Diagnostic Dilemma - Pediatric Oncall
Hypoplastic marrow
Author: Narasimhappa
A 10 years old girl presented to us with jaundice for 10 days and fever for 3 days. On examination, there was icterus, purpura, ecchymoses, anemia and firm liver of 6-7 cm below costal margin {which made us think of acute on chronic liver disease}. There was no lymphadenopathy or splenomegaly. Her hemoglobin was 5.2 g, total count 1000 and platelet count was 3000. KF ring was positive on Slit lamp examination but ceruloplasmin and urinary copper were not suggestive of Wilson’s. Peripheral smear showed no evidence of hemolysis. All hepatitis viral markers including hepatitis A,B,C were negative. ANA – negative. Her bilirubin was 8.2 with direct of 4.2. Liver transaminases were elevated 1200 and 1100. Serum albumin, PT, PTT were normal. Bone marrow aspiration done at 2 centres showed hypoplastic marrow. Bone marrow biopsy was not done. Other autoimmune hepatitis markers awaited and parvovirus serology is awaited. We thought initially as autoimmune hepatitis or parvovirus induced bone marrow suppression or infection induced suppression. She was started on methylprednisolone but her counts kept on going down. TLC- 750 and platelets – 2000. We stopped steroids and she is on taxim and amikacin. She is too stable for her condition.
Answers of this discussion
Author :- James Renner on 07 June 2011.
Answer :- Patient appears to have an autoimmune disorder. No information however is given concerning routine drug use or local herbs. my diagnosis will be drug induced hepatitis with a differential of autoimmune disorder

Author :- khalduncash on 07 June 2011.
Answer :- still viral causes should be considered and as ti is known it will self limiting disease

Author :- jayashree kanthila on 07 June 2011.
Answer :- is urine copper done afer post penicillamine challenge_?

Author :- mukesh panwar on 09 June 2011.
Answer :- Hduueh

Author :- mukesh panwar on 09 June 2011.
Answer :- Chronic hepatitis

Author :- Vishal Baldua on 15 June 2011.
Answer :- I think you should consider EBV . we HAD A 13 YR OLD WITH DIREST JAUNDICE OF 18 THAT WENT UPTO 23 -- pANCYTOPENIA WITH ALL LINES DEPRESSED -- EXTREMELY STABLE OTHERWISE -- iT TURNED OUT TO BE EBV related HEMOPHAGOCYTOSIS I wud recommend ferritin , triglycerides, fibrinogen and Igm EBV or EBNA, PCR EBV causes pancytopenia through HLH or direct marrow suppression

Author :- DrMohit Kehar on 16 June 2011.
Answer :- can go for CD 54 and all for PNH

Author :- Anil Kumarc on 18 June 2011.
Answer :- uiop

Author :- Rakesh Kumar on 18 June 2011.
Answer :- first give supportive therapy in the form of pRBC and platelet transfusion. then consider ATG and, or cyclophosphamide. carry out serum globulin, see A, G ratio which gets reversed in autoimmune hepatitis` That is the probable diagnosis.

Author :- Ameencash a on 18 June 2011.
Answer :- wait for parvovirus serology.It is likely.Also worth looking for other viral titres like cmv.As patient is very stable it is unlikely to be something progressive.

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