A febrile child
A 2year old boy presents with a history of being unwell for the last 72hours. His parents report that over the past few days he has just not been himself. Today he has developed fevers, had a number of vomits and has cried for most of the day. He has had minimal oral intake.
On examination, he is lying in mum’s arms crying. He is febrile, tachycardic, tachypnoeic and looks unwell. He has an audible grunt but no other signs of increased work of breathing and has a clear chest on auscultation. He cries on attempts to examine his abdomen, but it appears soft. Examinations of his cardiovascular system, ENT and skin are all normal.
His investigations reveal a high white cell count and CRP with a normal chest X-ray. He settles with analgesia and a fluid bolus. He receives IV Antibiotics for treatment of sepsis and is admitted to the Paediatric ward.
On review the next morning, there are concerns that he has focal abdominal tenderness. He goes on to have an USS of his abdomen which reveals appendicitis with evidence of perforation.
1) Grunting is a sign of serious illness in children
Grunting respirations can be seen in children with respiratory distress (in an attempt to splint open small airways), fever or pain. Grunting is also a recognised sign of serious illness, with studies showing that children who grunt are more likely to have a serious bacterial illness, particularly pneumonia.
2) Appendicitis in young children is rare, presents atypically and has high rates of complications
In young children, appendicitis often presents atypically, with vomiting, diarrhoea, fever, grunting, cough or complaints of right hip pain. On examination, only 50% have focal abdominal tenderness.
As it is often difficult to pick, studies have shown that the misdiagnosis rate in those < 3 years is 70-100% and that these children are more prone to perforation as a result.
NB: Subtle changes have been made to this case to protect patient confidentiality
Dr Danielle Scarfe
Dr Danielle Scarfe