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From the American College of Rheumatology

Rheumatology for Primary Care
  • Symptoms
    • Fever
    • Joint Pain
    • Muscle Pain and/or Weakness
    • Rashes
    • Raynaud’s Phenomenon
  • Diseases
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Drug and Medication-Induced Rheumatic Diseases
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Idiopathic Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Multisystem Inflammatory Syndrome in Children
    • Myositis
    • Polyarteritis Nodosa
    • Polymyalgia Rheumatica
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Case Studies
    • ANCA-Associated Vasculitis
    • Behcet’s Syndrome
    • Crystalline Arthropathies
    • Giant Cell Arteritis
    • Henoch-Schönlein Purpura
    • IgG4-Related Disease
    • Juvenile Dermatomyositis
    • Juvenile Inflammatory Arthritis
    • Kawasaki Disease
    • Mixed Connective Tissue Disease
    • Myositis
    • Pediatric Fevers
    • Polyarteritis Nodosa
    • Polymalgia Rheumatica
    • Raynaud’s Phenomenon
    • Rheumatoid Arthritis
    • Sarcoidosis
    • Sicca/Sjogren’s Disease
    • Spondyloarthritis
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
  • Labs
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    • Commonly Used Rheumatology Meds
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Pediatric Fever Case Studies

Home ยป Pediatric Fever Case Studies
Pediatric Fever Case Studies
  • Case 1

  • Case 2

  • Case 1

A 16 yo F presents with 21 days of fever, worsening fatigue, and wrist pain.

Physical Exam

Exam notable for:

  • Erythematous rash on cheeks that crosses nasal bridge
  • Redness of hard palate
  • Cervical lymphadenopathy
  • Swelling of ankles
  • BP is 133/95
Questions to Consider

Diagnostic Workup

  • HEADSS assessment unrevealing
  • Lost weight in the past few months
  • No concern for infectious exposure history
  • Labs: WBC 3.2, Hgb 10.4 (MCV96), Plt 140, CRP 1.7, ESR 94, uric acid 5.8, peripheral smear with normocytic anemia but no blasts, EBV IgG positive but IgM negative
New Questions to Consider

Next Steps

  • Mom recalls that patient’s grandmother has lupus
  • Consult nephrology about her BP, and they suggest getting a UA
  • Additional labs show C3 of 21 and undetectable C4
  • UA shows 3+ blood and 3+ protein
  • You then get an ANA that is positive at 1:1280, concerning for lupus
  • Referral to rheumatology – she is seen in pediatric rheumatology the following week

Diagnosis & Treatment

  • Kidney biopsy the following week shows class V lupus nephritis
  • She is started on steroids and mycophenolate

Clinical Pearl

Make sure to ask review of systems questions not only for the period of fever, but also for the weeks-months preceding onset of fever. This can provide many clues!

  • Case 2

A 9 yo F with systemic JIA who is managed with steroids and tocilizumab presents to clinic with 4 days of fever. 

Physical Exam

Exam notable for:

  • Fever of 39°C
  • HR 120
  • Flow murmur at lower sternal border
  • Some shoddy cervical lymphadenopathy
Questions to Consider

Diagnostic Workup

Initial

You have a lab in your office and decide to run the following:

  • ESR 40, CRP 0.7, WBC 14.5
  • Respiratory viral panel is negative
New Questions to Consider
3 Days Later
  • Patient presents with persistent fevers, fatigue, and new shortness of breath.
  • The murmur you heard before is now louder, and you note new red nodules on the bilateral palms.

Next Steps

  • You direct family to the ER.
  • Echocardiogram confirms your suspicion for endocarditis. Blood culture grows staph aureus and patient is initiated on IV antibiotics.

Clinical Pearl

Tocilizumab inhibits IL-6, which helps promote production of CRP, so this patient’s normal CRP was actually inappropriately low.

Questions to Ask Yourself

What infections are you worried about/can you test for in your office?

Is there family history of autoimmune disease?

Are you about to do a HEADSS exam?

New Questions to Consider

Do you have a local pediatric rheumatologist you can consult via phone?

What other specialists could you consider consulting prior to sending additional labwork?

New Questions to Consider

Does the CRP rule out acute infection?

Are parents willing to bring patient back in a few days if fevers don’t resolve?

Questions to Ask Yourself

What workup are you able to do in office or same day?

After how many days do you want to reassess and consider expanding workup?

Related Links

Fevers

 

Treatment Considerations

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Primary Care2024-05-21T13:50:47+00:00

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This product was funded by a medical grant from Pfizer. The content was written by a physician work group. See Authors

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