Case Study

[ericdamiansean]

Hey guys, I got this question to review as my finals in peds, didn’t do to well, would like to review it. Most of the details are in the case as what I have remembered, any feedback would be great.

Case:
10 year old boy who’s a known case of leukemia undergoing induction chemo has fever of 39-40 C for 2 days. There were no foci of infection other than rhinorrhea and unproductive cough. Was given Erythromycin 250 mg 8 hourly orally. Fever persisted and on the third day of fever, his mother pointed that the boy had a few painful skin nodules around the anal region.
He became tachycardic, pulse 120, BP 100/70. Hb: 10, WBC 1200, Platelets 8000. Chest X-ray showed patchy consolidation in the right lobe.
Blood culture was taken, followed by parental abx but condition worsened. 2 of the anal nodules are now black and he developed petechiaes all over the lower limbs. On the 6th day of illness, he developed hematemesis. Blood cultures came back negative, temperature remained at 40 C. He was also anuric for the last 6 hours.
Soon after, his vitals worsened, systolic BP 90, diastolic unrecordable. All efforts to resuscitate him failed.

Question:
List down the problems and pathophysiology as the disease progressed. How would you have investigated and managed the patient.

My answer:

For a 10 year old boy, I’m thinking that he has ALL, and due to the chemo and leukemia, is severely immunocompromised. Rhinorrhea and cough were basically opportunistic infections, and the skin nodules were caused either by Pseudomonas or S. fecalis or a virus. The abx given was useless against these groups of pathogens, thus, they did not manage to lower the fever and instead worsened the condition. A negative blood culture would indicate that the nodules were more likely caused by a virus. Hematemesis is probably due to low platelets secondary from the chemo and leukemia.
He then went into septicemic shock.
If it were me, I would have taken the blood culture, but from his blood results, started him on Acyclovir instead and monitored his serum electrolytes closely. And also transfused some blood as well.

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[Bertelman]

I'm not usually for cross-posting, but this sounds like a great question for the Peds residency forum.

 

[colbgw02]

Hey guys, I got this question to review as my finals in peds, didn’t do to well, would like to review it. Most of the details are in the case as what I have remembered, any feedback would be great.

Case:
10 year old boy who’s a known case of leukemia undergoing induction chemo has fever of 39-40 C for 2 days. There were no foci of infection other than rhinorrhea and unproductive cough. Was given Erythromycin 250 mg 8 hourly orally. Fever persisted and on the third day of fever, his mother pointed that the boy had a few painful skin nodules around the anal region.
He became tachycardic, pulse 120, BP 100/70. Hb: 10, WBC 1200, Platelets 8000. Chest X-ray showed patchy consolidation in the right lobe.
Blood culture was taken, followed by parental abx but condition worsened. 2 of the anal nodules are now black and he developed petechiaes all over the lower limbs. On the 6th day of illness, he developed hematemesis. Blood cultures came back negative, temperature remained at 40 C. He was also anuric for the last 6 hours.
Soon after, his vitals worsened, systolic BP 90, diastolic unrecordable. All efforts to resuscitate him failed.

Question:
List down the problems and pathophysiology as the disease progressed. How would you have investigated and managed the patient.

My answer:

For a 10 year old boy, I’m thinking that he has ALL, and due to the chemo and leukemia, is severely immunocompromised. Rhinorrhea and cough were basically opportunistic infections, and the skin nodules were caused either by Pseudomonas or S. fecalis or a virus. The abx given was useless against these groups of pathogens, thus, they did not manage to lower the fever and instead worsened the condition. A negative blood culture would indicate that the nodules were more likely caused by a virus. Hematemesis is probably due to low platelets secondary from the chemo and leukemia.
He then went into septicemic shock.
If it were me, I would have taken the blood culture, but from his blood results, started him on Acyclovir instead and monitored his serum electrolytes closely. And also transfused some blood as well.

i'm not a pediatrician and i'm not really sure what your specific question is, but i'll bite...

you're correct in thinking that the patient is immunocompromised; your diagnostic thought process is pretty solid. my only critique is to remember that the most common pathogens in immunocompromised patients are the same pathogens that affect immunocompetent patients. (attendings love to ask what the most common cause of bacterial pneumonia in HIV patients is (pneumococcus)) so, i wouldn't have necessarily jumped right to opportunistic infections. did they want you to give a specific pathogen?

initially, i think you have to treat this patient as if he were neutropenic. his WBC might be through the roof, but you have to assume that they're not functioning. strong gram-negative coverage (e.g. gent) might have been a good addition to erythromycin.

when thing's turn for the worse, given his immunocompromised status, this kid needs broad-spectrum abx, to include anti-virals (acyclovir, as you mentioned) and anti-fungals. normally, those would be weaned once culture data is available. the fact that the cultures are negative doesn't mean too much; it just means you can't narrow your abx coverage yet. i probably see more septic patients with negative cultures than i do with positive ones.

one thing you didn't mention is that this kid has pneumonia, right? fever + tachycardia + patchy infiltrate on CXR = pneumonia until proven otherwise. they probably wanted you to run down a pneumonia differential diagnosis.

regarding the hematemesis, it's probably from the pneumonia, right? sure, dysfunctional platelets are going to exacerbate the situation, but your platelet count has to be extraordinarily low (less than 15K) to bleed spontaneously. this is a common misconception that i see all the time, even from experienced clinicians. having low platelets or being anti-coagulated is rarely the cause of bleeding, it's just an aggravating factor. so when you see the GI bleeder in the ER who's on coumadin for his A-fib, it's not enough to just stop the coumadin - you have to stop the source of the bleeding by getting scoped and sclerosing the diverticuli.

by the end, as you mentioned, it's a full court press for septic shock, to include abx, fluid resuscitation, blood products, vasopressive agents, and probably a ventilator. hopefully they didn't want/expect you to go into all of that though.

like i said, i'm not a pediatrician, so folks should feel free to correct me, but i hope this helps...

 

[ericdamiansean]

i'm not a pediatrician and i'm not really sure what your specific question is, but i'll bite...

(In the case, the patient died, so if you were the attending, how would you have managed the patient differently and along the way, offered some explanation on how the signs and symptoms worsened)

you're correct in thinking that the patient is immunocompromised; your diagnostic thought process is pretty solid. my only critique is to remember that the most common pathogens in immunocompromised patients are the same pathogens that affect immunocompetent patients. (attendings love to ask what the most common cause of bacterial pneumonia in HIV patients is (pneumococcus)) so, i wouldn't have necessarily jumped right to opportunistic infections. did they want you to give a specific pathogen?

(Nope, we were not required to look for a specific pathogen, but it would be good because we were told at the end of the exam that there was one specific pathogen which caused the skin nodules around the anal region, I don’t think it’s a virus, so most likely it should be Pseudomonas or S. fecalis, because these 2 are the commonest normal flora around the region and presentation in an immucompromised patient would be that, but perhaps someone would know better? Anyone?)

initially, i think you have to treat this patient as if he were neutropenic. his WBC might be through the roof, but you have to assume that they're not functioning. strong gram-negative coverage (e.g. gent) might have been a good addition to erythromycin.

(Yup, I would have given genta instead of Erythromycin)

when thing's turn for the worse, given his immunocompromised status, this kid needs broad-spectrum abx, to include anti-virals (acyclovir, as you mentioned) and anti-fungals. normally, those would be weaned once culture data is available. the fact that the cultures are negative doesn't mean too much; it just means you can't narrow your abx coverage yet. i probably see more septic patients with negative cultures than i do with positive ones.one thing you didn't mention is that this kid has pneumonia, right? fever + tachycardia + patchy infiltrate on CXR = pneumonia until proven otherwise. they probably wanted you to run down a pneumonia differential diagnosis.

(If pneumonia were to be a differential, would the condition deteriorate in that manner? I was thinking along the way of a respiratory arrest, atelectasis ie. More respiratory symptoms, and genta would have been able to help)

regarding the hematemesis, it's probably from the pneumonia, right? sure, dysfunctional platelets are going to exacerbate the situation, but your platelet count has to be extraordinarily low (less than 15K) to bleed spontaneously. this is a common misconception that i see all the time, even from experienced clinicians. having low platelets or being anti-coagulated is rarely the cause of bleeding, it's just an aggravating factor. so when you see the GI bleeder in the ER who's on coumadin for his A-fib, it's not enough to just stop the coumadin - you have to stop the source of the bleeding by getting scoped and sclerosing the diverticuli.

(You’ve a point about the hematemesis, it’s probably from the pneumonia because although platelets are less than 15k, if he were to bleed from that, it would have been earlier and not sudden as in the case)

by the end, as you mentioned, it's a full court press for septic shock, to include abx, fluid resuscitation, blood products, vasopressive agents, and probably a ventilator. hopefully they didn't want/expect you to go into all of that though.

(Actually, we do have to go through all of those, final year…sigh…Thus, for this case, I'll first give an abx cover of abx of genta after the blood culture, and once it's negative, i'll add acyclovir to it, and at all times, keeping tabs on serum electrolytes and blood pressure. If these drop,with a Hb of 10, i'll transfure packed cells about 2 units and vasopressors, likely norepinephrine. Any comments?)