Question

A 6-year-old boy presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he had a headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He denies recent cough, congestion, sore throat, joint pains, or sick contacts. His vitals are: T 101.3 F, BP 108/71 mmHg, P 110 bpm, R 28 bpm, O2 sat 100% on RA. On physical exam, you notice blanching, erythematous macules on his ankles and several petechiae on his wrists. Upon questioning, his mother says that the spots on his wrists previously looked like the spots on his ankles. His neck is supple and there is no hepatosplenomegaly or lymphadenopathy. He reports no sick contacts, but recently visited his cousins in North Carolina. What is the best next step in management

Answer 1

Based on the symptoms,

Differential diagnoses for the boy includes:

1. Rocky Mountain Spotted Fever (RMSF) owing to his recent visit to Florida
2. Meningitis

Course of treatment:

• The patient needs to be admitted
• Diagnostic tests including CBC, cultures of both blood and CSF to rule out meningitis should be done

Explanation:

Initial line of treatment with loading dose of doxycycline at 2.2 mg/kg and ceftriaxone at 100 mg/kg/day can be started.

RMSF is a contagious disease caused by ticks and is predominant in the southeastern regions of the United States like North Carolina. So the boy could have got the disease from his visit to N. Carolina. Doxycycline is a broad spectrum antibiotic is the most preferred treatment of choice for RMSF

Meningitis is a bacterial disease affecting the brain. Ceftriaxone is the treatment of choice for empirical treatment of meningitis.

Since the boy’s symptoms like fever, headache, petechial rashes etc are symptomatic of both RMSF and meningitis, both the antibiotics should be administered initially.

Then depending upon the culture results, other specific antibiotics and treatments can be started.