Grand Rounds

Fever, rash and convulsions

Department of Medical Sciences, Pediatric Oncall, Mumbai

Address for Correspondence: Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.

Clinical Problem :
Case Report: A two and a half years old boy born of third degree consanguineous marriage presented with fever for 6 days and maculopapular rash starting from face and then spreading to rest of the body for 2 days. He had a generalized tonic clonic convulsion half an hour back and was treated with IV Midazolam, Phenytoin and Phenobarbitone after which seizure subsided. He now had post itcal drowsiness. There is no otorrhoea, contact with TB. He is fully immunized till Booster 1 and milestones are normal. On examination, he has tachycardia {heart rate = 120, min} with hypotension {B.P. = 90, 60 mm of Hg} and prolonged capillary refill time. He is drowsy with normal power and reflexes. There are no meningeal signs. He has a maculopapular erythematous rash all over the body. He has hepatomegaly and other examination findings are normal.

What is the diagnosis_?

Discussion :
This child has presented with fever, rash and a convulsion without meningeal signs suggestive of infection involving the brain in form of encephalitis. Among the common infections, bacterial and viral infections would be on the forefront. The common bacterial infections affecting the brain at this age are H.influenza b, meningococcus and streptococcus pneumoniae and pneumococcal. Of these, meningococcus is the only one which leads to rash. However, the rash is usually petechial and the child would have toxicity and shock and multisystem organ dysfunction. Also bacterical infections will have meningeal signs. Thus, meningococcal infection or other bacterial infection seems unlikely. Viral infections commonly occur with fever, rash and encephalitis and common viral infections that can lead to brain involvement are enteroviruses, herpes virus, measles, mumps, arenavirus, dengue, poliovirus. Herpes and enteroviruses usually do not cause generalized rash. Mumps may be accompanied by parotid enlargement. The child has already received measles and polio vaccine and thus, they seem to be unlikely. Dengue may lead to fever, rash and brain involvement. Also, dengue can lead to hypotension too. Thus, in this child, one may suspect dengue encephalitis. In this child, complete blood count showed thrombocytopenia {platelet count = 97,000, cumm} with CSF showing 8 lymphocytes, cumm with normal proteins and sugar. CSF culture was negative. Dengue IgM by Panbio test was 3 {Normal is Less than 0.9 AI}. His electrolytes, blood sugar and calcium were normal. He was treated with IV Fluids and he responded on his own with subsequent normalization of platelet count.

E-published: January 2010 Vol 7 Issue 1 Art No 5

Correct Answers :  yes 100%
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