Generalized infection with unknown starting point in children hospitalized in a district hospital

IntroductionInfection is the most common cause of children medical consultations. Often the clinical picture of the patient is disproportionate to the results of laboratory tests which may indicate for generalized infection. Case reports Case 1: A 4-year-old patient admitted to the Department due to a fever 39˚C lasting from 2 days and periodic abdominal pain. Good general condition, throat slightly red. In laboratory studies, procalcitonin 44.5 ng/ml, CRP 121.5 mg/dl, WBC 15.32 ths/ul. Empirical treatment with ceftriaxone and vancomycin was included. Blood cultures, Staphylococcus hominis MLSB, MRCNS. Case 2: A patient nearly 5 years old admitted to the Department due to a fever 39.5˚C. In outpatient examinations CRP 41 mg/dl, WBC 39 ths/ul. Physical examination: reddening of throat mucosa, palatine tonsils slightly enlarged, reddish, without rash. In laboratory tests CRP 95 mg/dl, WBC 41.95 ths/ul, PCT 1.19 ng/ml. On the second day of hospitalization, an increase in inflammatory markers was observed (PCT 1.47 ng/ml, CRP 235.7 mg/dl). Vancomycin was added. Case3: 18-month-old boy admitted to the Department due to fever 40.5˚C. Good general condition, throat slightly reddened, occasional cough. In laboratory tests PCT 8.07 ng/ml. Empirical antibiotic therapy with ceftriaxone was implemented. Due to persistence of fever up to 39.5˚C - control tests of PCT 10.03 ng / ml. Vancomycin was implemented. Urine culture negative, in blood culture the present growth of Staphylococcus warneri. ConclusionsIt is extremely important to be vigilant in case of feverish children. Sometimes, despite a good general condition and no significant abnormalities in a physical examination, we can deal with generalized infection. results: procalcitonin 1.19 ng/ml, CRP 95 mg/dl, WBC 41.5 ths/ul. Chest X-ray was performed without any abnormality and abdominal ultrasound – within normal limits. Urinalysis without the characteristics of infection in the urinary system. Latex test for CNS infections negative. Renal and hepatic parameters below upper normal range. Coagulation system: APTT 31 s, INR 1,4, fibrinogen 430 mg/dl. On the second day of stay in the ward, a laboratory control was carried out, revealing an increase in inflammatory markers - procalcitonin 1.47 ng/ml, CRP 235.7 mg/dl and a significant decrease in leukocyte levels - up to 23.03 ths/ul. Microscopic blood smear: 89% divided leukocytes, 1% eosinophils, 2% monocytes, 8% lymphocytes, no visible atypical lymphocytes. Vancomycin was added to empiric antibiotic therapy. The general condition of the patient did not raise any objections, she did not report any symptoms nor had a fever. On the third day, the parametres of inflammatory process were again assessed - procalcitonin 1.01 ng/ml, CRP 102.9 mg/dl, WBC 8.26 ths/ul. Antibiotic therapy was maintained. In the blood and urine culture, there was no growth of the bacterial flora. Due to symptoms of hypertrophy of the pharyngeal tonsil in the form of numerous recurrent infections of the upper respiratory tract and snoring at night, the patient was consulted otolaryngologically - qualified for adenotomy. On the sixth day of hospitalization, laboratory tests were carried out - procalcytonin 0.241 ng/ml, CRP 14.1 mg/dl, WBC 6.44 ths/ul. In good condition, the patient was discharged home with a referral to the Allergology and Otolaryngology Outpatient Clinic. At admission, general condition quite good, conscious, cardiovascularly and respiratorily stable, body temperature 37.4 Celsius degrees, clean skin, in nose mucopurulent secretion, posterior throat wall and palatine arches reddened, palatine tonsils swollen, slightly red. Auscultation over the pulmonary fields, alveolar murmur, heart rate approx. 140/min. soft abdomen, liver, spleen not enlarged. Negative meningeal symptoms, child's behavior appropriate to age. In laboratory tests, the level of procalcitonin 8,07 ng ml, CRP <1mg/dl, WBC 16.32/ul. Normal renal parameters, elevated transaminases (ALT 64U/l, ASAT 142 U/l). Coagulation: APTT 22.9 s, INR 1.3, fibrinogen 247 mg/dl. Blood and urine culture were performed. Empirical antibiotic therapy with ceftriaxone and vancomycin was implemented. In the ward, the boy presented a fever up to 39.5 Celsius degrees until the third day of hospitalization. Sporadic cough appeared, mucopurulent secretion in the nasal passages and single bronchial inflammatory changes in the bronchi. The swelling of the face was also temporarily observed, mainly in the area of the orbital cavities. Attention was drawn by breathing through the mouth during the child's sleep and snoring. Mother of the patient also reported recurrent infections of the upper respiratory tract. The control laboratory tests were carried out on the third day of the stay in the ward - procalcitonin 10.03 ng/ ml, CRP <1 mg/dl, WBC 9.55 thousand/ul. Empirical antibiotic therapy was maintained and the level of procalcitonin was checked on the following day - 4.91 ng/ml. Chest X-ray performed without any abnormalities, abdominal ultrasound without visible pathologies. After the fever subsided, the child's condition improved, the rhinitis and cough decreased, the bronchial inflammatory lesions subsided. Blood culture revealed Staphylococcus warneri contamination, culture of urine - negative. On the fifth and sixth day of hospitalization, symptoms of gastrointestinal infection appeared in the form of numerous loose stools and vomiting.