Case 12 A boy with fever and rigors
Sanjay, a previously healthy 7-year-old boy, presents to the ED with a 3-day history of fever and rigors. He had been seen by his GP and diagnosed with influenza 2 days earlier, and was advised to take antipyretics. Sanjay looks unwell but there are no abnormal findings on examination apart from a temperature of 38.4°C and heart rate of 115/minute. Urinalysis is unremarkable. The ED doctor decides to take some bloods which show a WCC of 16.3 × 109/L (normal 4.5–13 × 109/L), neutrophils 11.3 × 109/L (2–6 × 109/L) and a CRP of 99 mg/L (<6 mg/L). He refers Sanjay to the Paediatric ST2 for a second opinion as he has no focus for the fever.
How would you manage the child at this point?
A second physical examination confirms that there is no obvious focus of infection. Sanjay is admitted to the Paediatric ward with a provisional diagnosis of sepsis. A CXR is done and urine and blood cultures are taken. He is commenced on iv ceftriaxone at a dose of 50 mg/kg. He has one more spike of fever (38.8°C) overnight, but by the next morning he is feeling a little better. On the ward round the registrar decides to continue the antibiotics for 48 hours pending the blood culture results. Late in the afternoon the ST2 receives a telephone call from the microbiology registrar to inform him that the blood cultures are growing Staphylococci, and he advises that treatment be continued until further results are available. The next day Sanjay is feeling much better and has been afebrile for 12 hours. Thorough physical examination remains unremarkable. The organism isolated from the blood culture is confirmed as Staphylococcus aureus and the microbiologist recommends changing treatment to iv flucloxacillin. However, the Paediatric team elects to continue with once daily ceftriaxone so that Sanjay can receive ambulatory treatment for a total of one week.
What do you think of this management strategy?
Two weeks later Sanjay returns to the ED in the evening, with increasing malaise and a low-grade fever over the last 5 days. He now has a 2/6 ejection systolic murmur loudest in the aortic area and an early diastolic murmur, and has 2+ blood and 1+ protein on urine dipstick analysis.
What is the likely diagnosis and what would you do now?
Sanjay is readmitted to the paediatric ward and after blood cultures have been taken he is commenced on intravenous ceftriaxone again. During the night he is found collapsed on the floor of the ward toilet, unresponsive. He is subsequently found to have had an embolic stroke as a result of vegetations on a previously undiagnosed bicuspid aortic valve. Although Sanjay survives, he has persistent neurological deficits that affect his speech and movement, and frequent seizures. His parents sue the hospital claiming that the diagnosis of infective endocarditis was completely missed and that this caused their son to have an adverse outcome.
Expert opinion
Staphylococcus aureus bacteraemia is frequently associated with a focus of infection: this may be an abscess or an infected prosthetic or intravascular device, and it is an increasingly common cause of endocarditis. The source of the infection should be actively sought, and removed if feasible. Recommended investigations include a CXR, abdominal US and echocardiography. Flucloxacillin is the preferred antibiotic in most cases, and the usual duration of iv antibiotic therapy is at least 14 days for uncomplicated infections with no focus of infection (or following removal of a focus) and 4–6 weeks when there is a deep focus of infection such as osteomyelitis. In this case the reason for the S. aureus bacteremia in Sanjay was not adequately investigated, the duration of treatment was less than recommended, and the decision to use once daily ceftriaxone instead of flucloxacillin may have reduced the effectiveness of treatment. Sanjay probably had infective endocarditis at the time of the initial presentation, and even if vegetations were not visible at that time, the presence of a valvular abnormality would have increased the index of suspicion. Absence of a murmur on physical examination does not exclude infective endocarditis, and failure to investigate adequately with an echocardiogram after finding S. aureus in the blood cultures is highly likely to have contributed to the subsequent adverse events.
Legal comment
It seems that an expert will say that the failure to look for a focus of infection after Staphylococcus aureus had been identified and to then treat it properly could not be justified by any responsible body of medical opinion.
The hospital will therefore be responsible for all the consequences of that failure. The hospital’s lawyers may wish to explore whether, by the time Staphylococcus aureus was identified, it was too late for iv flucloxacillin to have prevented the stroke. But that may be a forlorn hope.
Failing that, this case is going to be very expensive for the Trust as Sanjay is very young and is going to need a lot of care all his life. He and his parents can expect compensation for the cost of his care for his whole life, and for his pain and suffering.
Compensation for the cost of care will be calculated by evaluating the cost of Sanjay’s needs for a year and then applying a multiplier to reflect his expected longevity. Depending on the strength of the case and Sanjay’s life expectancy, any settlement is likely to be well over a million pounds and could easily be several million pounds.
