CASE 1:
A 10-month-old girl presented with a history of being grizzly, quiet, off food and tugging at her ears for 18 hours with associated low-grade pyrexia. She had 2 loose bowel motions and 6 wet nappies that day with good fluid intake. There were no other concerns and the only past medical history was gastroschisis. On examination she was well perfused with good hydration status. She was tachycardic in association with a pyrexia but nil else to find. After a night of observation her heart rate had normalised, as had her temperature. She had vomited three times and appeared grizzly, pale and lethargic with dry mucous membranes. By the afternoon she was tolerating fluids well, apyrexial and the diarrhoea and vomiting had resolved. She was discharged home.
The next afternoon she reattended not tolerating fluids but still passing urine with associated sleepiness. On examination she had a congested throat but otherwise appeared well. She was kept in overnight as she was still not drinking good volumes and given Difflam spray to encourage fluid intake. The next morning she had another low-grade temperature but other observations were within normal limits. She was tolerating fluids. On examination she was irritable and pulling at her ears. She was noted to have some mild neck stiffness.
Q1. At this point what would your management plan be?
a) Continue encouraging oral fluids and observe through the day.
b) Pass NGT for fluid resuscitation.
c) Discharge home.
d) Blood tests for FBC, CRP and U
þ Es
e) Start antibiotics for Pharyngitis.
e) Blood tests for FBC, CRP, U
þ Es, blood culture and LP then start on Ceftriaxone and Dexamethasone.
Q2. What is the most common cause of bacterial meningitis in children more than 3 months?
a) H influenzae Type B
b) Meningococcus C
c) Pneumococcus
d) Meningococcus B
e) Group B Streptococcus
Q3. Which of the following signs are contraindications to performing a lumbar puncture?
a) Tachycardia
b) Spreading purpura
c) Platelets 55
109/litre
d) GCS 14
e) Focal neurological signs
Answer
A1 e) In view of these subtle signs of meningism she had bloods taken, an LP done and was started on IV Ceftriaxone and Dexamethasone. The CSF was turbid with a glucose of less than 0.3, protein of 2.67, 90% polymorphs and 10% lymphocytes with gram negative diplococci grown later confirmed to be meningococcus. Her bloods showed a CRP of 169 and the blood culture grew meningococcus as well. She was treated with 4 days of Dexamethasone and 7 days of Ceftriaxone as per the NICE guidance for Meningococcal Meningitis.
A2 d) Following the introduction of vaccinations Meningococcus C, Hib and Pneumococcus have all decreased their presentation with Meningococcus B being the most common cause of bacterial meningitis in children more than 3 months.
A3 b,c,e) Contraindications to LP in a child with suspected meningitis include signs suggesting raised intracra-nial pressure: reduced or fluctuating level of consciousness
i.e. Glasgow Coma Scale score less than 9 or a drop of 3 or more; relative bradycardia and hypertension; focal neurological signs; abnormal posture or posturing; unequal, dilated or poorly responsive pupils; papilledema; abnormal ‘doll’s eye’ movements or shock, extensive or spreading purpura, after convulsions until stabilised, coagulation abnormalities: coagulation results outside the normal range; platelet count below 100
109/litre; receiving anticoagulant therapy or local superficial infection at the lumbar puncture site or respiratory insufficiency.
This case shows how difficult it can be to identify meningitis. Once neck stiffness was identified she was investigated. However literature shows how non-specific the presentation of meningitis can be. A systematic review of prospective data in 2010 showed that complaints of bulging fontanelle, neck stiffness, seizures (outside febrile-convulsion age range) or reduced feeds raised concern about the presence of meningitis while on examination, jaundice, being toxic or moribund, meningeal signs, neck stiffness, bulging fontanel, Kernig sign, tone up, fever of more than 40 C and Brudzinski sign independently raised the likelihood of meningitis. The absence of meningeal signs and an abnormal cry independently lowered the likelihood of meningitis. The absence of fever did not rule out meningitis. This review concluded that no isolated clinical feature is diagnostic, and the most accurate diagnostic combination is unclear.
--------------------------------------------
Case 2
A normally delivered term baby weighed 3.67 kg (50th centile). At
home, he breastfed well and had immunisations at 2 and 3 months with no complications. He stopped breastfeeding at 16 weeks and started a weaning diet soon after. At 5 months he was admitted with a 2-week history of cough, unresponsive to amoxicillin and cephalexin. He had pallor on coughing but no apnoeas. He had mild intercostal recession during feeding only, which was not reduced. Despite this, baseline oxygenation saturations were 84% in air, improving in 1 l/min nasal oxygen. His admission weight was 6.4 kg (2nd to 9th centile). No organism was identified and he was discharged 6 days later to complete 10 days of clarithromycin. Three weeks later he developed Rotavirus-positive diarrhoea, which settled with frozen breast milk. His weight was 6.48 kg (2nd centile). Three weeks later he was readmitted with ongoing diarrhoea and a chesty cough, vomiting phlegm. His weight was 6.18 kg (<0.4th centile). He had a wasted appearance, crackles in the right mid-zone, and respiratory rate of 40 per minute with mild recession. He had no eczema. Chest x-ray showed generalised haziness and stool remained Rotavirus-positive. Oxygen saturations were normal in air. Cefotaxime and clarithromycin were started. Over the course of the next 3 days, he clinically deteriorated and required invasive ventilation via endotracheal tube; oxygenation was harder to achieve than carbon dioxide clearance and he developed evidence of severe barotrauma, with pneumomediastinum and surgical emphysema .
(a) Which of the following investigations considered before his acute deterioration is most likely to be abnormal?
Sweat test
Coeliac screening
Immunoglobulins and lymphocyte subsets
Bone scan Urine organic acids
(b) Which investigation is needed urgently following intubation?
Respiratory sample for Pneumocystis jirovecii
Respiratory sample for Aspergillus
Respiratory viral screen
Respiratory mucus elastase
Surfactant proteins
(c) What specific treatment
would you start blindly while waiting for results?
High dose steroids
Antifungals
High dose co-trimoxazole
High dose co-trimoxazole and steroids
Surfactant
The answer
(a) Immunoglobulins and lymphocyte subsets
(b) Respiratory sample for Pneumocystis jirovecii
(c) High dose co-trimoxazole
A 10-month-old girl presented with a history of being grizzly, quiet, off food and tugging at her ears for 18 hours with associated low-grade pyrexia. She had 2 loose bowel motions and 6 wet nappies that day with good fluid intake. There were no other concerns and the only past medical history was gastroschisis. On examination she was well perfused with good hydration status. She was tachycardic in association with a pyrexia but nil else to find. After a night of observation her heart rate had normalised, as had her temperature. She had vomited three times and appeared grizzly, pale and lethargic with dry mucous membranes. By the afternoon she was tolerating fluids well, apyrexial and the diarrhoea and vomiting had resolved. She was discharged home.
The next afternoon she reattended not tolerating fluids but still passing urine with associated sleepiness. On examination she had a congested throat but otherwise appeared well. She was kept in overnight as she was still not drinking good volumes and given Difflam spray to encourage fluid intake. The next morning she had another low-grade temperature but other observations were within normal limits. She was tolerating fluids. On examination she was irritable and pulling at her ears. She was noted to have some mild neck stiffness.
Q1. At this point what would your management plan be?
a) Continue encouraging oral fluids and observe through the day.
b) Pass NGT for fluid resuscitation.
c) Discharge home.
d) Blood tests for FBC, CRP and U
þ Es
e) Start antibiotics for Pharyngitis.
e) Blood tests for FBC, CRP, U
þ Es, blood culture and LP then start on Ceftriaxone and Dexamethasone.
Q2. What is the most common cause of bacterial meningitis in children more than 3 months?
a) H influenzae Type B
b) Meningococcus C
c) Pneumococcus
d) Meningococcus B
e) Group B Streptococcus
Q3. Which of the following signs are contraindications to performing a lumbar puncture?
a) Tachycardia
b) Spreading purpura
c) Platelets 55
109/litre
d) GCS 14
e) Focal neurological signs
Answer
A1 e) In view of these subtle signs of meningism she had bloods taken, an LP done and was started on IV Ceftriaxone and Dexamethasone. The CSF was turbid with a glucose of less than 0.3, protein of 2.67, 90% polymorphs and 10% lymphocytes with gram negative diplococci grown later confirmed to be meningococcus. Her bloods showed a CRP of 169 and the blood culture grew meningococcus as well. She was treated with 4 days of Dexamethasone and 7 days of Ceftriaxone as per the NICE guidance for Meningococcal Meningitis.
A2 d) Following the introduction of vaccinations Meningococcus C, Hib and Pneumococcus have all decreased their presentation with Meningococcus B being the most common cause of bacterial meningitis in children more than 3 months.
A3 b,c,e) Contraindications to LP in a child with suspected meningitis include signs suggesting raised intracra-nial pressure: reduced or fluctuating level of consciousness
i.e. Glasgow Coma Scale score less than 9 or a drop of 3 or more; relative bradycardia and hypertension; focal neurological signs; abnormal posture or posturing; unequal, dilated or poorly responsive pupils; papilledema; abnormal ‘doll’s eye’ movements or shock, extensive or spreading purpura, after convulsions until stabilised, coagulation abnormalities: coagulation results outside the normal range; platelet count below 100
109/litre; receiving anticoagulant therapy or local superficial infection at the lumbar puncture site or respiratory insufficiency.
This case shows how difficult it can be to identify meningitis. Once neck stiffness was identified she was investigated. However literature shows how non-specific the presentation of meningitis can be. A systematic review of prospective data in 2010 showed that complaints of bulging fontanelle, neck stiffness, seizures (outside febrile-convulsion age range) or reduced feeds raised concern about the presence of meningitis while on examination, jaundice, being toxic or moribund, meningeal signs, neck stiffness, bulging fontanel, Kernig sign, tone up, fever of more than 40 C and Brudzinski sign independently raised the likelihood of meningitis. The absence of meningeal signs and an abnormal cry independently lowered the likelihood of meningitis. The absence of fever did not rule out meningitis. This review concluded that no isolated clinical feature is diagnostic, and the most accurate diagnostic combination is unclear.
--------------------------------------------
Case 2
A normally delivered term baby weighed 3.67 kg (50th centile). At
home, he breastfed well and had immunisations at 2 and 3 months with no complications. He stopped breastfeeding at 16 weeks and started a weaning diet soon after. At 5 months he was admitted with a 2-week history of cough, unresponsive to amoxicillin and cephalexin. He had pallor on coughing but no apnoeas. He had mild intercostal recession during feeding only, which was not reduced. Despite this, baseline oxygenation saturations were 84% in air, improving in 1 l/min nasal oxygen. His admission weight was 6.4 kg (2nd to 9th centile). No organism was identified and he was discharged 6 days later to complete 10 days of clarithromycin. Three weeks later he developed Rotavirus-positive diarrhoea, which settled with frozen breast milk. His weight was 6.48 kg (2nd centile). Three weeks later he was readmitted with ongoing diarrhoea and a chesty cough, vomiting phlegm. His weight was 6.18 kg (<0.4th centile). He had a wasted appearance, crackles in the right mid-zone, and respiratory rate of 40 per minute with mild recession. He had no eczema. Chest x-ray showed generalised haziness and stool remained Rotavirus-positive. Oxygen saturations were normal in air. Cefotaxime and clarithromycin were started. Over the course of the next 3 days, he clinically deteriorated and required invasive ventilation via endotracheal tube; oxygenation was harder to achieve than carbon dioxide clearance and he developed evidence of severe barotrauma, with pneumomediastinum and surgical emphysema .
(a) Which of the following investigations considered before his acute deterioration is most likely to be abnormal?
Sweat test
Coeliac screening
Immunoglobulins and lymphocyte subsets
Bone scan Urine organic acids
(b) Which investigation is needed urgently following intubation?
Respiratory sample for Pneumocystis jirovecii
Respiratory sample for Aspergillus
Respiratory viral screen
Respiratory mucus elastase
Surfactant proteins
(c) What specific treatment
would you start blindly while waiting for results?
High dose steroids
Antifungals
High dose co-trimoxazole
High dose co-trimoxazole and steroids
Surfactant
The answer
(a) Immunoglobulins and lymphocyte subsets
(b) Respiratory sample for Pneumocystis jirovecii
(c) High dose co-trimoxazole
