Prolonged Fever in an Adolescent

Jo Ann Serota, MSN, RN, CPNP

Disclosures

J Pediatr Health Care. 2008;22(4):262-263. 

In This Article

Introduction

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 \0x201Clump\0x201D 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 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.

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