Diagnostic Dilemma

Neonatal hepatitis

A 3½ months old boy born of non-consanguineous marriage presented with jaundice since day 3 of life, fever, vomiting, and loose motions with blood for 3 days and swelling over left thigh for 2 days. There were no clay-colored stools or maternal fever during pregnancy and birth history and milestones were normal. On examination, he was deeply icteric, had tense anterior fontanelle with decerebrate posturing and hepatosplenomegaly.

Should a lumbar puncture be done in this child?
Expert Opinion :
This child had jaundice from Day 3 of life with hepatosplenomegaly suggestive of neonatal hepatitis. Now the child seems to have decompensated for the past 3 days with fever and blood in stools. The child also has swelling over the left thigh for 2 days which may suggest a bleed. Thus, the child seems to have developed coagulopathy due to liver disease. Now the child is deeply icteric with decerebrate posturing suggestive of hepatic encephalopathy. The tense anterior fontanelle may either suggest an intraventricular bleed or meningitis. However, with liver disease and bleeding manifestations elsewhere, one may suspect intracranial bleed rather than infection. Thus lumbar puncture (LP) should be avoided and imaging should be done to rule out an intracranial bleed first. In this child, the child died after 4 hours, and post-mortem LP done showed blood in CSF confirming the diagnosis of intracranial bleed. Thus in a child with hepatic encephalopathy, coagulopathy is common and procedures that can lead to profuse bleeding such as arterial pricks (for ABG), etc should be avoided.
Answer Discussion :
Rama Putra
LP is contraindicated. I suggest heead CT instead to rule out intracranial conditions
9 months ago
Roshni Joshua
Intracerebral bleed most likely - lumbar puncture is not indicated
9 months ago

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