Fever without localizing sign in a 3-year-old boy
Prepared by...
Virat Sirisanthana, M.D.
Department of Pediatrics, Chiang Mai University
 
A 3 year-old-boy was brought to the Out-patient Department of CMU hospital in Feb 2001.
Address: Ampur Chaiprakarn, Chiang Mai
 
CC: Fever without localizing sign for 10 days
PI: 10 days PTA he developed fever. He has been seen in several clinics and had received symptomatic treatments with paracetamol and "cold medicine". He also had been on erythromycin for 4 days PTA
due to his "fever".
His mother denied any gastrointestinal symptom.
 

Past History: Birth wieght was 3000 grams. He has been healthy since birth. He has had routine immunization.
His growth and development has been in normal range. there was no history of TB contact.
 
Positive PE: a febrile boy, T. 39.5 0 C., mild anemia
Abd: liver 3 cm. below RCM, spleen 1 cm. below LCM.
 
Summery of problems.
1. Prolonged fever (10 days)
2. Anemia
3. Hepatosplenomegaly ( liver 3 cm. below RCM, spleen 1 cm. below LCM,)
 

Initial laboratory investigations:
CBC: Hb 8 mg, Hct 24.1%, WBC 8,200/cbmm (N 70%, L 27%, M 1%, E2%), platelet count 330,000/cbmm.
PBS: anisocytosis 1+, poikilocytosis 1+, hypochromia 1+, no malarial parasite.
UA: wnl
 
Course in the hospital:
He was given symptomatic and supportive care. Doxycycline was started on day 4 of admisssion. fever persisted. On day 6 of admission the hemoculture which was taken on day 1 of admission revealed gram negative rod. Doxycycline was discontinued and he was started on cefotaxime 100 MKD intravenously. The hemoculture was reported on the next day as Salmonella typhi (2 specimens), susceptible to cefotaxime, co-trimoxazole, ampicillin. The fever gradually subsided. He was afebril on day 7 of cefotaxime. Cefotaxime was then switched to oral co-trimoxazole. He was discharged from the hospital after he had been afebrile for 4 days.
 
 
Others laboratory investigations:
Hb typing : beta thalassemia trait
Repeated H/C before starting cefotaxime : Salmonella typhi
Repeated H/C 2 days after starting cefotaxime : no growth
Widal: day 1 of admission (day 11 of fever): O titer 1:80, H titer 1:640, day 12 of admission: O titer 1:160, H titer 1:320
Weil Felix : day 1 of admission (day 11 of fever): OX-2 1:80, OX-19 1:<20, OX-K 1:40
Thick film: no malarial parasite
Cold agglutinin titer : neg
Mycoplasma titer 1:<40
PPD skin test : 0 mm.
ESR 75 mm/hr
 
Diagnosis : Typhoid fever in a beta thalassemia trait boy
 

What did we learn from this case?
1. WBC count of typhoid fever patient is usually within normal range, but the PMN is predominate.
2. Widal test is not helpful in this case. Although the specificity is high, it is known that the sensitivity of the test is very low. Recent infection will show four fold rise of O titer.
3. Although Salmonella typhi is susceptible to cefotaxime, the fever usually gradually subside...... within 5 days. This fact is also "true" for other antibiotics, such as co-trimoxazole, ampicillin, chloramphenicol.
4. The reason of giving "doxycycline" is for the "Rickettsial infection" which is more common than typhoid fever. Fever will subside within 48 hours after "doxycycline" administration.

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