Persistent Fever in a 7 Year Old

A seven year old girl was hospitalized at a Tertiary Medical Center because of a seven day history of fever in the 40 C in June. It was associated with fatigue and poor appetite. She had also mild pain all over and swelling of the hands. One week before hospitalization, she was seen by their family physician and was diagnosed to have a viral illness. Two days before she was hospitalized, she had some rashes which were not itchy. A strep test of the throat was positive and amoxicillin was prescribed. On the day she was admitted in the hospital, she was having fever, rashes at the face, and redness of the conjunctiva (the white part of the eye).

She said she did not have headache, sore throat, or upper respiratory tract infection. Her immunizations were up to date and she did not have any contact with anyone with an illness. They live in wooded a community and they have a cat.

She was ill appearing and tired on physical examination with a temperature of 39.5 C, pulse of 125/minute, breathing rate of 42/minute. Her blood pressure was normal. Both of her eyes were red. Both cheeks were red too. Her throat was red. She no limited motion of the neck which has enlarged lymph nodes. Her lungs were clear and heart did no show any murmur. The abdomen was normal. Lower extremities were swollen. Skin showed raised rashes over her neck and trunk.

At the hospital blood tests were done and ceftriaxone was given intravenously, then doxycycline was given. She improved in the hospital.

What is this child suffering from?

Her blood test was positive for Ehrlichia chaffeensis which is the cause of human monocytic ehrlichiosis (HME).

Ehrlichiosis is a tick-born infection first recognized as a hemorrhagic illness of dogs. It appeared in epidemics in military working dogs in Vietnam in the 60s. The first case of human ehrlichiosis was reported in the USA in 1986. This organism primarily infects mononuclear cells and was identified as the cause of HME.

Erhlichiosis is an acute febrile illness characterized by fever (100%), muscle pain (67%), rashes (66%) headache (63%), and enlarged spleen & liver (41%). This illness could be easily mistaken with Rocky Mountain spotted disease.

Cough, throat infection, enlarged lymph nodes, diarrhea, vomiting, abdominal pain, and changes in behavior occur in about 10 to 40%. In severe cases, the patient with this illness can go into kidney failure.

The treatment is doxycycline intravenously or by mouth.

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Leo Leonidas, MD, FAAP

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