Resolved question:
We have an 8 month old baby. On Thursday last week he got a fever of 38.5 degrees celsius and puked once. We treated with paracetamol and the fever lasted until Friday.
On Saturday and Sunday, he felt absolutely fine. However on Monday he spiked a fever of 39.3 degrees celsius. At that point, we took him to a local doctor, who told us that he saw an ear infection in both ears and prescribed Amoxicillin of 3.6 millilitres, 2 times a day. (Dosage of actual antibiotic is 50 milligram/millilitre and it also contains asparatam, natr. benz. natr.citr, water)
The next day (Tuesday) we gave him paracetamol to fight with the fever. He was feeling fine during the day. Very active, but ate and drank less than normal. However in the evening he once again spiked a fever. This time of 40.0 degrees celsius. We took him to the local doctors again, this time they checked the ears again and said that the previous doctor may have been wrong as it is just a little red, not a major infection.
They took urine and blood samples (attached). The blood sample showed a spike in P CRP - O of 91. Which they told us is the bacterial infection marker. So this time they prescribed the anti-biotic again but with a higher dosage of 3 millilitres / 3 times a day and let us go home. The urine sample showed no signs of urinary tract infection, they said.
In addition they told us to give him paracetamol and ibuprofen. We have only been giving paracetamol. We gave him one dosage of paracetamol last night at 11PM and through the day (today, Wednesday) he was feeling well, and there was no fever. But this evening he again spiked a fever of 39.0 and we gave him paracetamol to fight it.
He did not have a blocked nose to begin with but through these three days the nose got progressively worse, not better. In addition to that, because they were now unsure about the ear infection and they could not tell us what infection it actually is, we are naturally worried. The lungs sounded clear, as well, according to the doctors.
In addition to that, he seems to have either developed some sort of a rash (picture attached), reaction to medicine or just reaction to fever as it is going away as I am writing this question. This might be irrelevant.
So, my question after all this is whether we should be worried and go to a different doctor? What can we do to improve his condition? Were we misdiagnosed? If we go to the doctors again, what should we push for?
P.S. His "rash" has more or less disappeared as I was typing this.
Submitted:
4 Days
Category:
Pediatrician
Hello,
Thank you for your question at DoctorSpring. I can understand your concern. Your description of the illness and its progression is very informative.
Summarizing your child's illness, it appears to be a biphasic febrile illness (it has occured in two distinct phases) and predominantly manifesting with systemic findings (not localizing to any particular organ system).
The reports suggest ongoing inflammation/infection - viral/bacterial in the body. Elevated CRP and increased counts may not always mean a bacterial infection, though it is by far the commonest cause.
The doctors treating your baby may have picked up some redness of the ear drums, which may or may not be due to an actual ear infection (otitis media). Children with high grade fever sometimes have non-specific redness of mucosal surfaces including ear drum (tympanic membranes).
Prescription of AMOXICILLIN in this scenario may not be wrong. But, the course of illness in your baby seems to be a bit different than what is anticipated for a simple ear infection.
My clinical suspicion based on my experience, points to a viral etiology (Ebstein Barr Virus) or systemic illness like DENGUE or RICKETTSIAL infection. This needs to be corroborated with the epidemiology including your locality, whether these infections are prevalent in your country in this part of the year. Unfortunately, I do not have details regarding your exact location and hence, would not be able to comment on the same. Occurence of such rash after amoxicillin is well described in children with EBV infections. Similarly biphasic illness with rash can be due to dengue (if that is common in your region) or rickettsial infection. Kindly request your doctor to examine the child for any enlarged lymph nodes. Similarly blood tests can help you diagnose or rule out these three conditions. Till then symptomatic therapy with PARACETAMOL and oral antibiotics seems good enough.
Keep a close watch for any fresh findings and promptly report to your pediatrician. Remember, infants have a variety of infections which progress rapidly and may be difficult to diagnose. Hence be patient yet watchful.
Hope this helps, please feel free to discuss further.
Regards
Dear Dr Saptharishi,
Thank you for your detailed reply, we really appreciate it and it has made the picture a lot clearer now.
We are located in Helsinki, Finland so probably DENGUE is not a possibility. Not sure if this helps, but we are from Russian descent.
Since I wrote last he was feeling fine but it is now 3:20 AM and he spiked up a fever of 39.8 degrees Celsius. He ate a whole bottle of baby formula but then puked a part of it at the end of the meal.
We gave him paracetamol and ibuprofen at the same time, as the doctors told us to. Together with the evening antibiotic, we have given him 5 doses over the course of two full days.
Since it is not helping, does this indicate that this might not be a bacterial infection after all? If so, what is our best course of action? Should we be asking for any specific tests to narrow down the diagnosis? Also, is it a good idea to give both Paracetamol and Ibuprofen as the doctors told us?
One last concern is that my wife suggested to rub the baby in water and vinegar. Personally, I am against such practice, but I am not sure if I can make a strong argument as to why.
The "rash" only appears when he has high fever of over 39.0 degrees Celsius and goes away completely when he is feeling normal.
Dear parent,
I appreciate the information regarding your location. You are right. It is unlikely to be either dengue or rickettsial infection, which leaves us with viral infections and hidden foci of bacterial infections.
The combination of paracetamol and ibuprofen has not been proven to be superior to paracetamol alone. Both these drugs are supposed to be equally efficacious as an antipyretic. Ibuprofen has been associated with higher gastritis and hence, less preferred in young children.
It is very difficult to comment on definitive diagnosis without detailed physical examination. Urinary tract and throat infections are also relatively common among young infants. Hence, it would be prudent to get urine routine, urine dipsticks and culture examination. Throat swab for gram stain and culture can help rule out a bacterial infection of the throat. Viral serologies and cultures as recommended by the local pediatrician may be considered. Further testing depends on the physical examination findings in your baby.
Regarding the query regarding use of water and vinegar for symptomatic control, there is no data to either support or refute its use. I personally would not recommend its use in infants.
Regards
Saptharishi L G