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13

Serious illnesses

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction

13-1 What serious bacterial infections are seen in children?

These are illnesses which can result in death if they are not correctly managed. Every effort must be made to prevent them, recognise them early and treat them correctly. Many serious illnesses which are rarely seen in children in developed countries, are still major problems in poor communities with overcrowding.

Important serious illnesses include:

Some serious illnesses, such as pneumonia and typhoid, are discussed in other units.

Acute rheumatic fever

13-2 What is acute rheumatic fever?

Acute rheumatic fever is the most common cause of acquired heart disease in children, especially in poor, overcrowded communities. It is a complication of pharyngitis (a throat infection) caused by Streptococcus bacteria. An unusual immune response by the body to this bacterial infection damages the joints, heart and other tissues of the body. The exact mechanism whereby this happens is still not fully understood. Acute rheumatic fever is usually seen in children aged 5 to 15 years.

Note
Many strains of Group A beta haemolytic Streptococcus can cause rheumatic fever which is a multisystem disease affecting the heart, joints, skin and brain. Recent studies suggest that skin infections (impetigo) may also cause rheumatic fever.

Rheumatic fever is the most common cause of acquired heart disease in children in developing countries.

13-3 What are the clinical features of acute rheumatic fever?

Acute rheumatic fever develops 2–3 weeks after a Streptococcal pharyngitis. The classical features of acute rheumatic fever are:

Children with acute rheumatic fever do not necessarily develop all the classical signs. The rash, subcutaneous nodules and chorea are less common signs of acute rheumatic fever.

13-4 What are the signs of carditis?

Carditis is an inflammation of the heart. The heart muscle, valves and pericardium are involved. The signs of carditis are:

13-5 How is the clinical diagnosis of acute rheumatic fever made?

By documenting a Streptococcal infection plus 2 major or 1 major and 2 minor criteria.

The major criteria are:

The minor criteria are:

Note
These are the modified Duckett-Jones criteria. A Streptococcal infection is documented by a positive throat culture or a raised antistreptolysin O titre. A blood culture is useful to exclude bacterial endocarditis which should be considered in any child with fever and a murmur. Two minor criteria are needed to diagnose acute rheumatic fever in a child with established rheumatic heart disease.

Always suspect acute rheumatic fever in an unwell child older than 3 years who presents with fever, tachycardia and shortness of breath or painful joints.

Strict clinical criteria are used to diagnose acute rheumatic fever.

13-6 How is acute rheumatic fever treated?

  1. Bed rest until all signs of acute rheumatic fever have disappeared and the resting heart rate is normal. All children with acute rheumatic fever should be admitted to hospital if possible
  2. Amoxycillin 10 mg/kg 6 hourly orally for 10 days or a single dose of benzathine penicillin 1.2 million units intramuscularly.
  3. Aspirin for symptomatic relief of fever and joint pain. Acute rheumatic fever is one of the very few indication for aspirin in children.
  4. Observe closely for signs of heart failure.

13-7 How can the first attack of acute rheumatic fever be prevented?

It is difficult to know if an acute sore throat is due to a virus or Streptococcus. Therefore, antibiotics should be given to all children under 15 years who have a fever and sore throat (pharyngitis) without the signs of a common cold, i.e. blocked nose and nasal discharge. Oral penicillin, amoxycillin or erythromycin for 5 days are needed. However, it is also important that antibiotics are not given to all children with a viral upper respiratory tract infections such as the common cold or influenza.

With the more frequent use of antibiotics, acute rheumatic fever has become uncommon in wealthy countries.

13-8 How can repeated attacks of acute rheumatic fever be prevented?

Repeated attacks of acute rheumatic fever can be prevented in children, who have previously suffered one or more attacks, by giving benzathine penicillin (Bicillin LA) 1.2 million units intramuscularly every 4 weeks (600 000 units if the child weighs less than 30 kg). This must be continued until adulthood when it should be reviewed. As the injections are painful, the child and family must understand that it is most important to prevent ongoing heart damage. The mother should keep a card which records the monthly injections. Careful follow up is essential.

13-9 What are the possible outcomes of acute rheumatic fever?

Acute rheumatic fever should resolve in 4 weeks. Some children recover completely while others are left with permanent damage to their hearts. Acute rheumatic fever tends to recur and the risk of permanent heart damage (rheumatic heart disease) increases with each acute attack. Every effort must therefore be made to prevent repeat attacks.

One or more attacks of acute rheumatic fever can cause permanent damage to one or more heart valves. This is called chronic rheumatic heart disease. Leaking of the mitral valve (mitral incompetence) or narrowing of the mitral valve (mitral stenosis) are the most common permanent valve defects. Damage to a valve or damage to the heart muscle can cause heart failure.

Every effort must be made to prevent repeated attacks of acute rheumatic fever.

13-10 What are the features of chronic rheumatic heart disease?

These children are often underweight and have delayed developmental milestones due to their heart disease. Their schooling may be interrupted. On examination they have signs of leaking (incompetent) or narrowed (stenotic) heart valves. They may also have signs of heart failure.

These children are at great risk of developing infective endocarditis after dental procedures (bacteria enter the blood stream and then stick to the heart values where they cause infection and damage). The dentist should give a dose of prophylactic antibiotic before the procedure.

Note
A large single oral dose of amoxycillin or clindamycin an hour before dental extraction reduces the risk of bacterial endocarditis on damaged valves.

Children with chronic rheumatic heart disease must be managed by a special cardiac clinic team. It is very important that they do not have any further attacks of rheumatic fever. Most children can be managed with drugs to control heart failure but some will require cardiac surgery.

13-11 What are the clinical symptoms and signs of heart failure?

There are many causes of heart failure, including acute rheumatic fever, chronic rheumatic heart disease, congenital heart disease and severe anaemia.

Acute glomerulonephritis

13-12 What is acute glomerulonephritis?

It is an acute inflammation of the kidney which follows a few weeks after an infection with Streptococcus. The infection is usually of the skin (i.e. impetigo) but may follow a throat infection (therefore often called acute post-streptococcal glomerulonephritis). The inflammation of the kidney is the result of an unusual response to the infection by the body’s immune system. Antibodies produced against the Streptococcus damage the kidney. This is similar to the immune response which results in acute rheumatic fever. Again, the reason for this unusual response is not fully understood.

Note
Damage to the glomeruli of both kidneys results in blood and protein leaking into the urine and a decrease in urine production. Retained fluid causes oedema and fluid overload. Although there are many causes of glomerulonephritis, acute glomerulonephritis is usually post-streptococcal. Proteins from specific strains of Group A Streptococcus combine with antibodies and complement to form immune complexes which are deposited in, and damage, the glomeruli.

13-13 What are the presenting signs of acute glomerulonephritis?

The severity of signs varies widely. In many children the condition is asymptomatic and would only be diagnosed by testing the urine for blood and protein, or by measuring the blood pressure.

Acute glomerulonephritis usually presents with dark urine, reduced urine output and oedema.

Note
Oedema plus marked proteinuria without haematuria suggests nephrotic syndrome.

13-14 What is the clinical course of acute glomerulonephritis?

Most children present with oedema and visible haematuria. However, hypertension can occur with no oedema and with haematuria only detected on reagent strips.

Children usually recover completely. By 2 weeks the urine output increases and the oedema and hypertension disappear. The urine may remain dark (due to blood) for up to 6 weeks but blood may be detected on reagent strips for a few months.

It is very important to look for signs of complications.

13-15 What are the complications of acute glomerulonephritis?

13-16 What is the management of a child with acute glomerulonephritis?

  1. Refer the child to hospital if possible.
  2. Oral phenoxymethyl penicillin (penicillin V) 12.5 mg/kg 6 hourly or oral amoxycillin for 10 days to treat the Streptococcal infection.
  3. Restrict the daily fluid intake to 20 ml/kg plus the volume of the previous day’s urine output. It is important to keep a careful check on the fluid intake and output.
  4. Weigh daily to assess fluid status.
  5. Low sodium and low protein diet until the urine output increases (diuresis). Bread, jam, rice, fruit and vegetables with no added salt is a practical diet.
  6. Furosemide (Lasix) 1 mg/kg orally to help increase urine output
  7. Observe the blood pressure every 6 hours.
  8. Check serum urea, creatinine and electrolytes to monitor any renal failure.
Note
Severe hypertension can be treated as an emergency with nifedipine (Adalat) 0.25 mg/kg sublingually (under the tongue). Convulsions can be stopped with rectal diazepam.

Respiratory distress due to pulmonary oedema should be managed with oxygen, furosemide 1 mg/kg intravenously, sitting the patient up and referring to hospital urgently.

Note
Serum C3 complement is classically markedly reduced. The chest X-ray often shows an enlarged heart plus features of pulmonary oedema due to fluid retention. Serum Streptococcal antibodies are usually raised.

13-17 How can acute glomerulonephritis be prevented?

Most cases occur in children over the age of 2 years in poor communities where Streptococcal infections, especially of the skin are common. It is important that skin infections are treated promptly with local antiseptics (e.g. Savlon). Scabies, which is often complicated by impetigo, should be treated. Oral penicillin should be given for 5 days if there is extensive impetigo. The more frequent use of antibiotics in developed countries has resulted in a fall in the number of children with acute glomerulonephritis (and acute rheumatic fever). However, this is not a reason to give antibiotics to every child with a few patches of impetigo that can be treated locally.

Septicaemia

13-18 What is septicaemia?

Septicaemia is an acute serious illness caused by bacterial infection of the blood. This is often a complication of local infection, such as pneumonia or pyelonephritis. Septicaemia may in turn result in the spread of infection to other sites, such as meningitis and osteitis.

Septicaemia may be caused by either Gram positive bacteria (such as Staphylococcus or Streptococcus) or Gram negative bacteria (such as E. coli or Klebsiella).

Note
Gram described the method of staining bacteria blue and then dividing them into those bacteria that retained the stain (Gram positive) and those that lost the stain (Gram negative) when exposed to other chemicals. Gram positive bacteria usually live on the skin and in the upper respiratory tract while Gram negative bacteria normally live in the bowel. Rarely fungi can also cause septicaemia.

13-19 What are the clinical features of septicaemia?

Children with septicaemia are seriously ill, often without an obvious site of infection.

13-20 What is shock?

Shock is the failure of normal peripheral circulation with a fall in blood pressure. The heart rate increases and urine output falls. The skin temperature may be low with shock and the hands and feet often feel cold. The oxygen saturation may also fall. Most importantly, the capillary filling time is prolonged to over 3 seconds.

Note
In early shock the blood pressure may still be normal (compensated shock) although the peripheral perfusion is poor. Later the blood pressure falls (uncompensated shock).

13-21 How is the capillary filling time measured?

This is estimated by compressing the skin for a few seconds over the hands, feet or chest, with your finger, to produce blanching (a pale area). When the pressure of the finger is removed, the time it takes for the pink colour to return is measured. This is called the capillary filling time. A normal capillary filling time is 3 seconds or less.

13-22 How is the clinical diagnosis of septicaemia confirmed?

With finding a positive blood culture. Always take a blood culture before starting treatment.

The white cell count may be high at first and later fall. The platelet count may also fall and the blood clotting factors may be low.

A blood culture is needed to confirm the clinical diagnosis of septicaemia.

Note
The C reactive protein (CRP) level may initially be normal but rises after a few hours.

13-23 What is the management of septicaemia?

  1. Start antibiotics immediately. Do not wait for the result of the blood culture.
  2. Treat shock if it is present.
  3. Transfer the patient urgently to hospital. Give oxygen during transport.
  4. Look for an underlying cause and monitor for complications such as organ failure.

The fist choice of antibiotics is either:

13-24 What is the treatment of shock?

The aim of treatment is to correct the blood pressure and improve the peripheral perfusion. A fast intravenous infusion must be started immediately with 20 ml/kg of normal saline or Ringer’s lactate. If the signs of shock are not corrected, repeat the bolus of intravenous fluid. This will usually correct the shock. Always give oxygen. Urgent transfer to hospital is needed. Start treating shock before moving the patient.

Shock must be treated before the patient is moved to hospital.

13-25 What is meningococcal septicaemia?

This is a serious illness caused by septicaemia due to Meningococcus (i.e. Neisseria meningitidis). Meningococcus is transmitted from person to person by droplet spread (coughing and sneezing). It often causes asymptomatic colonisation of the upper respiratory tract only. However, some people get a septicaemia, meningitis or both. Meningococcal infection is more common in overcrowded conditions where epidemics may occur.

13-26 What is the typical presentation of meningococcal septicaemia?

The patient presents with the signs of septicaemia. However, a rash also develops. This starts as small red spots on the skin and conjunctivae which rapidly become purpuric (larger pink or purple spots). The spots do not blanch when pressed. The rash becomes very dark and may become necrotic (ulcerate). Gangrene of the skin may occur. Without early treatment the mortality is high. It is very important to look for a rash in all children who are thought to have septicaemia.

Always look carefully for a rash if a child has a diagnosis of possible septicaemia.

Many children with meningococcal septicaemia will also have meningococcal meningitis. Most will rapidly develop shock.

13-27 How is meningococcal septicaemia managed?

Similarly to other types of septicaemia. The choice of antibiotic is benzyl penicillin or ceftriaxone intravenously. Start antibiotics immediately as the clinical condition deteriorates rapidly without treatment.

Do not do a lumber puncture as this is very dangerous due to brain swelling and will not alter the choice of initial treatment. Treat shock and move the patient to hospital urgently.

Meningococcal infection is a notifiable disease in South Africa.

13-28 How is meningococcal infection prevented?

All those in contact with the patient, including the health staff, should take rifampicin 10 mg/kg twice a day for 2 days (5 mg/kg in infants less than 1 month) or ceftriaxone 125 mg intramuscularly once. This will treat and prevent colonisation of the upper respiratory tract. All contacts should be closely observed for signs of illness.

A short-lived vaccine against meningococcus can be used to help end epidemics. Over­crowding in schools, army camps and crèches should be avoided.

Meningitis

13-29 What is meningitis?

It is a serious infection of the meninges (the membranes covering the brain). Meningitis may be due to a viral or bacterial infection. Bacterial meningitis is usually far more dangerous. Causes of bacterial meningitis include both Gram positive and Gram negative bacteria. The most common causes are Pneumococcus (Streptococcus pneumoniae), Haemophilus (Haemophilus influenzae) and Meningococcus (Neisseria meningitidis).

Bacteria usually reach the meninges via the blood stream. Rarely, infection is by direct spread, e.g. from mastoiditis. Tuberculosis also causes bacterial meningitis. Fungal meningitis may be seen in children with AIDS.

13-30 What are the symptoms and signs of meningitis?

The signs of meningitis and septicaemia are very similar. Both must be suspected in any child who is seriously ill or unconscious or who has a high fever without an obvious cause.

Headache, fever and vomiting suggest meningitis.

13-31 How is the clinical diagnosis of meningitis confirmed?

By obtaining a sample of cerebrospinal fluid (CSF) by lumbar puncture. CSF should be sent to the laboratory for chemistry, microscopic examination for cells and bacteria, and for culture. As many children with meningitis also have septicaemia, the bacterial cause can often also be identified on a blood culture.

Note
Do not do a lumbar puncture if there is reduced level of consciousness, focal neurological signs or features of meningococcal meningitis. With bacterial meningitis the CSF protein is raised (normal 0.15–0.4 g/l) and the glucose is low (normal 2–4 mmol/l) with many polymorphonuclear cells. Bacteria may be seen on a stained spun deposit or may be cultured.

13-32 Is it easy to tell clinically whether meningitis in a child is due to a bacterial or viral infection?

No. Therefore, all cases of clinical meningitis must initially be managed as if they are bacterial meningitis until the cause of the meningitis is identified. However, children with viral meningitis are often not as severely ill as children with bacterial meningitis. Only the findings on the lumbar puncture enable one to tell whether the infection is viral or bacterial.

Children with viral meningitis usually improve rapidly after a lumbar puncture and have fewer complications. The management is supportive and antibiotics can be stopped once the results of the lumbar puncture exclude bacterial meningitis. Tuberculous meningitis also has a similar presentation and must be distinguished on lumbar puncture and other investigations.

It is not possible to distinguish between viral and bacterial meningitis on clinical examination alone.

Note
In viral meningitis most cells in the CSF are lymphocytes, the CSF glucose is normal and the Gram stain and culture are negative for bacteria.

13-33 What is the correct management of bacterial meningitis?

The most important step is to start antibiotics as soon as possible. If a lumbar puncture cannot be done immediately, it is better to start antibiotics before transferring the child to hospital for investigation and further treatment. The sooner the treatment is started the better is the clinical outcome.

  1. The first choice of antibiotic is ceftriaxone 100 mg/kg intravenously immediately and then repeatedly daily. In older children the second choice is benzyl penicillin 100 000 units/kg 6 hourly plus chloramphenicol 25 mg/kg 6 hourly intravenously (or intramuscularly if an intravenous line cannot be started). In neonates the second choice is ampicillin and gentamicin.
  2. Convulsions should be stopped.
  3. Paracetamol and tepid sponging can be used to lower the temperature.
  4. Always look for signs of shock and exclude hypoglycaemia.
  5. The patient must be transferred urgently to hospital.

Antibiotics must be started as soon as possible if a clinical diagnosis of bacterial meningitis is made.

13-34 Can meningitis be prevented?

The introduction of immunisation against Haemophilus influenzae into the routine schedule at 6, 10 and 14 weeks after birth has prevented most cases of haemophilus meningitis. The promise of new vaccines against Pneumococcus and Meningococcus will hopefully also prevent these causes of meningitis.

All those in contact with a patient with meningococcal meningitis or septicaemia should be given rifampicin or ceftriaxone prophylaxis.

13-35 What are the complications of meningitis?

About 25% of children with bacterial meningitis will die and about 25% of the survivors will have permanent brain damage such as:

Pyelonephritis

13-36 What is pyelonephritis?

Pyelonephritis is a bacterial infection of the kidney and the most serious form of urinary tract infection. If not diagnosed and treated early, repeated attacks of pyelonephritis can lead to permanent kidney damage resulting in hypertension and renal failure.

E. coli (Escherichia coli) is usually the bacteria causing a urinary tract infection. Most commonly the infection is mild and only affects the bladder (cystitis). Less commonly, the infection spreads up the ureters to affect the kidney (pyelonephritis). Pyelonephritis may be secondary to a renal tract abnormality that causes an obstruction to the normal flow of urine. This increases the chance that infection will spread to one or both kidneys.

Note
Vesico-ureteric reflux, hydronephrosis and posterior urethra valves increase the chances that a urinary tract infection will result in pyelonephritis.

13-37 What are the clinical features of a urinary tract infection?

Often the symptoms are non-specific and, therefore, the diagnosis is frequently missed. Fever, dysuria (pain or discomfort when passing urine), frequency (passing frequent small amounts of urine) and abdominal or back pain are common presenting complaints. A high fever and vomiting suggests pyelonephritis rather than a mild form of urinary tract infection.

13-38 How is the clinical diagnosis of a urinary tract infection confirmed?

It is very important to get a clean specimen of urine. A midstream urine or clean catch sample (urine collected after the child has already started passing urine), a sample collected by passing a catheter into the bladder under aseptic methods or a suprapubic aspiration (best done with ultrasonography) are by far the best methods. Using a urine bag is very inaccurate and is should be avoided if possible.

Leukocytes, nitrites and protein, and sometimes blood, are typical findings when the urine is tested with a reagent strip. It is probably not a urinary tract infection if the reagent strip test on a sample of freshly passed urine is completely normal, i.e. negative for protein, nitrite, blood and leucocyte esterase.

Pus cells are usually present on a spun deposit of urine.

The only accurate way to confirm a urinary tract infection is a positive culture when the urine has been collected correctly. More than 100 000 bacteria/ml on a clean catch urine, more than 1 000 bacteria/ml on a catheter specimen or any bacteria on a suprapubic sample is abnormal.

It is very important to make an accurate diagnosis and not simply send a urine bag sample to the laboratory. A normal urine bag result will exclude a urinary tract infection but a positive result may simply be due to skin or stool contamination. A confirmed diagnosis is also important because it indicates that a series of management steps is required. Treating a presumed urinary tract infection without confirming the diagnosis is bad practice.

It is important to collect a clean specimen of urine to make an accurate diagnosis before starting treatment.

13-39 How should a urinary tract infection be managed?

  1. Once the urine sample has been collected, a course of antibiotics must be started, usually oral nalidixic acid 10 mg/kg 6 hourly for 7 days in children older than 3 months.
  2. In younger infants and any child with a clinical diagnosis of pyelonephritis, intravenous cefuroxime or intramuscular ceftriaxone is indicated.
  3. All children with a proven urinary tract infection must be referred for investigation. Usually an ultrasound examination is done. Other special investigations may also be needed.

Other bacterial infections

13-40 What serious bacterial infections are less common?

Diabetes

13-41 What is diabetes?

Diabetes is due to inadequate amounts of insulin being produced by the pancreas. As a result, the body cannot remove glucose from the blood leading to a very high blood glucose concentration. Diabetes, if not well controlled, may result in severe complications and even death. Therefore, it is important to diagnose diabetes as soon as possible.

13-42 What are the presenting symptoms and signs of diabetes?

The diagnosis of diabetes must be suspected if a very high blood glucose concentration is found, using reagent strips. All children with suspected diabetes must be referred urgently to hospital. An intravenous infusion with normal saline must be started before transferring a child with diabetic coma. Later the clinical diagnosis of diabetes must be confirmed with a glucose tolerance test. Children with diabetes usually need daily injections of insulin for life to control their diabetes.

Diabetes usually presents with tiredness, weight loss and polyuria.

Convulsions

13-43 What are convulsions?

Convulsions (fits) present with a sudden onset of abnormal movements and an altered level of consciousness due to abnormal brain activity. Convulsions have many different causes and may present in a wide variety of ways. Important causes are:

All children with convulsions must be urgently transferred to hospital for investigation, to establish the cause, and start correct management.

Before moving a child with convulsions, make sure the airway is open and give oxygen. Always measure the blood glucose concentration with a reagent strip and correct any hypoglycaemia. Cool the child if the temperature is very high.

13-44 How are convulsions stopped?

Always look very carefully for the cause and treat this if possible. If a fit last longer than 5 minutes it can be usually be stopped with one of the following:

Note
Lorazepam 0.1 mg/kg intravenously is very effective at stopping a convulsion. Buccal midazolam 0.1 to 0.2 mg/kg is also effective.

Any convulsion lasting longer than 5 minutes should be stopped.

13-45 What are febrile convulsions?

These are generalised convulsions caused by a high temperature. Often there is an obvious cause of the fever, e.g. upper respiratory tract infection. The child is usually between 6 months and 5 years old and there may be a family history of febrile convulsions. Some children have febrile convulsions whenever they have a viral infection with a high fever. Usually the convulsion does not last longer than 15 minutes and there are no other abnormal neurological signs after the child recovers from the convulsion.

Management is to lower the fever and reassure the parents. Given paracetamol (Panado) when the child is ill to keep the temperature normal. Do not use aspirin. Children usually outgrow febrile convulsions. Oral anticonvulsants are usually not used to prevent febrile convulsions.

Note
If the child is over 18 months, has a typical repeat febrile convulsion and there are no meningeal signs, a lumbar puncture is not needed.

13-46 What is epilepsy?

Children with epilepsy have repeated generalised convulsions. There is usually no obvious cause, and they are well between convulsions. The diagnosis is usually based on the history. Epilepsy often starts at puberty and can be controlled (prevented) with oral anticonvulsants. All children with epilepsy should be referred to a neurological clinic for assessment and initial management. Long-term management can be supervised from a primary care clinic.

Cancer

13-47 Are malignancies common in children?

Malignancies (‘cancers’) are not common in children. However, it is important to know the warning symptoms and signs of childhood malignancy as many childhood malignancies are curable if they are diagnosed and treated early.

Malignancy in children often has a good prognosis if diagnosed and treated early.

13-48 What malignancies occur in children?

Note
Less common malignancies in children include liver and bone cancer, retinoblastoma (eye), rhabdomyosarcoma (muscle) and germ cell tumours.

13-49 What are the warning signs of malignancy in children?

  1. Pallor and bleeding
  2. Aching bones or joints, especially waking the child at night; backache
  3. Unexplained weight loss, fever or fatigue
  4. Persistent, unexplained lymphadenopathy
  5. Abdominal masses
  6. Lumps in the neck, testes or limbs
  7. Eye changes: white pupil, sudden squint or loss of vision, bulging eyeball
  8. Neurological symptoms or signs: headaches, early morning vomiting, unsteady gait, cranial palsies, change in behaviour

Children presenting with any of these warning (danger) symptoms or signs must be urgently referred for an expert opinion.

Case study 1

A 5-year-old child presents with a fever and a one-week history of pain and swelling of the knees and elbows. Over the past few days the pain has moved from joint to joint. On examination the child is unwell with arthritis of both knees. The heart rate is noted to be 110 beats per minute. A soft murmur is heard when her heart is examined. The heart appears enlarged on a chest X-ray. On questioning the mother says the child had a sore throat a few weeks back.

1. What is your clinical diagnosis?

Acute rheumatic fever. The child has 2 major criteria (polyarthritis and carditis) and one minor criteria (fever). There is also a history of a sore throat.

2. What are the other major criteria?

A rash (erythema marginatum), subcutaneous nodules and chorea. Only 2 major criteria are needed to make the diagnosis of acute rheumatic fever.

3. What is the likely cause of the sore throat?

A streptococcal infection.

4. Which signs suggests that this child has carditis?

A heart murmur, tachycardia and enlarged heart.

5. What is the management of acute rheumatic fever?

The child should be referred to hospital. With bed rest, antibiotics (oral amoxycillin for 10 days or a single dose of intramuscular benzathine penicillin) and aspirin the acute rheumatic fever usually recovers within 4 weeks. It is important to look for signs of heart failure.

6. What is the danger of repeated attacks of acute rheumatic fever?

It may result in chronic rheumatic heart disease with damaged heart valves. Rheumatic fever is the most common cause of acquired heart disease in poor, overcrowded communities.

7. How can repeated attacks of acute rheumatic fever be prevented?

With 4 weekly intramuscular injections of benzathine penicillin.

Case study 2

A 3-year-old child has had a swollen face and dark urine for the past 24 hours. There are numerous areas of impetigo on his legs. The mother says he is very short of breath when he lies down.

1. What is the probable diagnosis?

Acute glomerulonephritis.

2. Why does he have dark urine and a swollen face.

The dark urine is probably due to the presence of blood. Haematuria can be confirmed with reagent strips. His swollen face is due to fluid overload as a result of decreased urine production.

3. What is the cause of this condition?

The streptococcal skin infection (impetigo). This is an unusual immune response to Streptococcus where antibodies damage the kidney.

4. How is this condition prevented?

By preventing or treating impetigo. Usually, local treatment is adequate. An oral antibiotic should be given with widespread impetigo.

5. Why is this child short of breath?

Due to fluid overload. The most serious complications of acute glomerulonephritis are:

6. What is the management of the fluid overload?

Reduced fluid intake, a low salt diet and furosemide. These children should be managed in hospital.

Case study 3

A severely ill child is brought to the clinic. He has a high temperature without an obvious cause. His heart rate is fast, blood pressure low and hands feel cold. The capillary filling time over the chest is 8 seconds. The nurse notices that he has a fine rash which reminds her of purpura. The child is fully conscious with no neck stiffness.

1. What is the likely diagnosis?

The child has the clinical signs of septicaemia.

2. Why is the blood pressure low?

The low blood pressure, fast pulse and cold hands, in spite of a fever, indicate that the child is shocked. This is often seen in patients with septicaemia.

3. What does a capillary filling time of 8 seconds mean?

It is abnormally long, as the pink colour should return to a blanched (pale compressed area) area of skin within 3 seconds. The long capillary filling time confirms that the child is shocked.

4. Why is there a rash?

A fine pink or purpuric rash strongly suggests that the septicaemia is due to Meningococcus. This is an extremely serious condition.

5. How is the diagnosis of septicaemia confirmed?

By finding a positive blood culture.

6. Do you think the child has meningitis?

There are no signs of meningitis. However, meningitis is very common with meningococcal septicaemia.

7. What is the correct management of septicaemia with shock?

Take a blood culture and start a fast intravenous infusion with normal saline or Ringer’s lactate. Immediately start antibiotics. Benzyl penicillin or ampicillin plus gentamicin or amikacin would be the antibiotic combination of choice. Do not perform a lumbar puncture. The child should be moved to hospital as soon as possible.