A 15-month-old boy is brought to the ER because of fever and a rash. Six hours earlier he was fine,

Discussion in 'MRCPCH forum' started by samuel, Sep 10, 2014.

  1. samuel

    samuel New Member

    A 15-month-old boy is brought to the ER because of fever and a rash. Six hours earlier he was fine, except for tugging on his ears; another physician diagnosed otitis media and prescribed amoxicillin. During the interim period, the child has developed an erythematous rash on his face, trunk, and extremities. Some of the lesions, which are of variable size, do not blanch on pressure. The child is now very irritable, and he does not interact well with the examiner. Temperature is 39.5°C (103.1°F). He continues to have injected, immobile tympanic membranes, but you are concerned about his change in mental status. Which of the following is the most appropriate next step in the management of this infant?
    a. Begin administration of IV ampicillin
    b. Begin diphenhydramine
    c. Discontinue administration of ampicillin and begin trimethoprim with sul-famethoxazole
    d. Perform bilateral myringotomies
    e. Perform a lumbar puncture
  2. samuel

    samuel New Member

    The ans is E
    Unsuspected bacteremia caused by H influenzaetype B (now rare), Neisseria meningitidis, or S pneumoniae(decreasing in frequency secondary to vaccination) should be considered before prescribing treatment for otitis media in a young, febrile, toxic-appearing infant. In this situation, blood culture should be performed before antibiotic therapy is initiated, and examination of the CSF is indicated if meningitis is suspected.
    The classic signs of meningitis are found with increasing reliability in children older than 6 months. Nevertheless, a febrile, irritable, inconsolable infant with an altered state of alertness deserves a lumbar puncture even in the absence of meningeal signs. A petechial rash, characteristically associated with meningococcal infection, has been known to occur with other bacterial infections as well. Organisms may be identified on smear of these lesions.
    A fever accompanied by inability to flex rather than rotate the neck immediately suggests meningitis (a sign more reliable in children older than 12 to 18 months of age). An indolent clinical course does not rule out bacterial meningitis. A lumbar puncture is of prime diagnostic importance in determining the presence of bacterial meningitis, which requires immediate antibiotic therapy. A delay in treatment can lead to complications such as cerebrovascular thrombosis, obstructive hydrocephalus, cerebritis with seizures or acute increased intracranial pressure, coma, or death. A missed diagnosis of meningitis is one of the most common reasons for civil litigation involving a pediatrician. In the described patient, lumbar puncture is warranted because of the change in his clinical status.

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