Grand Rounds


Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

Clinical Problem :
A 10 month old boy born of non consanguineous marriage presented with fever for 5 days, refusal of feeds for 3 days and drowsiness for 1 day. On examination, vital parameters were normal. He had pallor, drowsiness and hepatosplenomegaly. There was no icterus. Deep tendon reflexes were brisk and tone was normal. There was no focal neurological deficit, meningeal signs and other systems were normal. Investigations showed:

• Hemoglobin = 8.4 gm, dl
• WBC = 5,500, cumm {32 percent neutrophils, 67 percent lymphocytes, 1 percent eosinophils}
• Platelet count = 57,000, cumm
• S.electrolytes = Normal
• SGOT = 244 IU, L, SGPT = 138 IU, L
• Bilirubin = 0.8 mg percent
• Total proteins = 5.8 gm percent {albumin = 2.8 gm percent}
• No acidosis
• Blood sugar = 45 mg percent
• Serum ammonia = 465 µg, dl
• CRP = Negative
• Urine = Normal. No Ketones
• PT = 16.2 sec {elevated}, PTT = more than 2 min.

Patient was started on IV Fluids, Lactulose and Metronidazole and responded within 24 hours. His sensorium improved and abnormal parameters improved in next 3 days. However, hemoglobin dropped from 8.4 to 7.5 gm percent and platelet count dropped to 8000, cumm.

What is the diagnosis_?

Discussion :
This child has presented with an encephalopathy {altered sensorium}. She has fever for 5 days` one must consider an acute infective cause. The child does not have any meningeal signs, hence meningitis seems unlikely. One would consider a diagnosis of encephalitis {especially viral} as a possibility. However the child also has hepatosplenomegaly, thus other differential diagnosis such as cerebral malaria, Hepatic encephalopathy and Reye’s syndrome should be considered. Bilirubin is normal in this child and there is hypoglycemia with elevated liver enzymes and hyperammonemia leading to suspicion of Reye’s syndrome. Reye’s syndrome may be seen with metabolic disorders such as Fatty acid oxidation defects or can also occur due to viral infections. This child has prolonged prothrombin time and partial thromboplastin time along with thrombocytopenia and hemoconcentration {Hemoglobin dropped from 8.4 to 7.5 gm percent after starting IV fluids}. Hence one must consider viral hemorrhagic fever such as Dengue in this child which leads to hepatitis as well as encephalopathy especially DEN-2. Dengue 2 virus is hepatotrophic}. In this child, Dengue IgM was positive.

Correct Answers :  yes 9%
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