For healthcare professionals only

Endgames Picture Quiz

An 11 year old boy with chest pain and fever

BMJ 2009; 339 doi: (Published 10 December 2009) Cite this as: BMJ 2009;339:b4941
  1. C A Christie-Johnston, paediatric registrar1,
  2. T Connell, consultant paediatrician, infectious diseases physician123,
  3. T Mildenhall, paediatric resident1,
  4. M Danchin, consultant paediatrician, NHMRC postdoctoral research fellow, senior lecturer123
  1. 1Department of General Medicine, Royal Children’s Hospital, Melbourne, VIC 3052, Australia
  2. 2Department of Paediatrics, University of Melbourne, VIC 3052, Australia
  3. 3The Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
  1. Correspondence to: M Danchin margie.danchin{at}

    A previously well 11 year old boy was transferred to a regional hospital by his local doctor after being given an empirical dose of intramuscular ceftriaxone (25 mg/kg) because of a 24 hour history of fever (40°C), vomiting, headache, neck pain, and rash.

    On arrival the patient was alert, afebrile, and seemed to be haemodynamically stable, with a heart rate of 60 beats/min, blood pressure 120/70 mm Hg, respiratory rate 18 breaths/min, and a Glasgow coma score of 14. He had pronounced neck stiffness and a widespread non-blanching petechial rash but no focal neurological signs, and examination of his precordium and lung fields was normal. A blood culture was taken, and he was given a bolus of intravenous normal saline (20 ml/kg) plus cefotaxime (50 mg/kg), dexamethasone (0.15 mg/kg), and ondansetron (0.05 mg/kg).

    Initial investigations showed a haemoglobin of 132 g/l (normal range 110-150), platelet count 288×109/l (150-400), and peripheral white blood cell count 34.7×109/l (6.0-17.0) (absolute neutrophil count 24.3×109/l; bands 6.9×109/l). Sodium was 141 mmol/l (135-145) and glucose was 5.3 mmol/l (3.0-5.4). C reactive protein was 143 mg/l (normal <8 mg/l) and international normalised ratio was 2.0 (0.8-1.2).

    Within 90 minutes of arrival at the regional hospital, the patint’s clinical condition deteriorated greatly, with a decreasing level of consciousness (Glasgow coma score 10), and he was subsequently intubated and ventilated. Transfer to the intensive care unit was arranged, and intravenous aciclovir (16 mg/kg eight hourly) was added. A computed tomography brain scan and electroencephalogram were normal. A lumbar puncture was deferred because of the abnormal coagulation profile, but dexamethasone (0.15 mg/kg intravenously every six hours) was continued for four days on the presumptive diagnosis of meningitis. Inotrope support was not needed, and he was extubated within 24 hours of arrival.

    On …

    View Full Text

    Log in

    Log in through your institution


    * For online subscription