Diagnostic Dilemma


A 7-month-old boy born of non-consanguineous marriage presented with fever and irritability for 7 days and a staring look one day ago. Subsequently the child had become lethargic and did not recognize the mother and had neuroregressed. There was no focal neurological deficit, vomiting, rash or contact with tuberculosis. His immunization and milestones prior to illness were normal. He was on breast feeds as well as weaning diet. On examination, he was drowsy with Glasgow Coma Scale of 11. His pulse was 148/min with respiratory rate of 36/min. Blood pressure was 80/50 mm of Hg. He had a heavy head with inner table of anterior fontanelle closed. Cranial nerves were normal. Power and tone was normal. He had neck stiffness with brisk deep tendon reflexes. He had hepatosplenomegaly. Other system was normal. Investigations showed:
• Hemoglobin = 9.4 gm/dl
• PCV = 28.7%
• WBC count = 31,400/cumm (80% polymorphs, 20% lymphocytes)
• Platelet count = 70,000/cumm
• Malarial parasites were negative, Leptospira IgM = Negative
• HIV ELISA = Negative
• Blood culture = No growth
• CSF = 15 lymphocytes/hpf, 134 mg% proteins and 65 mg% sugar (corresponding blood sugar = 90 mg %)
• S. creatinine = 0.5 mg%
• Total proteins = 4.1 gm%, Albumin = 1.8 gm%
• S. electrolytes = Normal
• SGPT = 44 IU/L, SGOT = 86 IU/L
• PT = 21 sec (prolonged), RTT = 39.7 sec (prolonged)
• MRI brain = Mild ventriculomegaly
• Mantoux test, Chest X-Ray = Normal

A repeat CBC after 3 days showed:
• Hemoglobin = 6.3 gm/dl
• PCV = 19.3%
• WBC count = 11,800/cumm (75% polymorphs, 20% lymphocytes)
• Platelet count = 70,000/cumm

The child was treated with IV antibiotics. 48 hours later CSF was normal. Child improved clinically.

What is the diagnosis?
Expert Opinion :
This child has an encephalopathy (altered sensorium) with thrombocytopenia with normal sugar meningitis (all lymphocytes on CSF) with hepatosplenomegaly suggestive of a viral infection. CSF is not suggestive of bacterial infection. Though the child has neutrophilia on admission that could be due to seizure (Neutrophilia can occur post seizures due to stress). The CBC did normalize after 48 hours. Also CSF is normal in 48 hours. This is not commonly seen with bacterial meningitis. Thus, again viral meningoencephalitis is a possibility. In this child, the hemoglobin on admission was 9.4 gm% which has dropped to 6.3 gm% after 2 days. There is no bleeding or blood loss suggestive that the child had hemoconcentration initially. Also the child has slightly elevated liver transaminases with hypoalbuminemia and deranged prothrombin time and partial thromboplastin time with thrombocytopenia suggestive of infection with a virus leading to hemorrhagic fever. Thus one would consider a differential of dengue or kyasanur virus. In this child, Dengue IgM was positive suggesting a diagnosis of Dengue encephalitis.
Answer Discussion :
Irina Jipa
7 months ago
Anwar Sadat
7 months ago

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