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Prolonged Fever in an Adolescent
Department
www.jpedhc.org
Case Studies—Primary Care
Rockwood Clinic Pediatrics
Prolonged Fever in an Adolescent
Spokane, Washington Sally Walsh, MSN, RN, CPNP
Jo Ann Serota, MSN, RN, CPNP
Section Editors Carol Rudy, MPH, ARNP, CPNP
Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
Jo Ann Serota is Pediatric Nurse Practitioner, Ambler Pediatrics, Ambler, Pa. Correspondence: Jo Ann Serota, MSN, RN, CPNP, Ambler Pediatrics, 602 South Bethlehem Pike, Ambler, PA 19002; e-mail: [email protected]. J Pediatr Health Care. (2008). 22, 262-263. 0891-5245/$34.00 Copyright Q 2008 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2008.04.002
262
Volume 22
Number 4
Susan is a 17-year-old high school senior who came to the office complaining of fever and a sore throat for 4 days. The family had been on vacation about 3 weeks ago in South Carolina. Susan does not recall getting any bug bites or abrasions. She swam in the ocean, went horseback riding, and used the resort hot tub daily. Her physical examination revealed an injected pharynx and a few bilaterally shotty nodes. No fever, rash, or abnormality of the tympanic membranes was present while she was in the office. The remainder of her examination was unremarkable. Results of a rapid strep test were negative, and a throat culture was sent to the laboratory. She was instructed to take acetaminophen or ibuprofen for fever or discomfort. If the fever persisted for another 48 to 72 hours, Susan was instructed to call the office. Three days later, Susan’s mother called because her fever had persisted. Susan was feeling tired and a bit achy after 7 days of illness. A review of her symptoms revealed no cough, headache, or dysuria. Her sore throat was resolved, and there was no rash, vomiting, or diarrhea. Her last menses was about 3 weeks ago. The throat culture that had been sent to the laboratory was negative. Her physical examination was completely normal. During her examination (without her parents present), she was
asked about sexual activity. She did not have a boyfriend, was not sexually active, and did not have any sexual experiences while on vacation. Blood was drawn for a complete blood cell count, comprehensive metabolic panel, Epstein-Barr virus, Mono spot, Lyme IgG, IgM and Western Blot, sedimentation rate, and West Nile virus. A urinalysis and urine for culture and sensitivity were obtained. Results of her comprehensive metabolic panel, urinalysis, and urine culture were normal. Results of the tests for Lyme, Epstein-Barr virus, Mono spot, Western Blot, and West Nile virus were negative. The complete blood cell count revealed only a mild elevation of absolute neutrophils, and the sedimentation rate was elevated (75 mm/h). We instructed the parents to continue to observe for any additional symptoms or worsening of her condition. On day 12, Susan’s mother called because her fever continued. While in the office, Susan stated that when she voided, she felt discomfort, pain, and a ‘‘lump’’ in her vaginal area. This was the first time this complaint was mentioned. A clean catch urine was obtained for urinalysis and urine culture. The patient was draped and examined privately. Her vaginal vault showed some redness but there was no observable discharge or odor from the vagina. A quarter-sized open Journal of Pediatric Health Care
purulent draining lesion was found at the lower left vulvovaginal vestibule at the 4 o’clock position. The surrounding tissue was red and moderately swollen and tender to the touch. A culture of the lesion was obtained for anaerobic and
aerobic bacteria as well as gonorrhea and chlamydia. A cephalosporin was prescribed for the patient until the culture results were obtained. The patient stated that she did not say anything to per parents or to us about the vaginal
discomfort because she was very embarrassed. She began feeling this discomfort in her vaginal area about a week ago. The vaginal culture revealed no growth, and the antibiotic was discontinued.
CASE STUDY QUESTIONS 1. 2. 3. 4.
What would be your differential diagnoses? What are the clinical manifestations of this condition? What type of management and follow-up would be required? What questions would you add to your adolescent interview?
CASE STUDY ANSWERS 1. What would be your differential diagnoses? One would have to consider viral and bacterial conditions including vaginal herpes, vaginitis, genital warts, syphilis, and gonorrhea, as well as sebaceous cysts, hematomas, and endometriosis. Based on the location of this lesion and its presentation, a diagnosis of Bartholin’s gland abscess with spontaneous rupture was made. 2. What are the clinical manifestations of this condition? The function of Bartholin’s gland is to secrete mucous into the vagina’s vestibule. These glands are located at the four and eight o’clock position in the vaginal vault. Occasionally, cysts and abscesses form within Bartholin’s gland (Omole, Simmons, & Hacker, 2003). A Bartholin cyst forms when the duct becomes obstructed and the duct or gland becomes distended because of fluid accumulation. Most of these cysts are small and asymptomatic, although some may become larger, causing pain and discomfort when ambulating or during intercourse. A Bartholin abscess occurs
Journal of Pediatric Health Care
when the gland becomes infected. The abscess may point and drain, giving the patient immediate relief (Chen, 2006). 3. What type of management and follow-up would be required? An asymptomatic cyst requires no intervention. Cysts that are large and cause pain or discomfort may be incised and drained. These cysts usually are sterile and do not require antibiotic therapy. An abscess of the Bartholin gland may spontaneously drain or need surgical intervention. Abscesses should be cultured for anaerobic and aerobic bacteria, as well as for sexually transmitted diseases. The choice of antibiotic should be based on culture and sensitivity results. Also, sitz baths, ibuprofen, and other comfort measures maybe initiated (Chen, 2006). 4. What questions would you add to your adolescent interview? This case had an interesting presentation, and diagnosis took almost 2 weeks. The patient was seen by three health care providers, laboratory tests were unremarkable, and the patient did not reveal all that was symptomatic. We did ask about her sexual activ-
ities, menstrual history, and self exploration. For adolescents, additional questions about changes to their ‘‘private parts,’’ specifically any lumps, bumps, rashes, tenderness to the area, drainage, odor, and pain on walking, should be part of the history. The history also should include a detailed sexual history, which includes sexual partners of both sexes, any suspicion of sexual abuse, and activities that may irritate the vagina, such as horseback riding, gymnastics, or other activities affecting the vaginal vault. Our patient’s Bartholin cyst abscessed and drained spontaneously. Once this occurred, the fever diminished and there was less vaginal discomfort and no pain on wiping. The site was completely healed and asymptomatic within a week.
REFERENCES Chen, K.T. (2006). Disorders of Bartholin’s gland. Retrieved August 23, 2007, from http://proxy.library.upenn.edu Omole, F., Simmons, B. J., & Hacker, Y. (2003, July 1). Management of Bartholin’s duct cyst and gland abscessRetrieved August 23, 2007, from. American Family Physician. http://www. aafp.org/afp
July/August 2008
263
www.jpedhc.org
Case Studies—Primary Care
Rockwood Clinic Pediatrics
Prolonged Fever in an Adolescent
Spokane, Washington Sally Walsh, MSN, RN, CPNP
Jo Ann Serota, MSN, RN, CPNP
Section Editors Carol Rudy, MPH, ARNP, CPNP
Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
Jo Ann Serota is Pediatric Nurse Practitioner, Ambler Pediatrics, Ambler, Pa. Correspondence: Jo Ann Serota, MSN, RN, CPNP, Ambler Pediatrics, 602 South Bethlehem Pike, Ambler, PA 19002; e-mail: [email protected]. J Pediatr Health Care. (2008). 22, 262-263. 0891-5245/$34.00 Copyright Q 2008 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2008.04.002
262
Volume 22
Number 4
Susan is a 17-year-old high school senior who came to the office complaining of fever and a sore throat for 4 days. The family had been on vacation about 3 weeks ago in South Carolina. Susan does not recall getting any bug bites or abrasions. She swam in the ocean, went horseback riding, and used the resort hot tub daily. Her physical examination revealed an injected pharynx and a few bilaterally shotty nodes. No fever, rash, or abnormality of the tympanic membranes was present while she was in the office. The remainder of her examination was unremarkable. Results of a rapid strep test were negative, and a throat culture was sent to the laboratory. She was instructed to take acetaminophen or ibuprofen for fever or discomfort. If the fever persisted for another 48 to 72 hours, Susan was instructed to call the office. Three days later, Susan’s mother called because her fever had persisted. Susan was feeling tired and a bit achy after 7 days of illness. A review of her symptoms revealed no cough, headache, or dysuria. Her sore throat was resolved, and there was no rash, vomiting, or diarrhea. Her last menses was about 3 weeks ago. The throat culture that had been sent to the laboratory was negative. Her physical examination was completely normal. During her examination (without her parents present), she was
asked about sexual activity. She did not have a boyfriend, was not sexually active, and did not have any sexual experiences while on vacation. Blood was drawn for a complete blood cell count, comprehensive metabolic panel, Epstein-Barr virus, Mono spot, Lyme IgG, IgM and Western Blot, sedimentation rate, and West Nile virus. A urinalysis and urine for culture and sensitivity were obtained. Results of her comprehensive metabolic panel, urinalysis, and urine culture were normal. Results of the tests for Lyme, Epstein-Barr virus, Mono spot, Western Blot, and West Nile virus were negative. The complete blood cell count revealed only a mild elevation of absolute neutrophils, and the sedimentation rate was elevated (75 mm/h). We instructed the parents to continue to observe for any additional symptoms or worsening of her condition. On day 12, Susan’s mother called because her fever continued. While in the office, Susan stated that when she voided, she felt discomfort, pain, and a ‘‘lump’’ in her vaginal area. This was the first time this complaint was mentioned. A clean catch urine was obtained for urinalysis and urine culture. The patient was draped and examined privately. Her vaginal vault showed some redness but there was no observable discharge or odor from the vagina. A quarter-sized open Journal of Pediatric Health Care
purulent draining lesion was found at the lower left vulvovaginal vestibule at the 4 o’clock position. The surrounding tissue was red and moderately swollen and tender to the touch. A culture of the lesion was obtained for anaerobic and
aerobic bacteria as well as gonorrhea and chlamydia. A cephalosporin was prescribed for the patient until the culture results were obtained. The patient stated that she did not say anything to per parents or to us about the vaginal
discomfort because she was very embarrassed. She began feeling this discomfort in her vaginal area about a week ago. The vaginal culture revealed no growth, and the antibiotic was discontinued.
CASE STUDY QUESTIONS 1. 2. 3. 4.
What would be your differential diagnoses? What are the clinical manifestations of this condition? What type of management and follow-up would be required? What questions would you add to your adolescent interview?
CASE STUDY ANSWERS 1. What would be your differential diagnoses? One would have to consider viral and bacterial conditions including vaginal herpes, vaginitis, genital warts, syphilis, and gonorrhea, as well as sebaceous cysts, hematomas, and endometriosis. Based on the location of this lesion and its presentation, a diagnosis of Bartholin’s gland abscess with spontaneous rupture was made. 2. What are the clinical manifestations of this condition? The function of Bartholin’s gland is to secrete mucous into the vagina’s vestibule. These glands are located at the four and eight o’clock position in the vaginal vault. Occasionally, cysts and abscesses form within Bartholin’s gland (Omole, Simmons, & Hacker, 2003). A Bartholin cyst forms when the duct becomes obstructed and the duct or gland becomes distended because of fluid accumulation. Most of these cysts are small and asymptomatic, although some may become larger, causing pain and discomfort when ambulating or during intercourse. A Bartholin abscess occurs
Journal of Pediatric Health Care
when the gland becomes infected. The abscess may point and drain, giving the patient immediate relief (Chen, 2006). 3. What type of management and follow-up would be required? An asymptomatic cyst requires no intervention. Cysts that are large and cause pain or discomfort may be incised and drained. These cysts usually are sterile and do not require antibiotic therapy. An abscess of the Bartholin gland may spontaneously drain or need surgical intervention. Abscesses should be cultured for anaerobic and aerobic bacteria, as well as for sexually transmitted diseases. The choice of antibiotic should be based on culture and sensitivity results. Also, sitz baths, ibuprofen, and other comfort measures maybe initiated (Chen, 2006). 4. What questions would you add to your adolescent interview? This case had an interesting presentation, and diagnosis took almost 2 weeks. The patient was seen by three health care providers, laboratory tests were unremarkable, and the patient did not reveal all that was symptomatic. We did ask about her sexual activ-
ities, menstrual history, and self exploration. For adolescents, additional questions about changes to their ‘‘private parts,’’ specifically any lumps, bumps, rashes, tenderness to the area, drainage, odor, and pain on walking, should be part of the history. The history also should include a detailed sexual history, which includes sexual partners of both sexes, any suspicion of sexual abuse, and activities that may irritate the vagina, such as horseback riding, gymnastics, or other activities affecting the vaginal vault. Our patient’s Bartholin cyst abscessed and drained spontaneously. Once this occurred, the fever diminished and there was less vaginal discomfort and no pain on wiping. The site was completely healed and asymptomatic within a week.
REFERENCES Chen, K.T. (2006). Disorders of Bartholin’s gland. Retrieved August 23, 2007, from http://proxy.library.upenn.edu Omole, F., Simmons, B. J., & Hacker, Y. (2003, July 1). Management of Bartholin’s duct cyst and gland abscessRetrieved August 23, 2007, from. American Family Physician. http://www. aafp.org/afp
July/August 2008
263