put on ceclor - apparently was still well with no focus.
--> As her FP, I would not have done that. This does not sound like the sort of patient to "try" another empirical treatment on. This is not a sensible adult with a visible and obvious diagnosis, like cellulitis, which seems to be resolving too slowly or not at all on some antibiotic... It's a poor historian with age-related-dysphasia and a nervous system which is poor at localising symptoms and making them obvious to doctors... I'd have referred back to the specialist department they had already been dealing with, i.e. yours.
> A further 4 days later she returned to the ED with ongoing fever - she was still very well and had no focus (now 10 days into the illness)
--> 4th visit to health professional. 2nd to a specialist unit. No better despite 2 antibiotics and 10 days...
I think this is where I call in the Delta Force...
I'd do "everything" at this stage.
I'd expect this to turn out to be a waste with most cases even at this stage, but, even in the penny-pinching NHS (and, boy, do I have a good pincer grip), this is where my risk:benefit ratio for doing the full work-up is on the side of benefit for sure...
> At no time was there any sign for kawasaki's disease other than the fever.
--> Good to consider, though...
> At this visit the antibiotic were ceased, she was observed for 12 hours and sent home... She returned a further 3 days later with ongoing fever (now off a/b for 4 days).
--> Already addressed the issue of observation...
I would treat this FIFTH visit as a sign that I was WRONG not to have thrown the book at it at the previous one...
> ...but looked well and was eating junk food in the ED
--> I do agree with you that one of our skills as EPs is to pick up subtle hints such as whether the child eats or not... But I would NOT dare use this sign at this stage. It's a SUBTLE clue that this child may well be better off than you'd think she is if she declined to eat the BigM. But she's IN ED FOR THE FIFTH TIME DESPITE ALL WE'VE DONE... That is NOT a subtle sign and it sorts of fades out the significance of eating vs. not... I.e. she may well be better than if she were not eating, but she's NOT better enough...
> FBE - WCC 15, CRP>250 other bloods ok.
--> Nice, but no good!
Of course, I WOULD have done these at this stage. But to me, at this stage, these two results are nowhere near specific enough. There is NO CRP result at this stage, nor any white cell count, which would have made me think she was well. If her WCC was perfectly mid-range and her CRP was MINUS TWELVE, she'd still be donating CSF for a good cause. I'm sure you'd agree.
> Admitted for observation LP done 12 hours later
--> I have already stated my objection to this delay through "observation". If I get given this sort of case to analyse & critique, I'd say that it SEEMS that the admitting doctor here thought that there was "something" going on... In a 2 year old with a fever despite the progress thus far, that something is in the CSF until proven otherwise (in some parts of the world, of course, you'd be expecting TB meningitis or something like that). So, if you THINK something's going on, you go get it! It's sub-optimal to delay.
> Thanks again in anticipation of your replies to help us determine what to do in future such cases
--> Thank YOU for an honest presentation of an interesting case.
My final point would be to say that I am not sure whehter we should be surprised that she did well after all that. This sort of course of progress does not sound like an aggressive bug. It took a long slow time to get to "unwell" and it was still slow enough to be caught by you and beat back.
This is my opinion.
I HOPE others on this list have other opinions.
I EXPECT that they would.
I will probably have a different opinion myself in a few years' time!
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