Grand Rounds

Fever, cough, convulsion and hepatosplenomegaly

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 4½ months old boy born of non consanguineous marriage presented with fever and cough for 15 days. He was treated with IV antibiotics and nebulization for same. He also had an episode of uprolling of eyes 3 days ago for which he was treated with Diazepam. His eldest sister had died at 18 years of age due to fever and cough 4 months ago. The child was a full term normal delivery with birth weight of 4 kg on exclusive breast feeds and had received only oral polio vaccine. On examination, the child had tachycardia {heart rate = 120, min}, respiratory rate = 44, min with subcostal and intercostals retractions and chest indrawing. Weight was 7 kg and height was 63 cms. On respiratory system, there was bilateral rhonchi with minimal chest findings. He had hepatosplenomegaly. Other systems were normal.

What is the diagnosis_?

Discussion :
This child has presented with fever, cough for 15 days suggestive of a respiratory infection. Respiratory distress with indrawing suggests hypoxia. Thus the child has an infection that is leading to hypoxia. Thus most common cause would be either in the alveoli or the parenchyma leading to V, Q mismatch and hypoxia. Thus, one would consider pneumonia or interstitial lung disease. Since chest findings are minimal on examination it would suggest and interstitial lung disease. Common interstitial lung diseases, one would consider are:
• Miliary TB
• Pneumocystis carinii pneumonia
• Fungal infections
• Interstitial pneumonitis like UIP, LIP, DIP
• Sarcoidosis
• Histiocytosis

This child also has a convulsion. The convulsion could be due to infection in the brain such as meningitis or due to hypoxia. With meningitis one would consider Tuberculosis as an etiology. Hepatosplenomegaly would be seen with TB, and sarcoidosis or histiocytosis. Thus, one would consider a differential diagnosis of disseminated TB, histiocytosis or sarcoidosis in this child. On investigation, Chest X-Ray shows miliary reticulonodular shadows, Mantoux test was positive and CSF showed 45 cells with 100 percent lymphocytes and sugar of 60 mg percent. Thus, child was diagnosed as Tuberculosis and treated with 4 drugs ATT and steroids.

Correct Answers :  yes 32%
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