CASE STUDY FIFTEEN: HEENT
– The 6 day fever
CASE STUDY OBJECTIVES: After completion of this case study, the
participants will be able to complete the following:
1. Apply key points in the history and physical examination to develop a
differential diagnosis.
2. Discuss the variety of pathogens responsible for pharyngitis and infectious
mononucleosis.
3. Understand how sensitivity and specificity of laboratory tests aid in the
development of the differential diagnosis.
4. Understand how ethnic, cultural, and personal factors play a role in shared
decision making when developing a diagnostic and treatment plan.
CASE PRESENTATION AND DISCUSSION
MS is a 7 year old American child with a Peruvian father and a Puerto Rican
mother. She presents with a 6 day history of a sore throat associated with a
fever to 103 degrees F (39.5 degrees C), headache, malaise, painful
lymphadenopathy, and overwhelming fatigue. On day three of the illness, MS
was seen for pharyngitis. She was diagnosed with streptococcal pharyngitis after
a rapid strep test was positive. She was started on Omnicef at 14 mg/kg/day due
to a history of rash following Amoxil. The child is worse after 3 days of antibiotic.
The mother is concerned that there is something else wrong with the child.
1. What questions will you need to ask the family related to the
presenting complaints?
FURTHER INFORMATION
The child and mother confirm that they have been taking the antibiotic on a twice
a day schedule using a syringe for measurement. Nutritionally, the child reports
she is able to drink cool liquids, puddings, ice cream, and warm soups.
Regarding elimination, she is voiding at least six times a day and has a small,
brown, formed stool daily. Educatino and environment screening indicates that
she is in second grade and doing well. She has not been exposed to any sick
friends or family members. Concerning development/daycare, she goes to a
daycare center for an after–school program as well as being involved in
gymnastics 3 days a week, although she has not attended this week. Finally, for
sleep assessment, she reports taking at least two naps a day and sleeping 12
hours a night for the past 4 days. Normally she does not take naps and sleeps
about 9 hours a night.
MD’s mother reports giving Advil at an appropriate dosage (10mg/kg/dose) every
6 hours for the persistent fever. She denies the use of any other alternative
medication. The child feels worse than she did 3 days ago despite the Advil and
the Omnicef. The mother reports that MD is usually very energetic, and her
present behavior is unusual. The mother also denies any history of high
persistent fever(s) or serious illnesses in the past.
2. What is your differential diagnosis now?
3. Discuss the pathophysiology of infectious mononucleosis (IM).
Include other causes outside of Epstein–Barr Virus.
4. Discuss the epidemiology of infectious mononucleosis (IM).
5. Knowing the above differential diagnosis, what other information do
you need to obtain?
MORE INFORMATION
No one has been ill in the household or among the child’s close friends. The
child is not taking any other medications for routine health purposes and has not
been to any other provider, including a Native Medicine Man or Woman. The
child is exposed to the daycare children in the after–school program or in her
gymnastics class, where the children all use the same equipment. There is no
known exposure to cats or other pets. The child has no allergies and has not
been sexually assaulted.
Physical examination notes height, weight, blood pressure, and BMI are all on
the 50 th percentile for this Tanner 1 female who has not had any weight loss.
The physical examination is remarkable for 3+ erythematous tonsils without
exudate. There are palatal petechiae on the soft palate. The anterior cervical
chain is mildly tender and nodes range in size from 2 – 2.5 cm. The tonsillar
nodes are 2 cm. The nodes are not fixed or mattered. On the right side, there is
a 3 cm node on the posterior chain with a few nodes that are less than 1 cm
around it. These nodes are not fisced but are tender to touch. There is no
axillary, epitrochlear, inguinal, or popliteal nodes. The chest is clear and the
heart sounds are normal without murmurs. There is no hepatosplenomegaly or
abdominal masses present. The external genitalia is without redness, and the
hymenal ring is smooth and without increased redness on gross inspection. The
skin is clear without rash or petechiae.
6. Before ordering laboratory tests on ANY patient, list 5 key points you
should consider. Include a brief discussion on sensitivity,
specificity, and predictive value.
7. What initial laboratory diagnostic tests need to be ordered for this
patient?
MORE INFORMATION
MD’s monospot is negative. The CBC notes an elevated WBC with a manual
differential noting 40% atypical lymphocytes.
8. Your presumptive diagnosis is infectious mononucleosis based on
MD’s history and clinical findings. The mother is requesting an
explanation if MD’s monospot returned negative, how can you make
the diagnosis of infectious mononucleosis?
MORE INFORMATION
The family returns on day 8 of MD’s illness and want to know the exact cause of
MD’s illness because there are four other children in the household and more
than 20 cousins whom the family sees on a regular basis. After discussion of the
treatment plan, MD’s mother is instructed to get the lab work done in 2 days to
increase the specificity of the testing.
The results from day 10 of the illness show a negative Monospot test with a CBC
noting 78% lymphocytes and 18 atypical lymphocytes. The child still has a
predominance of fatigue and fever. The child still complains of a sore throat and
painful lymph nodes. The physical examination is unchanged and no
hepatosplenomegaly is found. You decide to do additional laboratory testing.
The results of laboratory testing done on day 10 of MD’s illness return noting the
EBC–specific antibodies include IgM and IgG against the viral capsid antigen
(VCA, early antigen (EA) diffuse staining, and EBV nuclear antigen (EBNA) are
all negative.
9. Which of these 2 tests are the most helpful in diagnosing an active
and recent infection for EBV?
MORE INFORMATION
The child’s AST and ALT are both elevated five times above normal, reflecting
mild hepatitis. The bilirubin and alkaline phosphatase levels are within normal
limits, indicating no biliary obstruction. The family is called with the results of the
serology and are asked to return in 2 days for reevaluation. At this time the fever
is starting to come down but the fatigue persists. The family persists in wanting
to know the exact cause of the illness and wants additional testing done. The
diagnosis of EBV–negative infectious mononucleosis is considered, and given the
attendance at a daycare center after–school program and the predominance of
fatigue and fever in the presentation you agree with the parents to proceed with
additional testing.
10. Discuss your plan and rationale for the laboratory testing that can
help confirm your EBV–negative IM diagnosis.
11. Therapeutic Plan: What will you do therapeutically for this child?
12. Educational Plan: What will you do to educate MD and her mother
about IM? Include instructions regarding when a child with IM
should be allowed to participate in sports
