Grand Rounds

Desquamating Rash with Hepatitis

Parminder Kaur, Vipul Gupta, Reena Jain, Shivanjali Sood
Department of Pediatrics, Government Medical College and Hospital, Chandigarh

Address for Correspondence: Dr Vipul Gupta, Assistant Professor, Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India. Email:

Clinical Problem:
A seven-year-old female child presented with fever for 3 days, oral ulcers and rash all over the body for one day. She was on sodium valproate at 20 mg/kg/day since a month in view of focal seizures. Baseline liver function tests (LFT) were normal prior to starting valproate. On admission, child had generalized exfoliating rash (Figure 1), jaundice and shock (blood pressure of 76/50 mm of Hg) requiring fluid resuscitation. She was treated with zinc, local paraffin application and glycerin mouth wash for oral ulcers. Sodium valproate was withdrawn and levetiracetam was started. Complete blood count revealed hemoglobin of 9.7 gm/dl, total leucocyte counts 10,000 cells/cumm (50% polymorphs, 40% lymphocytes and 6% eosinophils), platelet count 450,000 cells/cumm. Liver function tests (LFTs) were deranged (Table 1). Pancreatic function tests were also deranged with serum amylase of 162 IU/L and serum lipase of 448 IU/L. Ultrasound abdomen revealed hepatomegaly with increased gall bladder thickness. Serum creatinine was 0.4mg/dl. IgM for dengue and scrub typhus, hepatitis A IgM, Hepatitis E IgM, malaria antigen test, HIV Elisa were negative. Prothrombin time was 17 sec and INR was 1.8 which were corrected after Vitamin K injection.

Figure 1. Desquamating rash

Table 1. Trend of liver function test

What is the cause of rash and hepatitis in this child?

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