A 13-Year-Old Girl With Fever After Travel

Colleen Mathis, MD; Kimberly Monroe, MD, MS


October 30, 2020

The patient was initially hospitalized for an unclear etiology of her symptoms and fever of unknown origin. Although many fevers of unknown origin are ultimately infectious in nature, accounting for more than 60% of pediatric cases, recognizing other potential causes is important.[4] These include oncologic, autoimmune, endocrine, inflammatory, or neurologic conditions, which are important to recall in developing a differential diagnosis for fever of unknown origin.

This case represents a diagnosis that was initially delayed because of practitioners' bias toward fever representing an infectious cause, especially with the red herring of preceding international travel. Heuristic biases are "rules of thumb" and shortcuts used in clinical decision-making.[5] Heuristics are often appropriate; these mental shortcuts are developed by pattern recognition and allow practitioners to quickly associate symptoms with a common diagnosis. However, heuristic biases may lead to an incorrect or delayed diagnosis, as in this case. Using heuristics here, infection was considered to be most likely in a patient presenting with fever and diarrhea with recent international travel. However, this patient presented with thyrotoxicosis bordering on thyroid storm.

The pediatric endocrinology service was immediately consulted, and the patient was started on beta-blocker therapy with propranolol. Her tachycardia, fevers, and head pain all improved. Neck ultrasonography revealed a diffusely enlarged thyroid with no nodules. Nuclear medicine thyroid imaging showed toxic diffuse goiter consistent with Graves disease. TSI levels later returned elevated. Propranolol was uptitrated during her hospital stay, and she was started on methimazole. The patient was discharged home on hospital day 4, with great improvement in her symptoms.

The patient has been followed by an endocrinology specialist for her Graves disease and currently remains on medical therapy with low-dose methimazole. She is also being followed by an ophthalmology specialist for mild Graves eye disease. She has been euthyroid with resolution of presenting symptoms, including poorly recognized symptoms such as anxiety and even flawed hand-writing. She may require surgery in the future, because she is not a candidate for radioactive iodine therapy given her eye disease, but she is currently doing well over 1 year after diagnosis.


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