UNCOVERING A CASE OF FEVER OF UNKNOWN ORIGIN-

 
Dr.Subbulakshmi P S, Dr. Sajitha Nair, Dr. Sindhu, Dr. Sreya Nair, Dr.C.Jayakumar
Department of Paediatrics, AIMS, Kochi
 
Two year six months old male child with a history of febrile seizures and on intermittent clobasam prophylaxis presented with high-grade intermittent fever and a dry cough lasting 20 days and pain during micturition. He was initially managed as an outpatient case with oral Oseltamivir and Azithromycin, but later admitted to a near hospital in his home district .During this admission, he received multiple antibiotics, like Ampicillin Cefuroxime, Vancomycin and Piptaz. 
Due to persistent fever spikes and rising blood counts, the child was referred . There was no history of chest retractions, night sweats, joint or abdominal pain, vomiting, loose stools, contact with tuberculosis, recent travel, contact with pets, bleeding manifestations or weight loss noted or H/O unpasteurized milk consumption noted. 
On admission, the child was febrile and appeared tired, with noticeable pallor and bilateral non-significant multiple cervical lymphadenopathy. Except for redness over the prepuce rest of Systemic examination was within normal limits.
 
Differential diagnosis:
● Pneumonia
● Infectious etiology- Leptospirosis, Brucella, EBV
● Urinary tract infection
● Autoimmune conditions
● Malignancies
Investigations:
TC: 15.5K, N: 50, L: 37, E: 0.6, Hb: 10.9, Platelets: 296
ESR: 101, CRP: 17
OT/PT: 16/9
S.Creatinine: 0.32
S.Sodium: 134, S.K: 3.5
Chest Xray: Increased bronchovascular markings
EBV IgM/ Brucella IgM/ WIDAL/ Dengue IgM: Negative
Gene Xpert for TB : Negative
Lepto IgM: Positive and repeat titres showed increasing trend (From 12.2 PB units to 16.9 PB Units)
URE: Numerous Pus cells with 14-15 RBCs
CPK:  88.0 U/L
USG Abdomen: Borderline hepatomegaly. Mildly bulky and echogenic kidneys.
In view of the endemicity of the region from which the child is hailing and positive tests with increasing titres, a diagnosis of leptospirosis- anicteric phase was considered and the child was treated with IV Ceftriaxone and nitrofurantoin for a total of 10 days with other supportive management. Repeat counts and urine analysis were on improving trends and he was discharged with stable vitals.
 
DISCUSSION:
Leptospirosis
Definition:
Leptospirosis is a bacterial infection caused the Leptospira species, primarily transmitted to humans through contact with water, soil, or food contaminated the urine of infected animals.
Epidemiology:
● Transmission: Commonly occurs in tropical and subtropical regions, particularly during rainy seasons. 
● Reservoirs: Rodents are the primary reservoir, but it can also infect livestock and wild animals.
Pathophysiology:
The bacteria enter the body through mucous membranes or broken skin. They can spread through the bloodstream, affecting multiple organs, including the liver, kidneys, and lungs.
Clinical Features
Incubation Period: Typically 5 to 14 days.
Symptoms: Can range from mild flu-like symptoms to severe illness. Common symptoms include:
● High fever
● Chills
● Headache
● Muscle aches
● Vomiting
● Jaundice
● Rash
Severe Cases: Can lead to complications such as Weil’s disease, characterized jaundice, renal failure, and hemorrhagic manifestations.
Diagnosis:
● Clinical Evaluation: Based on symptoms and history of exposure.
 
● Laboratory Tests: 
a. Serology (MAT – Microscopic Agglutination Test) to detect antibodies.
b. PCR for detecting Leptospira DNA in blood or urine.
 
 
Management:
Antibiotics: Doxycycline, penicillin, azithromycin, Ceftriaxone are commonly used. 
Supportive Care: Hydration and management of complications.
Prevention: Avoiding contact with potentially contaminated water or soil, Vaccination for at-risk populations (e.g., farmers, veterinarians), Public health measures to control rodent populations.
TAKE HOME MESSAGE: With prompt treatment, the prognosis is generally good. Severe cases can lead to significant morbidity or mortality if untreated. It requires awareness of risk factors, early diagnosis, and appropriate treatment to reduce complications and improve outcomes.