Question of the Week

Question :
Posted On : 20 Feb 2018
A 12 years old previously well child admitted with 6 days h, o high fever - 39C to 40C. Fever was associated with chills. No other associated symptoms. He had no cold, no cough, no GI or urinary symptoms. His General physical examination and systemic examination was normal. ENT examination was normal. Fundus normal. Skin and joints no abnormality detected. No meneingeal signs.
His WBC count was 6600, Neutrophils-4800, Platelet count 122, Hb-11 g, dl.
ALT- borderline high- 109 IU, L. Rest of LFT was normal.
ESR was 50, C-reactive protien was 354 mg, L.
Uric acid, LDH- WNL. Peripheral smear- normal.
Blood and Urine clture later showed no bacterial growth.
Chest x-ray-Normal
U, S abdomen and KUB- normal
Nasal endoscopy - no abnormality
X-ray PNS- normal
No prior antibiotic treatment was given.

We treated him with Ceftriaxone for 7 days as presumed bacterial infection o the basis of high fever and high CRP. He became afebrile on Day 2 of antibiotic treatment.
His CRP repeated Day 3 of treatment showed a falling trend to 274.
My question is:
- What is the significance f high CRP in the absence of any focus of infection clinically and normal White cell count_?
- Could we have waited without antibiotic treatment_?
Aasma Rasul
General pediatrician
Sultanate Of Oman
Expert Answer :
CRP is an indicator of inflammation. Though high CRP is considered as a marker of bacterial infection, its role is limited to neonatal and paraneonatal period for the same. In case of older children, even with viral infections, CRP may be seen elevated upto 60mg, dl. In case of high CRP it may suggest bacterial infection or even autoimmune disorders. In your patient, though CRP was high, there was also borderline thrombocytopenia. Thus repeat a CBC to see if platelets have normalised. This high CRP with thrombocytopenia may be seen with dengue also.
Answer Discussion :
lobna Mohammad
there was low platlet count indicating that viral infection is possiple
regular antipyretics with extra fluids and close observation for temp may be beneficial befor starting antibiotics

3 years ago
blood c/s is not 100% sensitive , however I think if not life threatening can wait, till more investigations done

3 years ago
with a normal TLC and neutrophilia and a raised CRP, 02 days wait can be done. a viral infection will also raise the CRP. A raised PCT can confirm a bacterial sepsis. antibiotics can be decided thereafter
3 years ago
mouid mohammed abdalla
hight fever with no focus and low platlet posopility of malaria and vasculitis is hight
3 years ago
if no focus was found a trail of antipyretic for 2 days and on 3rd day repeat cbc and crp but working in middle east it is difficult to take risks
3 years ago

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