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Hanne Hansen, age 7

months
Department of Paediatrics
Henrik Døllner (revised 2007)

Part 1
Now 7 months old, Hanne was born at term after a normal pregnancy. Her birth
weight was 3480 g and length 49 cm. She has developed normally, and has
followed the standard vaccination programme without any complications. She is
the second of two siblings. Her 5-year-old sister has been suffering from
bronchitis. The parents are married, and both work full time. During the day
Hanne is looked after by a nanny, and her sister attends a full-time kindergarten.

For two or three days Hanne has had a runny nose and a fever with temperatures
ranging from 38.0 o C to 39.5 o C, peaking in the evenings. Her general condition
has been quite good, eating less than usual but drinking well. After one day of
fever the doctor on call prescribed a 7-day course of penicillin, suspecting acute
otitis media on the left side. Twenty-four hours later Hanne was still feverish but in
good general condition, although a bit grumpy and weak at times. Another doctor
on call finds a bulging and tense frontal fontanelle.

• Would you refer this child to the hospital?

• Discuss differential diagnoses.

Part 2
Hanne is admitted to hospital, and the findings on admission are:

Seven month old girl who is awake and makes adequate contact. She seems
grumpy and irritable. Temperature 39.1 o C, weight 7250 grams, length 67 cm,

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head circumference 44 cm. No neck or back stiffness, but the anterior fontanelle
is bulging and seems tense. No rash.

Ophthalmoscopy: bilateral red pupillary reflexes, but it is not possible to see the
optic disc.

BP 80/60, HR 130/minute. Good peripheral circulation and normal capillary filling

time. No signs of dehydration.

Otoscopy: redness of the left tympanic membrane along the shaft of the malleus.
The upper part of the membrane is bulging slightly. The right ear is normal.

The mucus membranes of the throat and the tonsils are red and injected, but
there are no plaques. A few palpable lymph nodes in the neck bilaterally.

Normal findings upon examination of the heart, lungs and abdomen, notably no
enlargement of the liver or spleen.

• How do you assess tension of the fontanelle, and neck and back stiffness in
a 7-month-old child?

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Part 3
A lumbar puncture is performed. The cerebrospinal fluid contains no cells, the
glucose level is 4.5 mmol/L and the protein is 0.25 g/L. Culture (bacteria, virus)
negative.

Blood tests on admission:

• CRP 43 mg/l
• WBC 5.6
• Differential count:
◦ Granulocytes 38%
◦ Lymphocytes 51%
◦ Monocytes 5%
◦ Eosinophils 6%
• Hgb 11.3 g/l
• Platelets 345
• Glucose 6.2 mmol/l
• Blood gas and electrolytes normal

• How do you interpret the cerebrospinal fluid findings, the CRP level and the
blood-count tests in relation to the differential diagnoses?

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Part 4
Hanne is observed in hospital overnight without treatment. The next day her
temperature is 37.6 o C. At the ward round it is noticed that Hanne has developed
a rash on the trunk and neck .The rash is maculopapular with spots measuring
2-5 mm, partly confluent, and it disappears when pressure is applied. She is in
good general condition, is breast feeding and having baby food for breakfast. The
fontanelle is normal.

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Repeat blood tests show:

• CRP 23 mg/l
• WBC 3.4
• Differential count:
◦ Granulocytes 23%
◦ Lymphocytes 71%
◦ Monocytes 4%
◦ Eosinophils 2%
• Platelets 463
• Hgb 10.9 g/l

Hanne is discharged from the hospital the same day.

• Which diagnosis is the most likely?

• When can Hanne return to her nanny?

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