Suggest treatment for recurrent high fever and Pyelonephritis

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Posted on Mon, 2 Mar 2015 in Child Health
Question: My 2 year old daughter suffers from recurrent high fevers (103-104). She has been hospitalized twice for pyelonephritis and went septic with it at 6 weeks old. She has also suffered from a febrile seizure and numerous ear and sinus infections. She developed a blood clot at 8 weeks from a PICC line and was diagnosed with a MTHFR double C mutation. Her IgA, IgG, and IgM levels all appear in the average range. Her most recent blood work abnormal results after a fever spell with no known cause is below. I'm at a loss at what to think and my doctor wants to wait three months to test her blood again. Any idea what could be wrong with her causing the recurrent infections and high fevers (some with no known cause). And should I seek advice from a specialty doctor sooner than 3 months?

WBC 15.0 (H) Ref. Range 4.6-10.2
RBC 3.88 (L) Ref. Range 4.04-6.13
HGB 10.0 (L) Ref. Range 12.0-16.0
MCH 25.8 (L) Ref. Range 27.0-31.2
MCHC 31.4 (L) Ref. Range 31.8-36.0
RDW 16.1 (H) Ref. Range 11.6-15.5
NEUT # 8.6 (H) Ref. Range 2.0-7.2
LYMPH # 4.0 (H) Ref. Range 0.6-3.4
MONO # 2.3 (H) Ref. Range 0.0-0.9
MONO% 15.5 (H) Ref. Range 0.0-12.0
SED RATE 29 (H) Ref. Range 0-20
CRP was reported to me to be 69 with normal range of 2, but it isn't showing on this report.

She was in the hospital 5 days before these labs were ran with the high fever and they reported to me a left shift, but I don't see anything noting that specifically on these labs. I haven't received a copy of the hospital labs yet to reference.

Any thoughts? My concerns are Lupus, JRA, Leukemia.
doctor
Answered by Dr. Sumanth Amperayani 55 minutes later
Brief Answer:
Immunodeficiency needs to be ruled out

Detailed Answer:
Hi...I have a few questions for you.

1. What was her birth weight and current weight?
2. What's her current height and exact date of birthday?
3. Was she in ICU any time during her hospitalizations?
4. Did she have any bone and joint infections in past?
5. Does she have recurrent skin infections or abscesses or boils?
6. What was her exact immunoglobulin profile levels and ranges?
7. Please look into her mouth with her tongue out and see if you can see her tonsils easily or not?

Suggestions -
1. All this is going on since 6 weeks if life - so unlikely to be leukemia.
2. Jra doesn't start that early.
3. That leaves immunodeficiency as a strong possibility.

Please get back with answers and I will guide you.

Regards - Dr. Sumanth
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Sumanth Amperayani 29 minutes later
Her birth weight was 10 lbs 4 oz and she was 2 weeks early via c-section. I did not have gestational diabetes but was on daily lovenox shots for my MTHFR double c mutation. Her current weight is 32 pounds.

Her current height is 33 inches and her birthday is 10-5-12.

She was never admitted to ICU. She was in the hospital for a little over a week with the septic pyelonephritisat 6 weeks. She was in the hospital for 2 days with the blood clot. They would have kept her longer but I had experience with it and the lovenox shots I had to administer to her for four months. She was hospitalized for 3 days to run tests for reasons for the febrile seizure. None were found. She was hospitalized for four days with her last bout of pyelonephritis.

She has no known bone or joint infections.

She has some eczema patches on her cheeks and arms, but that is the only issues with her skin.

We reran her immunoglobuin profiles last week. They were ran at one year and her IgA was low but not deficient. I don't remember the exact number. I am IgA deficient and so is my paternal grandfather. That's why we initially ran them.

IgA result was 94 Normal Range was 27-246
IgG was 930 Normal Range was 468-1250
IgM was 78 Normal Range was 37-184

Her tonsils are unusually large always, just like mine.

We have an appointment with my immunologist this Thursday, but I was ready to rule out an immunological issue after those results appeared in the normal range. What other immunodeficiency issue could there be that I should potentially bring up to my immunologist? Should we check her IgE or IgD levels? Are there other immunological tests we can run? What other immunological disorders appear with these types of symptoms/results?
doctor
Answered by Dr. Sumanth Amperayani 29 minutes later
Brief Answer:
Suggestions on immunodeficiency

Detailed Answer:
Hi...
1. She's under height but normal weight for her age.
2. As her tonsils are large - unlikely to be hypogammaglobulinemia.
3. Not JRA or Leukemia as mentioned precious.
4. Immunodeficiency stands a strong possibility with family history being positing.

Possibilities -
1. Selective IgA deficiency.
2. Wiskott Aldrich syndrome - recurring infection and eczema... But the caveat is normal platelet counts.
3. NK cell deficiency.
4. Chronic Granulomatous disease.
5. Hyper IgE syndrome - least likely - as there's no abscess formation.

Tests -
1. IgE and IgD.
2. Flowcytometry for T and B cell markers.
3. NBT TEST along with genetic mutation analysis for Chronic Granulomatous disease.
4. HIV Elisa test.
5.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
Answered by
Dr.
Dr. Sumanth Amperayani

Pediatrician, Pulmonology

Practicing since :2003

Answered : 8192 Questions

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