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.
Expert Opinion :
Regarding infectious mononucleosis, his EBNA IgG is positive, which suggests past infection. Since EBNA IgM is negative, it rules out acute infection.

For rickettsia, weil felix is not a very test to diagnose. Besides, this child has no rash, eschar and no response to chloramphenicol. Doxycyline was avoided as there was no clear evidence of rickettsial infection and the child is only 5 years of age.

The other differential diagnosis that most of you have suggested is autoimmune, JIA. That is exactly what we thought and started the child on Naproxen to which his fever has responded in 5 days. He required naproxen for a month and then has had no fever. He is on regular follow up and is asymptomatic at the moment.

Answer Discussion :
ahmed sayeed
infectious mononeucliosis
4 years ago
sree harsha
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.

4 years ago
raghu reddy
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.
4 years ago
zainul Gagan
sickle should be tested in this child as LDH is on higher side

and a bone marrow ti rule out HLH

4 years ago
swati jainc
Start akt
4 years ago
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