You will be presented with 8 clinical scenarios of children with fever.
For each, interpret the clinical and diagnostic data and provide: 1) Diagnosis, 2) Any other test, 3) What to do next, 4) Follow-up plan.
Case 1
A 12-day-old neonate with fever 38.5°C (101.3°F), irritability, and poor feeding. Well-appearing initially.
WBC
18,000/µL (elevated)
CRP
2.5 mg/dL (elevated)
Procalcitonin
2.0 ng/mL (elevated)
UA
Negative (LE, nitrite, WBC)
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Neonatal meningitis (viral or early bacterial/HSV) – CSF pleocytosis, elevated CRP/PCT. Age <28 days mandates full sepsis workup.
• Any other test: Blood culture, CSF, HSV PCR (CSF, blood, surface), enterovirus PCR (CSF), blood gas, electrolytes, CXR.
• What to do next: Hospitalize, IV ampicillin + cefotaxime (or gentamicin) + acyclovir (60 mg/kg/day) empirically. Monitor for seizures, apnea.
• Follow-up plan: Repeat CSF if no improvement in 48h. Neurodevelopmental follow-up. Audiologic assessment if bacterial meningitis.
Case 2
A 4-year-old with fever for 7 days, red eyes, cracked red lips, strawberry tongue.
WBC
20,000/µL (elevated)
Platelets
450,000/µL (elevated, normal 150-400)
ESR
95 mm/hr (elevated)
CRP
15 mg/dL (elevated)
Albumin
3.0 g/dL (low, normal 3.5-5.0)
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Kawasaki disease (KD) – fever ≥5 days + ≥4 clinical criteria, elevated inflammatory markers, coronary dilation on echo.
• Any other test: Echocardiogram for dilaratopn of Coronary artery z-score: , Complete blood count, liver function tests, urinalysis, blood culture (exclude sepsis), ECG, repeat echocardiogram in 2 weeks and 6-8 weeks.
• What to do next: IVIG 2 g/kg single dose within 10 days of fever onset. High-dose aspirin 30-50 mg/kg/day divided q6h until afebrile, then low-dose aspirin 3-5 mg/kg/day for antiplatelet effect.
• Follow-up plan: Cardiology follow-up. Echo at 2 weeks and 6-8 weeks. If coronary aneurysms persist, continue aspirin ± warfarin/LMWH. Avoid live vaccines for 11 months after IVIG.
Case 3
A 7-year-old with fever 39.5°C, headache, vomiting, photophobia, and nuchal rigidity. Alert but irritable.
WBC
22,000/µL (elevated)
CRP
18 mg/dL (elevated)
Blood Culture
Pending
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Bacterial meningitis (S. pneumoniae) – CSF pleocytosis with neutrophil predominance, low glucose, high protein, gram-positive diplococci.
• Any other test: CSF, Gram Stain, Blood culture, CSF culture and PCR (S. pneumoniae, N. meningitidis), serum electrolytes, coagulation profile, CT head (if focal deficit or altered sensorium).
• What to do next: Start IV ceftriaxone + vancomycin + dexamethasone (0.15 mg/kg q6h for 2-4 days) before or with first antibiotic dose. Admit ICU.
• Follow-up plan: Repeat LP at 48h if no improvement. Audiometry (hearing loss), neurodevelopmental follow-up. Vaccination review (PCV13, PPSV23 if high risk).
Case 4
A 5-year-old with fever for 3 weeks, daily spikes to 39.5°C (103.1°F) twice a day , and joint pain and swelling especially knees.
WBC
25,000/µL (elevated)
Hemoglobin
9.5 g/dL (low, normal 10.5-13.5)
Platelets
550,000/µL (elevated)
ESR
110 mm/hr (elevated)
CRP
18 mg/dL (elevated)
Ferritin
8,500 ng/mL (markedly elevated)
ANA, RF
Negative
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Systemic juvenile idiopathic arthritis (sJIA) – double quotidian fever, evanescent rash with fever, arthritis, elevated ferritin, negative ANA/RF.
• Any other test: Liver function tests, triglycerides, fibrinogen (screen for MAS), bone marrow exam (if cytopenias), blood cultures (exclude infection), echocardiogram.
• What to do next: NSAIDs (naproxen), corticosteroids (prednisone) for severe symptoms, consider anakinra (IL-1 inhibitor) or tocilizumab (IL-6 inhibitor) as steroid-sparing.
• Follow-up plan: Monitor for MAS (falling ESR, hyperferritinemia, cytopenias). Rheumatology follow-up. Steroid taper. Watch for uveitis (less common in sJIA).
Case 5
A 45-day-old infant with fever 38.4°C (101.1°F). Well-appearing, feeding well, no source on exam.
WBC
8,000/µL (normal)
Bands
1,000/µL (normal, <1,500)
CRP
1.5 mg/dL (normal)
Procalcitonin
0.3 ng/mL (normal, <0.5)
UA
Negative (LE, nitrite, WBC)
Blood Culture
Pending
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Febrile infant (29-60 days) meeting low-risk criteria (Rochester/Step-by-Step) – normal WBC, bands, CRP, PCT, negative UA. Low probability of SBI.
• Any other test: None required if low-risk. Blood culture (already done). LP not indicated per AAP guidelines for low-risk 29-60d.
• What to do next: Outpatient observation with close follow-up within 24-36h. No antibiotics. Educate parents on signs of deterioration.
• Follow-up plan: Telephone or in-person follow-up in 24-36h. If cultures negative and infant remains well, discharge from care. If fever persists or worsens, re-evaluate.
Case 6
A 14-year-old with fever for 2 weeks, sore throat, fatigue, and generalized lymphadenopathy. Splenomegaly on exam.
WBC
14,000/µL (elevated, lymphocytosis)
Atypical Lymphocytes
20% (elevated)
ESR
45 mm/hr (elevated)
Liver Enzymes
AST 120, ALT 100 (elevated)
Monospot (Heterophile)
Positive
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Infectious mononucleosis (EBV) – fever, pharyngitis, lymphadenopathy, splenomegaly, atypical lymphocytes, positive Monospot, EBV VCA IgM.
• Any other test: Positive EBV VCA IgM, CBC with differential, liver function tests, abdominal ultrasound (spleen size), EBV serologies (if Monospot negative).
• What to do next: Supportive care (rest, hydration, analgesia). Avoid contact sports (splenic rupture risk) for 4-6 weeks. Avoid amoxicillin/ampicillin (rash risk).
• Follow-up plan: Monitor for complications: splenic rupture, airway obstruction, hepatitis, encephalitis. If splenomegaly persists, extend activity restrictions. Fatigue may persist weeks-months.
Case 7
A 6-month-old girl with fever 39.5°C (103.1°F) for 2 days. Well-appearing, fully vaccinated (PCV13, Hib). No focus on exam.
WBC
15,000/µL (normal)
CRP
4.5 mg/dL (elevated)
UA (catheter)
Leukocyte esterase +, nitrite +, WBC 50/hpf
Urine Culture
E. coli >100,000 CFU/mL
Blood Culture
Negative
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Febrile urinary tract infection (UTI) – most common occult bacterial infection in fully vaccinated children. E. coli >100,000 CFU/mL.
• Any other test: Renal/bladder ultrasound (to rule out hydronephrosis, abscess). Blood culture (already negative).
• What to do next: Start empiric oral antibiotics (cephalexin, cefixime, or TMP-SMX based on susceptibility) for 7-10 days. If ill-appearing or <2 months, consider IV ceftriaxone and admission.
• Follow-up plan: Renal/bladder ultrasound within 2 weeks (if abnormal or recurrent UTI, consider VCUG). Monitor urine culture for resistance. Counsel on hydration, bladder hygiene, constipation treatment.
Case 8
A 7-year-old with ALL, on chemotherapy, presents with fever 38.8°C (101.8°F). Well-appearing but has a central line.
WBC
500/µL (low)
ANC (Absolute Neutrophil Count)
100/µL (low)
CRP
12 mg/dL (elevated)
Blood Culture
Pending (central line and peripheral)
Chest X-ray
Normal
Urinalysis
Normal
1️⃣ Diagnosis: (Write your answer below)
2️⃣ Any other test: (Write your answer below)
3️⃣ What to do next: (Write your answer below)
4️⃣ Follow-up plan: (Write your answer below)
✅ Model Answer:
• Diagnosis: Febrile neutropenia – fever in immunocompromised child with ANC <500/µL. High risk of sepsis due to central line.
• Any other test: Blood cultures from central line and peripheral vein, urine culture, CXR, serum electrolytes, procalcitonin, lactate.
• What to do next: Admit. Start empiric IV antibiotics (antipseudomonal: cefepime or piperacillin-tazobactam ± vancomycin if MRSA risk). Monitor for sepsis.
• Follow-up plan: Daily CBC, CRP, blood cultures. De-escalate antibiotics based on cultures and clinical status. G-CSF if prolonged neutropenia. Infectious disease consult.