A Case of Bacteremia and Sepsis in a Pediatric Patient
Case Report Insights are in-depth interviews that take you inside the diagnosis with clinicians who recently published a Consultant case report.
In this Consultant Case Report Insights, Felicia Cooper, MD, and Drew Burgess speak about their study, "Slide Injury Leading to Bacteremia and Sepsis in a Pediatric Patient." Dr Cooper and Ms Burgess provide a comprehensive look at their study where they discuss its implications on multidisciplinary care, what they believe other clinicians can take away from the case, and more.
Additional Resource:
Burgess D, Cooper F, Watal P, Ali SA. Slide injury leading to bacteremia and sepsis in a pediatric patient. Consultant. 2023;63(8):e5. doi:10.25270/con.2023.08.000002
To read the full Photoclinic case report, visit: www.consultant360.com/photoclinic/slide-injury-leading-bacteremia-and-sepsis-pediatric-patient
TRANSCRIPTION:
Felicia Cooper, MD: Hi. My name is Dr. Felicia Cooper. I saw this case as a resident in Pediatrics at Nemours Children's Hospital in Orlando. And now I am a pediatric endocrinology fellow also at Nemours in Orlando.
Drew Burgess: Hi. My name is Drew Burgess. I am an undergraduate student at Wilkes Honors College at Florida Atlantic University. And Dr. Cooper is my mentor through our alumni network, and she graciously offered me the opportunity to join her on this case study.
Consultant360: How did you approach this case and did your approach change during the patient’s continuum of care?
Dr Cooper: When the patient first arrived to us, her main chief complaint was joint pain, and so when we think about the differential diagnosis for joint pain, which Ms. Burgess will go over, the thought about possibly bacteremia is far down on the list. Instead, we were thinking of something like juvenile idiopathic arthritis or JIA or maybe a reaction to a previous infection like transient synovitis or rheumatic fever. Being that the patient did have evidence of previous strep infection as well as several of the diagnostic criteria for rheumatic fever, that was our first leading diagnosis, and we had treated her as such. We had given her anti-inflammatories.
However, once we saw that her blood culture had popped up positive for MRSA [methicillin-resistant Staphylococcus aureus], our diagnostic leading diagnosis completely changed. Now, we were dealing with a much sicker child who required ICU level care and far more intensive treatment besides just anti-inflammatories like we had started off with.
C360: What aspect of this case made you either question or helped solidify your clinical assumptions?
Dr Cooper: Our biggest piece of evidence to support our diagnosis was definitely that positive blood culture that came on day two of the patient's hospitalization. But the patient also had a full body MRI, and in the MRI, we saw massive fluid and puss collections surrounding many of her organs, surrounding many of her muscles and osteomyelitis in her bones, and those were the diagnostic pieces that really solidified that this was all caused by MRSA.
C360: For this case you noted that you consulted with a rheumatologist and an orthopedic team. How do you approach and maintain the multidisciplinary care of the patient throughout their treatment?
Dr Cooper: This case definitely highlighted how important it was to have the knowledge of specialists on board. Initially, we had started with a rheumatologist and an orthopedist because we were considering that joint pain was the leading diagnosis and to diagnose that we would require several imaging studies to look at the bones and the joints. However, when the patient was diagnosed with bacteremia, then we needed Infectious Disease involved. When the patient had a mass in her heart with vegetation suggestive of endocarditis, then we needed the Cardiac Intensive Care Unit involved with cardiologists. And throughout her hospitalization, the patient was also working with physical therapists, with a neurologist, with speech therapists. We're very, very grateful for all of the specialists and all of the different people in the hospital for helping to take care of this patient because everyone had a different perspective on the diagnosis and the treatment.
We all worked together and communicated great to come up with a plan for the patient that would be in her best interest. I think that in any case, in any hospitalized child or even in the outpatient setting, collaboration with several sub specialists if you have a clinical question is always a great idea because everyone can offer a different perspective.
C360: What was the key piece of information or data point that confirmed your diagnosis?
It would be the blood culture from admission that showed that methicillin-resistant Staph aureus or MRSA as well as her full body MRI that showed fluid collections around her bones, joints and muscles.
C360: What did you learn from this case and what can other clinicians take away from it?
Drew Burgess: Definitely, the importance of a multidisciplinary approach to patient care, like Dr. Cooper said, cardiologists were involved, rheumatology, imaging, physical therapy, and definitely something I learned from the case, especially as an undergraduate student, is about endocarditis in general and its unique presentations. And even though the literature is sparse, I think that clinicians should keep an open mind and be aware of the possibilities and complications that may be uncommon even if the patient is normally healthy. So, I think case studies like this, of even just a single person, it really demonstrates the complexity of the human body that we should all take into account. And when we come across instances and unique presentations, it's important to add to the literature.
Dr Cooper: I also think that it really highlights about the diagnostic process and that the team should never pigeonhole themselves into thinking about just one diagnosis. Because the patient fit the criteria for rheumatic fever, that was all that the team was thinking about at the time, it was treating the rheumatic fever, not thinking about the other symptoms that she was presenting, might not have fit that criteria. So it's always important to cast a wide net and keep your thinking broad when thinking of a diagnosis and always realizing that the diagnosis can change at any point as well. Ms. Burgess, did this case inspire you further into a medical career?
Drew Burgess: Yes. I really enjoyed that it was about a pediatric patient. I think treating children is really close to my heart. I mentor a couple of young girls, and being able to help in that way is definitely inspiring.
C360: Looking ahead, how do you think this case will impact clinical care?
Dr Cooper: As I mentioned, it's so important to cast a wide net and not be stuck on one diagnosis or utilize the diagnostic momentum. Just because one subspecialist feels that this is the leading diagnosis as the rheumatologist did, it's always important to consider all the other symptoms that the patient is presenting, even uncommon, as Ms. Burgess said. Endocarditis and bacteremia and eventually a septic emboli into the brain are all very uncommon, especially in the pediatric population. But it was important that we thought outside of the box and looked for those, as we say, zebras or rare cases that can sometimes happen. So I think that going forward, our team definitely learned to consider all of the rare diagnoses and being okay with transitioning to another diagnosis once we have more evidence is important.
Drew Burgess: And I would also like to add a bit about effective communication between the team. I think it's very admirable that you guys were able to switch, and sometimes for a patient, I'm sure it can be overwhelming being transferred to the new units. And for you all to be able to do that as smoothly as possible to provide the best care shows that you guys really know how to communicate.
Dr Cooper: Yes, I was the resident who made the initial call to the Cardiac Intensive Care Unit, and while that was intimidating, I feel that effective handoff is very, very integral to patient care. I completely agree with Ms. Burgess. By collaborating together and showing the intensivists what we had already found out and what we were hoping that her team could help us with was a really great way of strategizing how to best care for the patient.
Dr Cooper: I'm really happy to present this case because not only is it a very interesting presentation, and not only did it happen from a pretty uncommon situation, a scrape on a playground slide or a carnival slide, excuse me, but it has a happy ending and I always appreciate when patients are able to be discharged from the hospital with no long-term sequelae.
This patient did very well. She just had mild hip stiffness the last time that we had followed up with her, and I think this really speaks to how resilient children are and why I love what I do in pediatrics because children are very tough, and this patient was very brave and we really appreciate that this patient and her mother allowed us to share this story with you so that way other clinicians in a similar situation might be able to see our case report and manage their patients accordingly.
Drew Burgess: I'm also very proud to have been able to work on this case study. It was a first time for me, I got to experience the writing and the revising process, and I feel that it's really going to further my journey to become a pediatrician. And because it was such a unique presentation of all these different complications, it makes me excited to be able to share this with others and inform them of the different possibilities and solutions to caring for a patient.