Case 3: Two Preschoolers with Fever

Shraddha Mittal; Lauren Marlowe; Dustin Elliott; Deana Gifford; Kristen Ritenour; Howard Topol

doi:10.1542/pir.2016-0202

This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.

Download PDF

Shraddha Mittal, MD*,^†
Lauren Marlowe, MD*,^†
Dustin Elliott, MD*,^†
Deana Gifford, MD*,^†
Kristen Ritenour, MD*,^†
Howard Topol, MD*,^†

^*Children's Hospital of Philadelphia,
^†CHOP Inpatient Pediatrics at Virtua, Voorhees, NJ

AUTHOR DISCLOSURE
Drs Mittal, Marlowe, Elliott, Gifford, Ritenour, and Topol have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Case 1

A 15-month-old Boy with Fever, Refusal to Bear Weight, and Small Foot Lesions

Presentation

A 15-month-old boy presents to the emergency department in May with a 3-day history of fever, irritability, poor oral intake, and refusal to bear weight. He has no history of cough, vomiting, diarrhea, or rash other than a lesion on the sole of his left foot, where his mother reports there was a possible insect bite 1 week earlier. He was previously healthy, and his immunizations are up to date. He lives in a rural area of southern New Jersey. The family denies recent travel or ingestion of raw foods or milk. He had visited a farm 2 weeks earlier but denies direct contact with farm animals. He has had contact with a 2-year-old cat but denies bites or scratches.

On examination he is ill appearing. Vital signs reveal a temperature of 103.5°F (39.7°C) and tachycardia. He is irritable but does not have meningismus. His abdominal examination findings are normal. He has no appreciable lymphadenopathy. On extremity examination his strength is normal. He has two 2-mm, erythematous, raised, tender papules on the plantar aspect of his left foot, but otherwise no specific tenderness to palpation or swelling along his lower extremities. Due to fever and irritability, he underwent a full sepsis evaluation, including lumbar puncture, blood culture, and urine culture. Initial cerebrospinal fluid cell count was normal. His laboratory values are notable for a white blood cell (WBC) count of 15,700 × 10³/μL (15.7 × 10⁹/L), with 60% neutrophils, 31% lymphocytes, and 6% bands; C-reactive protein (CRP), 115 mg/L …