Diagnostic Dilemma - Pediatric Oncall
Author: Pediatric Oncall
Case Report: - A 5 years old boy presented with remittent fever for 2½ months. There is no cough, urine or bowel complaints or contact with TB. He was treated with various antibiotics – Piperacillin plus Tazobactum, Ampicillin, Ciprofloxacin but had no response. On examination, he was febrile, had multiple insignificant cervical, axillary and inguinal lymphadenopathy with splenomegaly. Other examination findings were normal. Investigations showed:

• Hemoglobin: 8.2gm, dl, WBC: 6700 {54 percent polymorphs, 45 percent lymphocytes}, platelets = 3,77,000, cumm and ESR of 70 mm at end of 1 hour
• SGPT = 22 IU, L
• S. Creatinine = 0.7 mg percent
• Total proteins = IgM percent, Albumin = 3.2 gm percent
• OptiMAL test for malaria = Negative
• LDH = 902 IU, L, Uric Acid = 2.7 mg percent
• Weil Felix test = OX–19 = 1:160, OX–2 = 1: 640
• Brucella IgG, IgM – Negative
• USG Abdomen = Splenic microabscesses with multiple , Subcentimetric lymphnodes
• CT Abdomen = Splenomegaly
• Stool and Urine examination = Normal
• Blood culture = Negative
• HIV ELISA = Negative
• RA factor, ANA, dsDNA = Negative
• Bone marrow = Normal
• Lymph node biopsy = Reactive hyperplasia
• EBV nuclear antigen IgG = Weakly positive

The child was treated with Inj Ceftriaxone and Cloxacillin for splenic microabscesses which were stopped after CT abdomen did not show any abscesses. He also received chloramphenicol for 7 days in view of Weil Felix test but fever did not subside. On Day 8 of admission, he developed bilateral knee and ankle joint swelling which responded to Valacyclovir {10 days} given in view of positive EBV nuclear antigen test. However fever persists.
Answers of this discussion
Author :- rt rndcash on 28 July 2012.
Answer :- Juvenile idiopathic arthriris Anti CCP antibody could be tried.

Author :- abdalatif khorwatt on 28 July 2012.
Answer :- proceed to exclude systemic Tb and mage accordingly

Author :- abdalatif khorwatt on 28 July 2012.
Answer :- proceed to exclude systemic Tb and mage accordingly

Author :- Taher Y Kagalwala on 28 July 2012.
Answer :- This may still be a rheumatic disorder. One should stop using antibiotics and repeat blood counts after 48-72 hours. A 5mear for M.P. is also mandatory.

Author :- Pramod Kulkarni on 29 July 2012.
Answer :- SOJIA is most likely rash_? remittantfever,LNpathy,splenomegaly,arthritis dev later -S, O systemic inflammatory disease

Author :- swati jainc on 29 July 2012.
Answer :- Start akt

Author :- zainul Gagan on 29 July 2012.
Answer :- sickle should be tested in this child as LDH is on higher side and a bone marrow ti rule out HLH

Author :- raghu reddy on 29 July 2012.
Answer :- hi iam Dr. Raghu prakash reddy Microbiologist - this pattern of fever is seen in Brucellosis . you can start on streptomycin and doxy after fifth day response will be seen. here blood culture showed be kept for 20 days incubation, so confirm how many days vails are incubated.

Author :- sree harsha on 30 July 2012.
Answer :- 1.u can first treat ricketsial fever with doxycycycline for 7 days 2.if no response treat only with paracetamol , NSAIDS. 3.In due course u may come across evolving rheumatic disease such as JRA 4.one more investigation that is left out is ECHO to detect Infective endocarditis.

Author :- Ebru Ergenekon on 30 July 2012.
Answer :- Rickettsia disease doxycycline for treatment

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