Diagnostic Dilemma

Fever and Ileus

A 22 months old girl presented with fever for 10 days, diarrhea and abdominal distension for 3 days. On examination, she was pale, heart rate was 104/min, capillary refill time (CRT) was < 3 seconds. The abdomen was distended with sluggish bowel sounds. Other systems were normal. X-Ray abdomen showed multiple air fluid levels and serum electrolytes were low (sodium = 129 mg/dl, potassium = 2.8 mg/dl). There was no acidosis. Hemogram showed hemoglobin of 8.4 gm/dl, WBC count of 3,000/cumm (48% polymorphs, 52% lymphocytes), platelet count of 1,18,000/cumm. She was kept nil by mount (NBM) and started on intravenous (IV) Fluids, IV antibiotics, and potassium correction. Her potassium normalized in 24 hours but abdominal distension and sluggish bowel sounds persisted. Subsequently, she developed edema and ascites. Investigations showed:

• Hemoglobin = 8.3 gm/dl
• WBC = 8,300/cumm (70% polymorphs, 30% lymphocytes)
• Platelet = 40,000/cumm
• SGPT = 67 IU/L
• Blood culture = No growth
• Creatinine = 0.7 mg%
• BUN = 11 mg%
• Prothrombin Time = 23.2 sec (prolonged)
• Partial thromboplastin Time = 43.6 sec (prolonged)
• Urine = Normal
• Total proteins = 3.4 gm%, Albumin = 1.8 gm%.

What is the likely diagnosis?
Expert Opinion :
This child has paralytic ileus which was initially thought to be due to hypokalemia. However, with the improvement of serum potassium, the ileus still persisted. Thus, other causes such as intestinal obstruction and infection should be kept in mind. The blood culture is negative. The child also has edema suggestive of either hypoalbuminemia or capillary leaks. In this child, with prolonged PT and PTT with low platelet count, capillary leaks seems a possibility along with hypoalbuminemia. (The low Albumin may be due to loss of Albumin in interstitial space). Thus this child has deranged PT, PTT, thrombocytopenia, capillary leaks, initial leucopenia, hepatic transaminase dysfunction and fever suggestive of Dengue hemorrhagic fever. In this child, on suspicion of dengue. Dengue IgM ELISA was done which was positive (3.34 units).

Thus, paralytic ileus may be a presentation of dengue and if a child presents with intestinal obstruction along with capillary leaks and coagulopathy, one must suspect viral hemorrhagic fevers along with sepsis.
Answer Discussion :
Pugalenthi Shanmugam
liver failure
4 years ago
Anup Kumar Madhesia
typhoid fever
4 years ago

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