An Infant with Fever, Raised Inflammatory Makers and No Apparent Focus for Fever

Kollannoor B, Roberts M, Abdelaziz M
Department of Pediatrics, St Helens and Knowsley NHS Teaching Hospitals.

Address for Correspondence: Dr Maysara Abdelaziz, Consultant Paediatrician, St Helens & Knowsley NHS trust, Warrington Road, Prescot, Liverpool L35 5DR, UK. Email: Maysara.Aziz@sthk.nhs.uk


Clinical Problem:
A 4 month old male infant presented with fever for 4 days. He had no localizing signs on examination. He was irritable and suspected to have meningitis. Investigations showed white blood cells 28,100/cumm (neutrophils 21,500/cumm), platelets 554000/cumm and CRP 312mg/dl. Chest X-ray was normal and urine showed 25 pus cells/hpf but urine culture did not grow any organism. Cerebrospinal fluid (CSF) showed 8 cells/cumm, 1 red blood cell. CSF cultures were negative. Abdominal ultrasound (USG) and CT brain was normal. He was treated with intravenous antibiotics cefotaxime, amoxicillin and acyclovir. After 2 days of admission, he had a swollen ankle and slightly red lips. X-ray of the ankle was normal. Radioisotope bone scan showed no osteomyelitis. CRP was 212 mg/dl after 7 days of antibiotic treatment. Echocardiogram was done on day 8 which was normal. He remained irritable throughout this period.

What is the diagnosis?