Grand Rounds

Vomiting with Ventricular Septal Defect

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. India

Clinical Problem :
A 6 month old boy with congenital moderate ventricular septal defect {VSD} on decongestive measures consisting of frusemide and Digoxin presented with irritability, vomiting and oliguria since 2 days. There is no fever, refusal of feeds or lethargy. On examination, he is malnourished {weight = 4kg}, with some dehydration, has heart rate of 100 , min and a pansystolic murmur at the apex. Other systems are normal

What is the diagnosis_? How to treat_?

Discussion :
This child has presented with vomiting and oliguria. Oliguria may be due dehydration and decreased intravascular volume. The dehydration is because of persistent vomiting. Vomiting could be because of several reasons such as infection, gastritis or drug induced. This child has no fever or refusal of feeds. Thus infection seems an unlikely cause. Gastritis in a normally feeding infant is unlikely {There being no infection or nil by mouth}. Thus vomiting seems to be drug induced. Digoxin in toxic levels can lead to vomiting. Digoxin toxicity can also lead to bradyarrhythmia. In this child even though the child is dehydrated, there is no tachycardia. {Though bradycardia is not present, the heart rate seems to have remained normal due to simultaneous dehydration}. Thus, in this child the diagnosis is Digoxin toxicity. Serum Digoxin levels in the child were elevated {2.7 {Normal being Less than 2.2}} Digoxin toxicity when diagnosed, one should stop Digoxin till Digoxin levels return to normal. FAB antibodies can be used to prevent Digoxin effect.

E-published: January 2011 Vol 8 Issue 1 Art No. 4

Correct Answers :  yes 100%
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