The Fever Files: A Case of Tummy Troubles

The Case: You are called to your international airport for a six-year-old boy who is deplaning after an 8 1/2-hour flight from London’s Heathrow Airport in the UK. The dispatcher states the passenger you have been called for traveled from Bangalore, India. After passing through the double gates onto the tarmac, your escort vehicle guides you past fuel trucks, baggage carts, and pushback tugs before stopping at a jetbridge. You climb the stairs and board the plane. You find a family of four hovering near the front of the recently emptied plane in the business class seats near the door you entered. Sitting in front of you is a boy who looks unwell.

Your initial glance is not reassuring. The child is floppy, with eyes closed and a waxy look on his face. He rouses to your loud voice looks at you, moans, and closes his eyes again, dropping his head to his side. His father explains it was a very long flight; his mother tells you he has been complaining of belly pain since being in the airport lounge at Heathrow.

You delve into questions while your partner applies the monitor and collects a set of vital signs, which are:

HR 155 sinus 

RR 60 

SpO2 91 

BP 70/30 

Temp 39.8C/103.6F

What is your differential diagnosis?

Your careful interview skills pay off; you learn that the child has felt warm since about six hours ago; he was feeling fine prior. Despite being given acetaminophen, his fever persisted. There has been no vomiting or diarrhea, but the child has complained of belly pain, and your partner elicits a groan when he palpates the abdomen in all 4 quadrants. Before the flight, he was well. He has no other physical findings, and no other organ systems seem to be involved based on your questioning.

The child arrived in Bangalore 6 weeks ago; the family traveled there for a short-term business opportunity. They spent 4 weeks in a hotel, with the children exploring the sites around the state including visits to the beach and local food stalls. The child did have a few days of diarrhea and belly pain, but this resolved on its own about a week before departure. They then flew to the UK to spend 2 weeks visiting family in London.

The child is fully vaccinated but did not have any special vaccines or treatments before traveling. Because they were staying in a nice hotel, they did not take malaria chemoprophylaxis on the advice of the company they were visiting. He is otherwise perfectly healthy.

Has your differential diagnosis changed?

On exam, the child has a supple neck without stiffness; increased respiratory rate but no increased work of breathing; clear lungs; a very tender abdomen; and cool extremities. There is a slightly delayed capillary refill at 4 seconds in the nailbeds. There is no rash.

You and your partner decide the child might have an infection and could have sepsis. You extricate to your vehicle. The local hospital is 10 minutes away. The pediatric hospital is 25 minutes away.

Pop Quiz: 

What interventions will you perform? 

Which hospital will you choose as your destination?

Sepsis Treatment: 

You initiate IV access, oxygen therapy, and a fluid bolus of 20cc/kg of crystalloid fluid. There is some uncertainty about the superiority of lactated ringers over normal saline; if you have the choice, it’s up to you. D5W should not be bolused in this case. If you have antibiotics such as ceftriaxone, it would be reasonable to give a dose for suspected abdominal sepsis.

Response to Treatment:  

On reassessment, the child has perked up but continues to complain of abdominal pain, especially when the ambulance hits bumps on the road. His HR has come down to 140 and his blood pressure has improved to 90/40. The RR has reduced to 40 and the oxygen saturation has increased to 99% on a 40% ventimask.

Ok, Sherlock! What’s your diagnosis?

This is a case of typhoid fever with bowel perforation. Salmonella enterica (including subspecies typhi and paratyphi) is ingested by food and water that has been contaminated by the “Four F” vectors: flies, fingers, feces, and fomites. Gastrointestinal symptoms begin six to thirty days later. The most dreaded complication occurs two to three weeks after symptom onset. “Peyer’s patches” of necrotic tissue occur in the terminal ileum, leading to bowel perforation and abdominal sepsis. Patients can become severely septic and require surgery and antibiotics. Meningitis is another feared complication of the disease.

Blair Bigham worked for a decade as a flight paramedic on four continents, a job he misses every day. He is now an ER and ICU physician at the University of Toronto and a public health researcher at the Dalla Lana School of Public Health. @BlairBigham blairbigham.com