What is the diagnosis and treatment for a child with fever and oral thrush symptoms?

Diagnosis and Treatment Plan

This 6-year-old female has acute herpangina (likely viral pharyngitis with oral ulcerations) causing fever and oral lesions, which should be treated symptomatically with antipyretics and oral nystatin suspension for the oral lesions.

Clinical Assessment

The presentation of on-and-off fever for 5 days (occurring nightly until early morning) with multiple oral ulcerations ("singaw") on the tongue and oral mucosa in a 6-year-old child is most consistent with herpangina or viral pharyngitis with oral ulcerations. The CBC shows normal WBC (10.5 x 10⁹/L) with relative lymphopenia (0.40), which is consistent with a viral illness rather than bacterial infection 1. The normal urinalysis excludes urinary tract infection 2.

Key Diagnostic Considerations

• Viral pharyngitis/herpangina is the most likely diagnosis given the fever pattern, oral ulcerations, and normal laboratory findings 1
• The absence of leukocytosis, thrombocytopenia, or elevated bands argues against serious bacterial infection 1
• Streptococcal pharyngitis is less likely given the prominent oral ulcerations rather than exudative pharyngitis 1
• The 5-day fever duration requires consideration of Kawasaki disease, but the patient lacks the other required criteria (conjunctival injection, rash, extremity changes, lymphadenopathy) 2

Treatment Plan

Symptomatic Management

• Paracetamol 250 mg (15 mg/kg/dose) every 4-6 hours as needed for fever (maximum 5 doses/24 hours)
  • Dispense: 20 tablets of 250 mg
  • Duration: 5-7 days or until fever resolves

Oral Lesion Treatment

• Nystatin oral suspension 2 mL (200,000 units) four times daily 3
  • Use dropper to place one-half of dose (1 mL) in each side of mouth
  • Avoid feeding for 5-10 minutes after administration 3
  • Retain in mouth as long as possible before swallowing 3
  • Dispense: 60 mL bottle
  • Duration: Continue for at least 48 hours after oral symptoms disappear 3

Total estimated cost: Paracetamol 250mg #20 (₱50-80) + Nystatin suspension 60mL (₱150-200) = ~₱200-280

Clinical Rationale

While the oral lesions are likely viral ulcerations rather than true candidiasis, nystatin suspension provides symptomatic relief and prevents secondary fungal overgrowth 3, 4. The FDA-approved dosing for children is 2 mL (200,000 units) four times daily 3. Although fluconazole shows superior efficacy for true oral candidiasis 5, nystatin is appropriate for this clinical scenario and falls within the PhilHealth formulary budget constraint.

Follow-up Recommendations

• Reassess within 48-72 hours if no improvement 6, 2
• Fever should resolve within 5-7 days of onset in viral illness 1
• If fever persists beyond 7 days total or patient develops new symptoms (rash, conjunctival injection, extremity swelling), return immediately for Kawasaki disease evaluation 2
• Ensure adequate hydration given oral discomfort

Medical Certificate

Diagnosis: Acute viral pharyngitis with oral ulcerations (Herpangina)

Recommendation: Symptomatic treatment with antipyretics and oral nystatin suspension. Rest and adequate hydration. Return if fever persists beyond 7 days or new symptoms develop.

Paliwanag sa Magulang (Explanation to Parents)

Ang inyong anak ay may viral infection sa lalamunan at bibig na nagdudulot ng lagnat at mga sugat sa loob ng bibig. Ito ay karaniwan sa mga bata at kusang gagaling sa loob ng 5-7 araw. Ang gamot na paracetamol ay para sa lagnat, at ang nystatin drops ay para sa mga sugat sa bibig upang maiwasan ang secondary fungal infection at magbigay ng ginhawa. Mahalagang panatilihing hydrated ang bata kahit masakit ang paglunok. Bumalik agad kung ang lagnat ay tumatagal ng higit sa 7 araw o kung may lumilitaw na bagong sintomas.