Doctor Dalia
15-08-2005, 10:47 PM
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Pyrexia of unknown origin
Clinical problem:
10 years of female child presents with high fever for last 4 weeks. There have been no other significant symptoms reported. Physical examination reveals febrile child without any localizing signs. Investigations showed the following:
Total WBC count 25,000/c.mm (P 80 L 16 E 3 M 1)
Hb 12 Gm%
Platelet adequate
ESR 80 mms at the end of one hour
Urinalysis normal
Chest x-ray normal
Child was treated with oral Augmentin for 5 days and laboratory tests repeated because of no improvement. Antimalarial were also tried.
Repeat tests were as follows:
Total WBC count 38,000/c.mm(P 83 L 12 E 3 M 2)
ESR 95
Hb 10.5 Gm%
Platelet adequate
Chest x-ray normal
Child was hospitalized and treated with Ceftriaxone and Amikacin for next 7 days without any relief.
Repeat tests showed
WBC count 45,000/c.mm (P 82 L 13 E 3 M 2)
ESR 105
Further tests included blood culture / urine culture / abdominal USG / CT scan of chest / widal test . Bone marrow examination and radionucleide tagged WBC scans were considered for any haematological problems and to localize focus of infection.
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Experts Opinion
Dr. Y.K.Amdekar replies:
Analysis:
High neutrophilic leucocytosis may not mean infection alone. It represents inflammation for which common cause may be bacterial infection but not always. Such high counts are rarely seen in clinical practice and whenever seen, such patients clearly demonstrate serious bacterial infection in the form of pneumonia, meningitis or UTI. But when high counts of this order present no evident focus of bacterial infection, it is likely to be non-infective inflammatory disorder. Moreover, eosinophils are suppressed in acute bacterial infection and 0-1 % of eosinophils are usual in such cases. This child therefore classically represents noninfective inflammation and not infection. Increasing counts suggest ongoing worsening inflammation and hence WBC count in this child steadily increased over next few weeks. Reduction of Hb is nonspecific. Thrombocytosis is a feature of most of inflammatory disorders but may also be an accompaniment of severe bacterial infections. Increasing counts without worsening clinical condition is another clue to noninfective condition in this child. This child suffered from systemic inflammatory disease and is impossible to assign a label to this disease at this stage as over few months, this child may evolve into typical syndrome such as Juvenile chronic arthritis and then in retrospect one would know that this child presented with systemic onset of JCA. Till then such patients need to be treated with NSAIDs and not antibiotics.
Comments:
Laboratory tests must be analysed in conjunction with clinical profile and not in isolation. Use of antibiotics without any clinical focus often leads to confusion rather than solving the problem. If serious life threatening infections can be ruled out clinically such as meningitis, pneumonia, sepsis, diptheria and intra-abdominal infections, it is prudent to pinpoint probable source of fever rather than antibiotics trial.
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Pyrexia of unknown origin
Clinical problem:
10 years of female child presents with high fever for last 4 weeks. There have been no other significant symptoms reported. Physical examination reveals febrile child without any localizing signs. Investigations showed the following:
Total WBC count 25,000/c.mm (P 80 L 16 E 3 M 1)
Hb 12 Gm%
Platelet adequate
ESR 80 mms at the end of one hour
Urinalysis normal
Chest x-ray normal
Child was treated with oral Augmentin for 5 days and laboratory tests repeated because of no improvement. Antimalarial were also tried.
Repeat tests were as follows:
Total WBC count 38,000/c.mm(P 83 L 12 E 3 M 2)
ESR 95
Hb 10.5 Gm%
Platelet adequate
Chest x-ray normal
Child was hospitalized and treated with Ceftriaxone and Amikacin for next 7 days without any relief.
Repeat tests showed
WBC count 45,000/c.mm (P 82 L 13 E 3 M 2)
ESR 105
Further tests included blood culture / urine culture / abdominal USG / CT scan of chest / widal test . Bone marrow examination and radionucleide tagged WBC scans were considered for any haematological problems and to localize focus of infection.
</FONT>
Experts Opinion
Dr. Y.K.Amdekar replies:
Analysis:
High neutrophilic leucocytosis may not mean infection alone. It represents inflammation for which common cause may be bacterial infection but not always. Such high counts are rarely seen in clinical practice and whenever seen, such patients clearly demonstrate serious bacterial infection in the form of pneumonia, meningitis or UTI. But when high counts of this order present no evident focus of bacterial infection, it is likely to be non-infective inflammatory disorder. Moreover, eosinophils are suppressed in acute bacterial infection and 0-1 % of eosinophils are usual in such cases. This child therefore classically represents noninfective inflammation and not infection. Increasing counts suggest ongoing worsening inflammation and hence WBC count in this child steadily increased over next few weeks. Reduction of Hb is nonspecific. Thrombocytosis is a feature of most of inflammatory disorders but may also be an accompaniment of severe bacterial infections. Increasing counts without worsening clinical condition is another clue to noninfective condition in this child. This child suffered from systemic inflammatory disease and is impossible to assign a label to this disease at this stage as over few months, this child may evolve into typical syndrome such as Juvenile chronic arthritis and then in retrospect one would know that this child presented with systemic onset of JCA. Till then such patients need to be treated with NSAIDs and not antibiotics.
Comments:
Laboratory tests must be analysed in conjunction with clinical profile and not in isolation. Use of antibiotics without any clinical focus often leads to confusion rather than solving the problem. If serious life threatening infections can be ruled out clinically such as meningitis, pneumonia, sepsis, diptheria and intra-abdominal infections, it is prudent to pinpoint probable source of fever rather than antibiotics trial.
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