Case 3 A persistent fever
Arun, a 4-year-old boy, presents to the ED with a fever, coryza and an earache. On examination he is found to have a temperature of 39.1°C, an erythematous throat and pink ear drums. A diagnosis of an upper respiratory tract infection is made by the FY2 doctor. Arun’s mother is told that the infection is probably viral and is asked to return if Arun does not improve with analgesia and antipyretics. Two days later Arun represents to ED and this time is seen by a different FY2 doctor. The temperature has persisted and is 39.2°C and Arun is still complaining of ear ache and is now also lethargic and anorexic. His mother also feels that Arun cannot hear properly in his right ear. There is no rash.
Which other symptoms and signs would it be important to document?
There is no documentation regarding symptoms and signs such as a headache, irritability, photophobia or neck stiffness in this or the previous attendance. The FY2 makes the same diagnosis but this time prescribes amoxicillin and Arun is discharged.
He returns 2 days later in the evening as he has deteriorated and is now also complaining of a headache and has vomited twice. This time he is referred to the paediatric team. He still has a temperature and an ear ache. He has no photophobia. The paediatric ST1 also documents that Arun has not been immunized. On examination, his temperature is 39.7°C and there is no rash. Arun’s throat is slightly erythematous but with no pus or tonsillar enlargement. His ears appear normal. He can extend his neck fully and can also flex his neck but is unable to get his chin to touch his chest. The registrar reviews Arun, elicits the same signs, and is unsure if the limited neck flexion is abnormal.
Is the neck flexion within normal limits?
A FBC, CRP, U and E’s, bone chemistry, LFTs, blood culture and meningococcal PCR are performed and urine is collected for microscopy and culture. The registrar wants to do a LP but Arun’s mother is reluctant for him ‘to have a needle put in his back’.
What would you do now?
The registrar decides to admit Arun and to administer high dose iv ceftriaxone. The FBC has a raised WBC of 22.4 × 109/L (normal 4–11 × 109/L), the CRP is also elevated at 143 mg/L (normal<6 mg/L) and the U and E’s, bone chemistry, LFTs and urine dipstick are normal. The following morning Arun has a 20-minute generalized seizure which is terminated with iv lorazepam. A cranial CT scan is done which is normal and later that afternoon a LP is performed. The CSF has a WBC count of 684 × 106/L (normal<5 × 106/L) of which 60% are polymorphs, a protein of 1.6 g/L (normal 0.2–0.4 g/L) and a glucose of 1.9 mmol/L (normal 2.8–4.4 mmol/L). Gram stain is negative but the rapid antigen screen is positive for Haemophilus influenzae and a diagnosis of H. influenzae meningitis is made.
Does this result influence your management plan?
Intravenous dexamethasone is then prescribed.
Arun subsequently has further fits and is commenced on phenytoin. He has a 7 day course of iv ceftriaxone and goes on to develop mild learning difficulties, epilepsy and right-sided hearing loss.
Arun’s mother makes a complaint and later sues the hospital stating that the diagnosis and treatment where inappropriately delayed.
Expert opinion
The absence of comprehensive documentation during the first two attendances makes it difficult to determine if the diagnosis and treatment were appropriate. Meningitis is such a serious condition that it should always be in the back of one’s mind when seeing a sick, febrile child and it is important in such cases to document the presence or absence of features associated with meningitis. It is not unusual for meningitis to be preceded by upper respiratory or gastrointestinal symptoms and it is possible that in the early stages of this case there was no headache, photophobia or neck stiffness. However, this should have been documented. The absence of immunizations in Arun would also have raised the risk of him having a serious bacterial infection and this fact should also have been documented at the first presentation. The FY2 doctors should have obtained a more senior ED or paediatric opinion on this child and this would be routine procedure in many EDs.
Neck stiffness can be difficult to assess in children under 1 year of age. However, over 1 year of age, and certainly at 4 years of age, the presence of neck stiffness should be clearly elicitable. When the meninges are inflamed flexing the neck in particular stretches the meninges and causes pain. A 4-year-old should be able to place his chin on his chest and his inability to do so denotes a degree of neck stiffness compatible with meningitis. Partial treatment of meningitis, as in this case, is quite common and can modify the signs and the investigation results and should lower the threshold for suspecting meningitis and performing a LP. Following the refusal of Arun’s mother to allow him to have a LP the registrar should have discussed the case with the consultant. A review of Arun by the consultant may have persuaded his mother to allow the LP.
Dexamethasone has been shown to decrease the risk of neurological sequelae and deafness in children with some types of bacterial meningitis, particularly Haemophilus influenzae. Dexamethasone should be administered just before or concomitantly with the first dose of antibiotic. However, the role of dexamethasone in partially treated meningitis has not been evaluated. It is therefore not possible to say whether its earlier use, following an immediate LP upon admission to the ward, would have made a difference to Arun. Nevertheless, there would be a case for administering it on purely clinical grounds, given the likely diagnosis of meningitis, immediately prior to the iv ceftriaxone as it has few adverse effects. Administering dexamethasone following the LP was a reasonable course of action even though the efficacy of the delayed administration of this drug is unknown.
It is possible that the deafness may have been unavoidable even with early treatment, but the accompanying epilepsy and mild learning difficulties may have been avoided with an earlier diagnosis and treatment.
Legal comment
An important factor in this case was Arun’s mother’s refusal to let him undergo a lumbar puncture: she refused to give her consent to the procedure. The Key Learning Points below state that, in such cases, a consultant should be informed. It may be argued that the clinicians could have performed the LP anyway, on the basis that the procedure was in the best interests of the child. However, this would have been very difficult in practice. It is always preferable to try to persuade parents of the need for a procedure or course of treatment, rather than to act unilaterally, and the consultant may have persuaded Arun’s mother of the need for the LP. Ignoring the wishes of a parent lays clinicians open to criticism and to a potential complaint.
There are failings in the treatment provided to Arun and the lack of documentation will make it difficult for the hospital to defend the standard of care. However, the family may have difficulty in establishing that earlier treatment would have altered the outcome. The Expert Opinion comments that deafness may have been unavoidable. But if an instructed expert concludes that the epilepsy and mild learning difficulties would probably have been avoided with earlier treatment, then the case could be worth several hundred thousand pounds and perhaps even more. This would depend on Arun’s ability to look after himself in the future and his prospects on the job market.
