A 4 month old with persistant bacteremia

Dr Ira Shah

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A 4 month old with persistent bacteremia

Dr Ira Shah.

Medical Services Department, 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.

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Clinical Problem
Case Report: A 4 months old girl born of 2nd degree consanguineous marriage presented with left sided tonic clonic convulsion. She had fever since 10 days, cough and diarrhea since 4 days. Aunt had epilepsy. She was a full term normal delivery with birth weight of 2.5 kg. She was on bottle feeds. On examination, she had erythematous skin rash over the back, pallor, hepatomegaly and hypertonia. Other examination findings were normal. Her present weight was 4.5 kg with total length of 38 cms. Investigations showed:
· Serum calcium = 8.69 mg/dl (Normal = 8.5 – 11 mg/dl)
· Serum phosphorus = 6.2 mg%, Alkaline phosphatase = 1020 IU/L
· Ionic calcium = 0.97 mol/L
· S. electrolytes, Creatinine, BUN = Normal
· SGPT = 103 IU/L
· Random blood sugar = 75 mg%
· Hemoglobin = 10.1 gm/dl, WBC count = 12,000/cumm [29% polymorphs, 70% lymphocytes, 1% eosinophils], platelet count = 1,14,000/cumm, ESR = 3 mm at end of 1 hour.
· MRI brain = Normal
· CRP = 15 mg/dl
· Chest X-Ray = Normal
· CSF = 1 Lymphocytes, Sugar = 48/75 mg%, proteins = 12 mg%
· Stool = Normal

She was treated with IV calcium gluconate and phenobarbitone but continued to have diarrhea, fever and 2 more episodes of seizures. Her repeat CRP was 101 mg/dl, blood culture grew staphylococcus aureus and ultrasound of abdomen showed left pleural effusion with hepatosplenomegaly and ascitis. She was treated with cefaperazone + sulbactum & ofloxacin as per blood culture sensitivity report. However, her condition showed no improvement and fever and diarrhea persisted. Her serial hemogram showed thrombocytopenia with leucocytosis.

	Day 10	Day 13	Day 20	Day 30	Day 35
Hemoglobin (gm/dl)	7.0	11.3	8.9	8.1	8.4
Hemoglobin (gm/dl)	7.0	11.3	8.9	8.1	8.4
WBC count	13,900	24,000	16,200	14,800	22,200
Polymorphs	35%	75%	40%	65%	62%
Lymphocytes	64%	25%	60%	65%	62%
Platelet count	67,000	1,45,000	1,99,000	64,000	61,000

She then developed heart failure and echocardiography showed trivial tricuspid regurgitation for which she was treated with blood transfusion and ionotropic support for 3 days. Her repeat blood culture after 8 days of antibiotics grew salmonella (biochemically resembling s.typhimurium) again sensitive to same antibiotics. A repeat culture on Day 15 & 25 of antibiotics also grew staphylococcus aureus sensitive to same antibiotics which were continued but fever and diarrhea persisted. Urine fungal culture grew candida for which the child received fluconazole.

Immunodeficiency workup in form of CD panel and HIV was normal.

What is the cause of persistent bacteremia in this child?

Discussion
Expert’s opinion: This child continues to have bacteremia inspite of treatment with antibiotics to which the organism is sensitive. Also, immunodeficiency seems to be unlikely as workup is normal. However in view of salmonella infection an Interferon Gamma loop defect should be ruled out. But repeated staphylococcal infection in the blood (twice blood culture grew stphylococcal) suggests constant seeding of the blood stream with staphylococcus. With infections being ruled out in the lungs, abdomen and brain, it is likely that the infection seems to be in the blood itself. Hence endocarditis must be ruled out. Even though the earlier echocardiography was normal, a repeat echocardiography is essential. A repeat echocardiography on Day 30 of illness showed pedunculated vegetations above tricuspid valve suggestive of infective endocarditis. Thus, in a child with persistent bacteremia and fever, infective endocarditis should always be kept in mind even if there is no heart disease.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

Cite this article as:
Shah I. A 4 month old with persistant bacteremia. Pediatr Oncall J. 2008;5: 105.