A 6-month-old child with cardiac dysfunction and convulsions

Dr  Ira Shah

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A 6-month-old child with cardiac dysfunction and convulsions

Dr Ira Shah.

Medical Sciences Department, Pediatric Oncall, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.

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Clinical Problem
A 6 month old boy exclusively breast-fed presented with a generalized tonic clonic convulsions lasting for 10 minutes. He had no fever, delayed development or altered sensorium. He had convulsions on Day10 of life and treated as hypocalcemic convulsions. He also had repeat convulsions at 5th month of age and was again diagnosed as hypocalcemic convulsions. Both the times no blood investigations had been done.
On presentation, he had wrist widening and beading. His heart rate was 150/min. His serum calcium was 8.5meq/L and ionic calcium was 1.04mmol/L. His serum alkaline phosphatase was 349 IU/L. His serum phosphorus was normal. X-ray of wrist showed white line of calcification. Lumbar puncture was normal. X-ray chest showed cardiomegaly. In view of tachycardia and cardiomegaly, an echocardiography was done that showed left ventricular dilatation with diastolic dysfunction (suspected as due to hypocalcemia). His Blood pressure was 140/90 in right upper arm. USG abdomen for kidneys was normal.

What is the diagnosis?

Discussion
Dr Ira Shah: This child has cardiac dysfunction with convulsion. Though the cardiac dysfunction was suspected to be due to hypocalcemia, it is very clear that the rickets is healing as the white line of calcification has appeared on the X-ray. Also ionic calcium is on the low normal range. Thus, it is unlikely that the convulsion or cardiac dysfunction is due to hypocalcemia. The other abnormal finding in this child was hypertension in the upper limb. Hypertension can lead to convulsions and left ventricular hypertrophy. The dilated left ventricle is unexplained. One possibility that can explain both is Coarctation of aorta. This would lead to hypertension in upper limbs as well as cardiac dysfunction. The easiest way to diagnose this is by feeling the lower limb pulses, which in this child were not present. A 4-limb blood pressure showed high blood pressure in both upper limbs whereas hypotension in lower limbs. Though echocardiography did not detect coarctation of aorta, a color Doppler of the entire aorta picked up narrowing distal to the left subclavian artery confirming the diagnosis of coarctation of aorta.
The highlight of this case is that every time the child had a convulsion, he was diagnosed as hypocalcemic convulsions but never were the lower limb pulses felt. Infact the femoral pulses should be felt in all newborn babies, as coarctation of aorta is a clinical diagnosis and can be picked up early and intervened early

Compliance with ethical standards

Funding: None

Conflict of Interest: None

Cite this article as:
Shah I. A 6-month-old child with cardiac dysfunction and convulsions. Pediatr Oncall J. 2005;2.