Need input on a patient condition please.

Specialties PICU

Published

Specializes in Pediatrics, ER.

Any input would be greatly appreciated to help save our patient.

Expreemie (less than 2 years old right now...don't want to get too specific because of HIPPA) with bilateral pulmonary vein stenosis, one side worse than the other. Most recent limited echo was stable. Trached and vented with moderate vent settings (PC + PS). Has had multiple ICU admissions for worsening respiratory distress, and has had multiple infections in the past. Recently treated for a UTI but still has blood/protein/casts in urine with a negative cx and no WBCs. Negative renal ultrasound and relatively negative CXR. Negative blood cultures and basically benign labs. Has been febrile for over a week straight, over 105 but mostly around 103. Was on dual abx coverage but stopped because there was no response. Minimal response to Tylenol (sometimes fever even increases) but some response to Motrin usually. Is MISERABLE. Cries when you go to touch them. Fever increases with agitation. Blood pressures have been trending higher, pt is usually 80s/40s and 50s. Has been 1-teens and 20s over 70s and 80s while asleep. The pt is not dry, BUN/cr was on the lower end and visually looks hydrated with good cap refill and turgor. Providers are thinking it's neuro with autonomic instability, but I just can't shake the feeling it's something else. I thought maybe an aseptic meningitis, but an LP is not warranted at this time. Pt had a fever > 106 at one point a couple of weeks ago and we were told it was because of a UTI, but has been febrile on and off since that point despite negative urine cx, and now febrile for over a week straight. What do you think? Any suggestion would be appreciated, we are all stumped by this case.

Up Vote Up Vote ×
Specializes in NICU, PICU, PCVICU and peds oncology.

Have they considered hemophagocytic lymphohistiocytosis? Are the kid's platelets low? Really low?? With ongoing anemia, high ferritin levels and neuroirritability?

Up Vote Up Vote ×
Specializes in Pediatrics, ER.
Have they considered hemophagocytic lymphohistiocytosis? Are the kid's platelets low? Really low?? With ongoing anemia, high ferritin levels and neuroirritability?

Hi, thanks for the response. No, platelets are WNL. They were actually elevated at one point but have normalized. Baby is chronically anemic and corrected with BID fe supplements. Last hgb/hct was somewhere in the realm of 10.4/34. I don't think he's had a ferritin level drawn but I will ask next time I'm on.

Up Vote Up Vote ×
Specializes in Pediatrics, ER.

Well, CBC was worse. WBCs up to 26.2 from 17 and ESR of 86...definitely not neuro. Everything but a trach aspirate was negative and he is being covered empirically with dual abx...finally afebrile, but not good there's no apparent cause. I have trouble believing a tracheitis would alter a CBC like that without also getting a + blood culture too. So, the mystery continues...

Up Vote Up Vote ×

Sounds like an LP was warrented, but maybe not now because he is afebrial. I agree that it's not tracheitis as well, he is most likely colonized. This explains the + culture. Doesn't sound like it has to do with any of his history. Maybe something viral, or a small foriegn body aspiration the body was fighting off. Something small wouldn't show up on the CXR.

Good Luck

Up Vote Up Vote ×
Specializes in Pediatrics, ER.

CHB, I totally agree. His CXR showed a very small perihilar patch but it wasn't significant enough to worry them. We may never know, but I'm just happy he's finally turning a corner. By the way, does CHB stand for Children's Hospital Boston?

Up Vote Up Vote ×
+ Add a Comment